A Rare Case of Postpartum Paraplegia: A Case Report

ABSTRACT

In this case report, a 27-year-old woman who had pre-eclampsia in the past and had a cesarean section as a result of the condition presents with an uncommon and difficult form of postpartum paraplegia. She experienced bilateral lower limb paralysis and urine incontinence soon after the surgery, which quickly led to unconsciousness and required mechanical ventilator support and intensive care treatment. Comprehensive diagnostic testing, which included magnetic resonance imaging scans of the brain and spinal cord, identified signs typical of “Posterior Reversible Encephalopathy Syndrome (PRES)” and spinal cord infarction affecting segments C3 to D2. “Antiphospholipid Antibody Syndrome (APLA)” was identified by laboratory testing, highlighting the significance of taking a thorough approach to comprehending this uncommon clinical condition. Treatment included anticoagulant therapy, high-dose steroid therapy, and antihypertensive drugs, emphasizing the crucial importance of inter-disciplinary care in handling such complex situations. Even if the patient’s symptoms have partially improved, their condition is still being closely monitored in the intensive care unit. In the context of postpartum neurological problems and the complex interplay between pre-eclampsia, spinal cord infarction, and related clinical symptoms, this case emphasizes the need for increased awareness and prompt management.

INTRODUCTION

A rare and concerning medical disorder called postpartum paraplegia can present with a wide range of clinical issues and calls for prompt diagnosis and treatment. In this case report, a 27-year-old female patient presented with a rare and complicated case of postpartum paraplegia that developed in the context of prior pre-eclampsia and a subsequent cesarean surgery. Already a serious obstetric problem, pre-eclampsia is characterized by hypertension and organ failure during pregnancy.[1,2,3,4,5] However, the clinical condition becomes extraordinarily unusual and difficult when exacerbated by the abrupt onset of paraplegia. This patient’s condition started when she was admitted to the hospital’s Gynecology wing after having just undergone a cesarean section as a result of pre-eclampsia. Her neurological condition did, however, quickly and unexpectedly deteriorate after that. Her neurological deterioration began with urine incontinence and bilateral lower limb paralysis. Her clinical picture was further complicated by the discovery of spinal shock during the later investigation. She eventually became unconscious, requiring intensive care assistance and mechanical ventilation under the strict monitoring of anesthetists and neurologists.

This fascinating case serves as an excellent illustration of the complicated interactions between pre-eclampsia, neurological complications, and the difficulties faced by medical professionals when faced with such a challenging clinical riddle. It emphasizes how crucially important timely and inter-disciplinary management is in dealing with this uncommon and severely debilitating illness. In the parts that follow, this case report will delve into the specific clinical course, diagnostic assessments, treatment plans, and the ongoing clinical result of this exceptional case with the goal of offering the medical community insightful information.

Case presentation and history

Patient Information: A 27-year-old female presented to the emergency department of the Gynecology wing with a history of pre-eclampsia, having recently undergone a cesarean section due to this condition.

Clinical Course: The patient started to develop bilateral lower limb weakness while being monitored, and this was accompanied by urinary incontinence. The patient displayed an extensor plantar reflex and wereflexia upon examination. Spinal shock was identified as the cause of the patient’s condition, which eventually led to unconsciousness. She was put on a ventilator as her condition deteriorated, and under the care of anesthetists and neurologists, she received intensive supportive care.

Diagnostic Evaluations: To determine the cause of the acute paraplegia, an extensive evaluation was undertaken. Posterior reversible encephalopathy syndrome (PRES) and spinal cord infarction affecting the C3-D2 regions of the spinal cord were both identified during magnetic resonance imaging (MRI) of the brain and spinal cord. Since the lupus anticoagulant titer was positive, laboratory testing supported the diagnosis of antiphospholipid antibody syndrome (APLA) syndrome.

Differential diagnosis

• NMO or optic neuropathy

• Vasculitis, multiple sclerosis, and infections such as tuberculosis, syphilis, and fungal causes of transverse myelitis

• Syringomyelia

• Subacute combined degeneration

• Paraneoplastic myelitis.

Investigations

Lab evaluation

Coagulation profile, thrombophilia profile – lupus anticoagulant positive (79.4s), electrocardiogram.

X-Ray chest PA View, D-dimer test.

Radiological assessment

Bilateral basal ganglia involvement seen by brain MRI supported the characteristics of atypical PRES. An MRI of the entire spine verified the eye of the owl indication, a marker of a spinal cord infarction. A 2D Echo was performed to rule out thromboembolic phenomena as the source of the aorta’s atherosclerotic condition. Because of the patients’ financial concerns, the scheduled computed tomography (CT) angiograms of the brain and spine were not performed.

Diagnostic criteria for APLA

• Sapporo criteria (clinical criteria):

  • Vascular thrombosis; problems associated with pregnancy

• Laboratory requirements (Sydney requirements):

  • LA or lupus anticoagulant
  • Anticardiolipin antibodies (aCL), either IgG or IgM
  • Antibodies against 2-glycoprotein I (2 GPI).

MRI findings

In circumstances of specific spinal cord illnesses, particularly in patients with spinal shock, transverse myelitis, or other spinal cord abnormalities, the “Eye of the Owl sign” is a radiological abnormality shown on MRI. On axial MRI images, it refers to a symmetric, oval-shaped spinal cord lesion. T2-weighted pictures of the lesion show that the core section is brighter (hyperintense), resembling the “pupil” of an owl’s eye, while the surrounding area is darker (hypointense), resembling the “iris” of an owl’s eye, Figure 1.

Figure 1.

MRI findings

DISCUSSION

The described case of postpartum paraplegia is a complex medical mystery that calls for a thorough analysis of the underlying causes, difficulties with the diagnosis process, and the inter-disciplinary strategy used to treat this unusual clinical situation.

Pre-eclampsia and Postpartum Paraplegia: Paraplegia in the postpartum period is a seldom seen condition, especially when it occurs in conjunction with pre-eclampsia. Pre-eclampsia during pregnancy, which is characterized by hypertension and organ failure, has serious hazards for both the mother and the fetus. The patient’s prior history of pre-eclampsia is an important place to start in this situation. It is frightening and demands immediate evaluation when paraplegia develops suddenly after a cesarean section.[6,7,8]

Diagnostic Difficulties: It was difficult to determine what caused this patient’s acute paraplegia. Early clinical indicators of neurological involvement included bilateral lower limb weakness and urine incontinence. A thorough diagnostic workup was necessary to distinguish between various probable causes, including neuromyelitis optica (NMO), vasculitis, multiple sclerosis, and viral etiologies. The use of MRI scans of the patient’s brain and spinal cord was crucial in solving the riddle surrounding this disease. Infarction of the spinal cord was indicated by the “Eye of the Owl sign” on imaging, which provided a crucial element to the diagnosis.[9,10,11,12]

Antiphospholipid Antibody Syndrome: Laboratory evaluations revealed the presence of lupus anticoagulant, confirming the diagnosis of APLA. Antiphospholipid antibodies are a hallmark of APLA, an autoimmune condition that can cause unnatural blood clotting. This diagnosis was particularly important since it demonstrated the link between APLA and unfavorable pregnancy outcomes, such as pre-eclampsia, and explained the thrombotic processes that caused the spinal cord infarction.[1,6,12]

Multi-disciplinary Approach: To effectively manage such a complicated case, specialists from the fields of neurology, obstetrics, anesthesiology, and critical care have to work together. The cerebral and vascular features of the illness were rapidly treated with high-dose steroid therapy, anticoagulants, and antihypertensive drugs. This emphasizes the value of a multi-disciplinary approach in improving patient outcomes, particularly when several systems are at play.[11,13,14]

Clinical outcomes: According to the most recent information, the patient is still being watched in the intensive care unit (ICU). Although she has recovered consciousness and half of her symptoms have subsided, it is still unclear how long it would take her to fully recover. Determining the patient’s long-term prognosis will require continued close monitoring and therapies.

Treatment and follow-up

1. Oral and intravenous antihypertensives were used to treat the patient. To manage blood pressure, 5 mg of IV labetalol was administered every hour, and oral ACE inhibitors were begun at a dose of 40 mg twice daily. The desired blood pressure was less than 140/90 mmHg.

2. 1 g/day of intravenous steroids for 5 days.

3. Anticoagulant medications were administered to stop thromboembolic events.

4. The patient received 5 days’ worth of IVIG (intravenous globulins) at a dosage of 2 mg/kg/day.

5. Additional critical and supportive treatment was given.

CONCLUSIONS

In the setting of pre-eclampsia and APLA syndrome, this unusual instance of postpartum paraplegia serves as a sobering reminder of the difficulties brought on by complex medical disorders. It emphasizes the need for alertness, prompt action, and a multi-disciplinary strategy in handling such circumstances. It is necessary to conduct further study on the interaction between pre-eclampsia and neurological problems in order to better understand these uncommon clinical situations and develop effective treatment plans. Her situation will continue to be the focus of continued medical observation and inquiry as the patient’s journey progresses.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.