Eclampsia complicated by acute subdural haematoma: A case report

Abstract

Introduction

Acute subdural haematoma (ASDH) is usually a post-traumatic sequel but only a few spontaneous cases complicating eclampsia have been reported.

Presentation of case

We report the case of a 19-year-old patient who presented with intrapartum eclampsia at 38 weeks gestation, and developed neurologic signs that persisted after delivery. Computerized tomography (brain) revealed an acute subdural haematoma which was successfully managed conservatively in our facility.

Discussion

Subdural haematoma is bleeding into the space between the dura and pia matter. This report presents the management of a case of eclampsia which was complicated by subdural haematoma. The decision to manage this patient non-operatively was due to her improved neurological status and brain CT scan finding which showed no significant mass effect being exerted by the haematoma.

Conclusion

The good outcome in this report demonstrates the importance of a multidisciplinary approach, early detection, and diagnosis which are crucial for the successful management of subdural haematoma that may complicate eclampsia.

Highlights

• •Subdural haematoma is usually a post-traumatic sequel but a few spontaneous cases complicating eclampsia have been reported.
• •Subdural haematoma can be managed non-operatively if there is improving neurological status and the cranial computed tomography scan finding shows no significant mass effect being exerted by the haematoma.
• •Consider the possibility of subdural haematoma when patients with eclampsia present with persistent loss of consciousness and convulsions.

1. Introduction

Intracranial hemorrhage is a rare but potentially fatal complication during pregnancy, which can contribute significantly to maternal mortality [1,2]. The main causes of intracranial haemorrhage are trauma, ruptured aneurysm, arteriovenous malformations (MAV) and hypertensive disorders of pregnancy [1]. In pregnancy, subdural haematoma is mainly reported as post-traumatic or as a complication of epidural anesthesia during labor [1].

Acute subdural haematoma (ASDH) is the presence of an acute blood clot between the brain and parenchyma and the overlying dura [3]. As a result of the dura sometimes being adherent to the overlying skull bone, the hematoma can be extensive in its spread over the brain substance [2,3]. While most cases of acute subdural haematoma are traumatic in origin with grave prognosis, spontaneous bleeds have been described occurring in cases of coagulopathy, microangiopathy, aneurysmal heamorrhage, arteriovenous malformation, cerebral amyloid angiopathy, acquired immunodeficiency syndrome, and neoplasms [2,3]. Spontaneous subdural haematoma has also been seen in epidural anaesthesia during labour [1,2,4].

Eclampsia which is the occurrence of seizures in pregnancy or within 10 days of delivery in a patient with preeclampsia is a significant cause of maternal mortality [5].

Spontaneous subdural haematoma from eclampsia has been reported as chronic subdural haematoma complicating eclampsia [6], postpartum eclampsia [2], and pregnancy-induced idiopathic thrombocytopenia [3]. A few cases of subdural haematoma complicating preeclampsia have also been reported [4].

Brain subdural hematomas on computed tomography scan appears as hyperdense hemorrhage within the subdural space, which is located between the dura and pia mater [7].

We report a rare case of acute subdural haematoma in a woman with intrapartum eclampsia which was successfully managed in our facility. This case has been reported in line with the SCARE criteria [8].

2. Case presentation

A 19-year-old in her first pregnancy with both speech and hearing impairments was referred from a maternity home as a case of eclampsia in labour. She was 38 weeks pregnant.

She had presented with the complaint of headache of three days duration, labour pains of 12hours duration, and two episodes of generalized clonic-tonic convulsions. There was no history of a fall or head trauma. She had no history of past bleeding disorders. She was single, lived with her grandmother as an orphan, and had no formal education. Her consort was a 17-year-old secondary school student.

The pregnancy was spontaneously achieved and was not desired but accepted. She had booked and received antenatal care at a primary health care centre in her rural community. Her pregnancy was uneventful until about three days before presentation when she developed the above complaint.

She had presented at the maternity home with complaint of labour pain. She made good progress in labour until when she experienced an episode of convulsion intrapartum, prompting her referral to our hospital for expert care. She was not a known hypertensive, diabetic or renal disease patient.

At presentation, she was restless and confused, her Glasgow coma score at presentation was 7 (Eyes Opening was 2, Verbal response was 2, Motor response was 3), both speech and hearing impaired. The right pupil was sluggish to light reflex while the left pupil was unreactive to light. Her pulse rate was 98 beats per minute, her blood pressure was 170/80mmHg, and her urinalysis showed moderate proteinuria. Her respiratory rate was 24 cycles per minute, and oxygen saturation in room air was 92%. She had three strong uterine contractions every ten minutes. The fetal heart rate was 178 beats per minute, her cervix was fully dilated and the presenting part was at one centimeter below the mid-cavity. A diagnosis of intrapartum eclampsia with fetal distress in second-stage labour was made.

She was commenced on oxygen via nasal prongs. Magnesium Sulphate (MgSO4) was commenced using by Zuspan regimen [9,10] and she received intravenous Labetalol 25mg stat (single dose) intravenously. A paediatrician was invited for neonatal resuscitation. She made good labour progress and had forceps delivery with the outcome of a live normal birth weight female neonate with good APGAR scores of 7 and 8 in the first and fifth minutes. The neonate was certified stable by Paediatrician and did not require intensive care. Following delivery, she was continued on MgSO4 maintenance. Despite blood pressure control which ranged between 110 and 130mmHg systolic and 70 to 90mmHg diastolic and MgSO4 maintenance, she had two more episodes of seizures which were aborted with 10mg intravenous diazepam. The medical team reviewed her and commenced her on intravenous phenytoin 100mg in 100ml of normal saline 8 hourly and requested for a brain computed tomography (CT) scan.

The brain CT (Fig. 1) scan showed “a very thin film of the left parieto-occipital concavo-convex lesion at the subdural space, no mass effect. The basal cistern was open and the foramen magnum was normal. There was no calvarial fracture or soft tissue swelling. This was in keeping with left parieto-occipital acute subdural haematoma.”

Fig. 1.

Cranial computed tomography (CT) scan showing subdural haematoma in the left parieto-occipital region.

She was reviewed by the neurosurgeon who decided on non-operative management. She was nursed in a 30-degree head-up with supportive medications. She was on parenteral anticonvulsant for 4 days, following which her drug was converted to oral Levetiracetam (anticonvulsant). A professional sign language translator for the speech and hearing impaired was recruited into the team to help translate and communicate with the patient. Her last seizure was on the 3rd day on admission for which MgSO4 was stopped 24 hours after her last seizure. She improved remarkably and was discharged after eight days after admission.

She was seen in both postnatal and neurosurgery clinics for follow-up every fortnight till six weeks. Her repeat brain CT (MRI preferred but was not available due to low resource setting) scan was normal 7days postpartum. At 6 weeks postpartum, she was discharged healthy with her baby from the postnatal clinic.

3. Discussion

Intracranial bleeding disorders following hypertensive disorders of pregnancies are rare and have high mortality [11]. It more commonly occurs secondary to rupture of an aneurysm and/or arteriovenous malformations which results in subdural haematoma [11]. Spontaneous acute subdural haematoma reported in this case due to eclampsia has been rarely reported in the literature.

Preeclampsia is a recognized complication of pregnancy and this can progress to HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome [4,12]. This syndrome is a recognized complication of pregnancy and this can predispose the patient to developing a subdural haematoma [4,12]. An acute event could have occurred with rupture of cortical vessels or (less commonly for this age group) bridging of the veins and could be a result of high blood vessels with fragile and susceptible vessels. While the hallmark of eclampsia is the onset of seizures in a patient with preeclampsia, the presence of blood on the cortex can cause brain irritation with subsequent seizure activities.

Patients with eclampsia usually present with convulsion which differentiates it from preeclampsia [10]. In this patient, her blood pressure was elevated with significant proteinuria and convulsion, making eclampsia a consideration. Eclampsia may be complicated by elevated liver enzymes, low platelets (HELLP) syndrome, and severe coagulopathy which can be lethal [10,13]. However, there was no evidence of HELLP syndrome or coagulopathy in this patient.

The pathogenesis of eclampsia involves vasospasm which leads to ischaemia, alteration of the blood–brain barrier and cerebral oedema [10]. While for subdural haematoma, the cause can be due to trauma, ruptured aneurysm, arteriovenous malformations (MAV) and hypertensive disorders of pregnancy leading to accumulation of blood between the dura and pia matter [1,7].

Thrombocytopaenia has been reported to be a possible contributory factor for developing subdural haematoma following eclampsia [2]. This was not so in our case, as the platelet count and coagulation profile were within normal limits.

The symptoms of eclampsia are coma, convulsions, transient mental changes, irritability, photophobia epigastric pain, severe headache, vomiting and blurred vision [10]. These features are also found in patients with subdural haematoma [2].

This patient was speech and hearing impaired, so her speech and cognitive recovery were difficult to assess. Since she was pregnant with elevated blood pressure and significant proteinuria, these symptoms were initially attributed to the eclampsia alone until a computed tomography scan was done due to the persistence of these neurological signs and symptoms.

Some factors that are associated with poor outcomes include increased age, time from injury to treatment, GCS on admission, lucid interval or immediate coma, CT findings (compression of basal cisterns, associated intradural lesion, degree of midline shift and hematoma volume) [13]. Our patient was young and though her GCS was 7 on presentation, it improved rapidly after the seizures were brought under control with parenteral antiepileptic agents (phenytoin).

The decision to manage this patient non-operatively was largely based on her improved neurological status and brain CT scan (Fig. 1) finding which showed no significant mass effect being exerted by the haematoma.

The effective management of this patient through prompt treatment and a multidisciplinary approach employed led to a good outcome as the obstetricians, neurosurgeons, physicians, radiologist, paediatricians and a translator for the speech and hearing impaired played significant roles in the good maternofetal outcome recorded.

This finding of eclampsia with spontaneous acute subdural haematoma brings to light the need for clinician to broaden their horizon during patient evaluation to detect such comorbidity and render precise intervention to prevent an adverse outcome.

4. Conclusion

In cases of subdural haematoma following eclampsia, early detection and treatment with a multidisciplinary approach may lead to good maternal and fetal outcomes. We recommend that obstetricians, midwives, and skilled birth attendants should also consider the possibility of subdural haematoma when patients with eclampsia present with persistent loss of consciousness and convulsions.

Consent

Patient gave a written consent which will be made available on request by the journal editor.

Ethical approval

Ethical approval is not required by our institution for this case report.

Funding

Payment of this publication was made by the Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin City, Nigeria.

Guarantor

The corresponding author.

CRediT authorship contribution statement

• Conceptualization: The corresponding author

• Writing: All authors

All authors read and approved the final version of this manuscript.

Declaration of competing interest

The authors do not have any conflict of interest to declare.