A difficult case of postpartum collapse

A 29-year-old woman was brought to hospital on 24 December, having gone into labour with her third child at 34 weeks gestation. Her first two pregnancies had been uneventful and she had enjoyed an uncomplicated third pregnancy, continuing to work a farm with her husband. Past medical history included an uncorrected Ebstein’s anomaly (a congenital heart defect where the opening of the tricuspid valve is displaced towards the apex of the right ventricle due to abnormal valve leaflet formation) and spinal stabilisation for childhood scoliosis.

At 6.21am, she delivered a healthy baby girl by normal vaginal delivery. At 8.00am, she walked to the shower. While there, she developed a “thumping headache” and “twitching” of her left hand. She had no further recollection of events, but was found collapsed in the shower at 8.40am. When the resuscitation team arrived, her Glasgow Coma Score (GCS) was 9 (E₂V₂M₅). She was breathing spontaneously, haemodynamically stable, but too drowsy to maintain her own airway. She was localising to pain with her right arm, but appeared not to be moving her left side. Plantar response was extensor on the left. Pupils were equal and reactive. She had a CT brain scan at 9.53am.

COMMENT

This woman has most likely had a stroke. There is probably an increased risk of stroke during pregnancy and for approximately six weeks after delivery; the risk in developed countries varies between 11 and 26 per 100 000 deliveries.1 Studies have repeatedly identified the immediate postpartum period as the greatest period of risk. Most of these are ischaemic strokes, in part perhaps because pregnancy and the puerperium are pro-thrombotic states.

Some ischaemic strokes in pregnancy can be attributed to specific causes such as pre-eclampsia or eclampsia, arterial dissection, antiphospholipid syndrome, postpartum angiopathy, …