Headache and seizure on postpartum day 5: late postpartum eclampsia.

The case: A previously healthy 37-year-old woman (gravida 3, para 1 with 2 first-trimester miscarriages) had an unremarkable pregnancy until the 35th week. Her blood pressure readings during pregnancy were between 100/70 mm Hg and 110/80 mm Hg. She had no previous seizure disorders or hypertension. At week 28, gestational diabetes was diagnosed by means of an oral glucose tolerance test and subsequently controlled by diet. At 35 weeks, mild pitting edema developed in both of the patient’s feet, but she had no other symptoms of eclampsia (Box 1). Her blood pressure was 149/89 mm Hg, and her patellar deep tendon reflexes were normal. A urine dipstick test revealed a protein level of about 0.3 g/L. The patient’s complete blood count and international normalized ratio were normal, as were her levels of bilirubin and liver transaminases. A nonstress test found normal reactivity. The patient was monitored closely. Her blood pressure remained marginally high (131/83 mm Hg to 141/84 mm Hg) over the next week. The results of repeat laboratory tests and nonstress tests were normal. At 36 weeks’ gestation, the patient had premature rupture of membranes followed by preterm onset of labour. On admission to hospital, her blood pressure was 131/83 mm Hg, the edema in her feet was unchanged, and a urine dipstick test showed no proteinuria. During the 49hour labour, the patient’s blood pressure fluctuated between 120/70 mm Hg and 130/80 mm Hg. Because of failure to progress, she had labour augmentation with oxytocin, and delivery was assisted by the use of midforceps. A healthy boy (3.023 kg) was delivered. The patient was discharged 1 day after delivery with blood pressure readings between 120/80 mm Hg and 135/85 mm Hg. On postpartum day 5, the patient presented to the emergency department with a 1-day history of a gradualonset throbbing occipital headache that was associated with photophobia and 3 episodes of vomiting. Her blood pressure on presentation was 205/105 mm Hg. Her other vital signs were unremarkable. She was given prochlorperazine maleate (10 mg administered intravenously) as an antiemetic. On assessment by the emergency department physician, her blood pressure was 172/82 mm Hg, and she had moderate pitting edema in both feet. She had no meningism, and her neurologic examination showed only increased patellar deep tendon reflexes. At the end of the assessment (about 2 hours and 10 minutes after she arrived at the emergency department), she had a generalized seizure that lasted for 2 minutes. The seizure was terminated by diazepam (2 mg administered intravenously). Subsequently she was in a postictal state for 20 minutes. Five minutes after the seizure, her blood pressure was 130/70 mm Hg. Initial laboratory investigations showed mild leukocytosis (leukocyte count 14.8 × 10) and mild anemia with a Headache and seizure on postpartum day 5: late postpartum eclampsia