Cerebral Venous Thrombosis in Pregnancy-A Poignant Allegory of an Unusual Case

Abstract

A 22-old-year P1L1 postpartum day seven was brought to gynaecology emergency with complaints of multiple episodes of seizures since, one day. She also had a continuously aggravating postural headache, predominantly located in the neck and both eyes. However, there was no history of fever. She had a full term vaginal delivery by a midwife (dai) at home seven days back, without any complications. There was no history of high blood pressure during pregnancy.On examination at admission, she was conscious but drowsy with a Glasgow Coma Scale of E4V2M6. She was normotensive, afebrile, respiratory rate of 18/min, pulse rate 100/minute good volume. There was no albuminuria. Chest and cardiovascular system were essentially normal. On abdominal examination, uterus was wellinvoluted; local examination showed healthy lochia.She was admitted in high dependency unit of the department and put on continuous maternal surveillance. She was administered loading dose of intravenous phenytoin followed by maintenance dose. All relevant blood investigations were sent. Intensive care and neurological referrals were taken and further examination showed no neurological deficit. Ultrasound whole abdomen revealed normal postpartum uterus with no pelvic collection. Her blood pressure remained normal throughout. Laboratory examination showed a normal complete blood count with haemoglobin 9.8mg/dl and normal renal, hepatic, and coagulation profiles. High vaginal swab showed infection with Escherichia coli and her antibiotics were changed as per sensitivity report. But she again convulsed, and hence, was put on injectable lorazepam 0.4mg as and when required. Fundal examination showed normal disc and non-contrast computed tomography scan of head showed white matter oedema in left frontal lobe [ Cerebral Venous Thrombosis (CVT), also known as cortical venous, cerebral sinus, cerebral venous sinus, or dural sinus thrombosis, is an infrequent grave condition affecting pregnant females, resulting from clot formation in one of the many outflow tracts of the brain. Although pregnancy-associated stroke or CVT is uncommon, the risk of stroke is greatly increased above the low baseline rate in young patients during late pregnancy and, even more so, during the puerperium. Haemorrhagic infarction can occur in the acute stage of CVT. The article reports a case of CVT in puerperium in woman without any risk factors for thrombosis, highlighting the difficulties encountered in differentiating this rare cause from common diagnoses such as eclampsia. Also, clinical considerations and relevant literature review on prognostic factors affecting outcome have been addressed. CVT is an uncommon serious neurologic disorder in young gravidas requiring prudent assessment of the potential differential diagnoses and prompt management.times of control value. Also, Colour Doppler of bilateral lower limbs was performed that revealed right sided deep vein thrombosis at distal femoral vein and popliteal veins, with recanalization of veins and thrombosis in great saphenous vei...

Acute Onset Neurological Disorders during Pregnancy: A Literature Review

“…Indefinite anticoagulation should be reserved to patients with idiopathic cases, recurrent episodes, and to those with high-risk thrombophilia (antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities). 52 53 54 55 …”

“…75,76 As so, more studies are warranted to define the real risk of thromboembolism in subsequent pregnancies and anticoagulation therapy to prevent complications and risk of recurrence in future pregnancies; the risk of thromboembolism should be discussed with women at risk and the reasons for individual recommendations explained. 13,43,47,51,54,55 Arteriovenous malformation complications are more frequent in the first trimester, contrasting to aneurysm rupture, which occurs more commonly in the second half of pregnancy; 6,56 both can lead to SAH. It is consensual that imaging investigation is vital and, during pregnancy, MRI is preferable to CT scan because of its higher resolution, sensitivity, and lack of ionizing radiation.…”

“…75 76 As so, more studies are warranted to define the real risk of thromboembolism in subsequent pregnancies and anticoagulation therapy to prevent complications and risk of recurrence in future pregnancies; the risk of thromboembolism should be discussed with women at risk and the reasons for individual recommendations explained. 13 43 47 51 54 55 …”

Cerebral venous sinus thrombosis in pregnancy and puerperium

“…[ 35 ] Physical examination may be remarkable for papilledema, signs of meningeal irritation from subarachnoid bleeding secondary to cortical infarction, and focal deficits. [ 36 ] Cerebrospinal fluid pressure is typically raised, and its analysis may reveal increased protein or cellular content. [ 37 ]…”

A case of primary antiphospholipid antibody syndrome with intermittent cerebral venous sinus thrombosis manifested with recurrent epilepsy

“…Female patients with APS generally present with RPL however, thrombosis of cerebral venous sinuses (CVT) may occur on rare instances. The risk of APS related CVT is greatly increased during late pregnancy and, even more so, during the puerperium [6]. APS related CVT is a quite uncommon manifestation in a patient without obstetric problem.…”