Posterior reversible encephalopathy syndrome after massive transfusion in a patient with postpartum vaginal hematoma

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological syndrome characterized by headache, potentially reversible neurological deficits. PRES has been described in various clinical settings, such as severe hypertension, eclampsia, and chemotherapy. Transfusion related PRES are rare. We report a patient with postpartum vaginal hematoma who manifested PRES after massive packed red blood cell transfusion confirmed by brain MRI and clinical features. A 34-year-old woman gravida 1, para 1 admitted for surgery of postpartum vaginal hematoma, rectum repair, sphincter repair. Twelve hours ago, she was delivered. After delivery her uterine contraction was poor and vaginal bleeding was persistent. On admission, her hematocrit was at 27.2%, and her hemoglobin was at 9.0 g/dl. She received 18 packed red blood cell transfusion and 10 packed fresh frozen plasma. Her hematocrit and hemoglobin increased 41.1% and 13.9 g/dl, and platelet increased up to 78,000/ul. After 2 days of the transfusion, she had a left eye ball deviation and 5 min prolonged confusion. Her blood pressure was normal, and no other contributing factors for PRES were found. Brain MRI showed regional T2 signal change in right occipital lobe including cortex, and small signal change in left occipital lobe. In this case, some relation may have existed between late postpartum eclampsia and PRES, but the pathogenesis remains unclear. Although blood transfusion is a common procedure with rare neurological complications, great caution should be taken with anemic patients because a rapid elevation in hemoglobin may precipitate PRES.