Postpartum hemorrhage (PPH) is a critical obstetric emergency requiring prompt and effective management to prevent maternal morbidity and mortality. The standard first-line treatment for PPH often includes the administration of uterotonics such as syntocinon (oxytocin), tranexamic acid, and misoprostol to promote uterine contraction and hemostasis. However, in some cases, patients may develop unexpected complications even after successful stabilization of bleeding. One such rare but serious complication is the development of seizures in a patient whose blood pressure remains normal following PPH management, notably when ergometrine is not administered.

Understanding the Scenario

A patient presents with PPH and is treated appropriately with:

• Syntocinon (Oxytocin): A synthetic hormone that induces uterine contractions to reduce bleeding by promoting uterine muscle tone.
• Tranexamic Acid: An antifibrinolytic agent that helps stabilize formed clots by inhibiting plasminogen activation, effectively reducing blood loss.
• Misoprostol: A prostaglandin analogue administered sublingually or orally to enhance uterine contraction and reduce hemorrhage.

Importantly, ergometrine is not given in this scenario. Ergometrine acts on uterine smooth muscle but is typically avoided in hypertensive patients due to its vasoconstrictive properties and associated risks.

Why Does Seizure Occur with Normal Blood Pressure post-PPH?

Seizures following PPH management, despite normal blood pressure, raise important clinical considerations:

1. Hypertensive Disorders Excluded: Since blood pressure is normal, seizures are unlikely due to eclampsia or other hypertensive pathologies.
2. Possible Causes of Seizure:
   1. Hypovolemia and cerebral hypoperfusion: Persistent or rapidly corrected hypovolemia during PPH can cause transient cerebral ischemia or metabolic disturbances, lowering the seizure threshold.
   1. Electrolyte Imbalance: Significant blood loss and fluid resuscitation can cause electrolyte disturbances like hyponatremia or hypocalcemia, provoking seizures.
   1. Drug-induced Seizures: Although uncommon, uterotonics such as high-dose misoprostol have been implicated in neurotoxicity in rare cases, but evidence remains limited.
   1. Cerebral Venous Thrombosis (CVT): Pregnancy and postpartum states carry prothrombotic risks, and seizures may indicate CVT, which presents independently of blood pressure changes.
   1. Amniotic fluid embolism or other neurological events: Seizures may be part of undiagnosed complications.

The absence of ergometrine reduces the risk of hypertensive crisis-related seizures, suggesting alternate etiologies.

Clinical Implications and Approach

• Prompt Neurological Assessment: In any postpartum patient developing seizures after hemorrhage control, detailed neurological evaluation and imaging (CT or MRI brain) should be considered urgently to identify intracranial pathology.
• Monitor Electrolytes and Correct Imbalances: Laboratories including serum sodium, calcium, and glucose should be checked and corrected.
• Continue Supportive Care: Maintain airway, breathing, and circulation, and use anticonvulsants if seizures persist.
• Review Medication and Doses: Ensure that none of the administered drugs were in toxic doses and check for interactions.
• Rule out Eclampsia and Other Causes: Even if blood pressure is normal, atypical eclampsia can rarely occur; check urine protein and other markers.

Summary

A postpartum patient managed successfully for PPH with syntocinon, tranexamic acid, and misoprostol who then develops seizures despite normal blood pressure should be carefully evaluated for causes beyond hypertensive disorders. Possible etiologies include electrolyte disturbances, cerebral ischemia due to hypovolemia, drug-related seizures, or neurovascular events like cerebral venous thrombosis.

Clinicians should remain vigilant for uncommon complications and provide timely multidisciplinary care to optimize maternal outcomes.

References

• World Health Organization. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. 2012.
• Sentilhes L, et al. Postpartum hemorrhage: prevention and treatment. Expert Rev Obstet Gynecol. 2014;9(3):315-328.
• Mavrides E, et al. Prevention and management of postpartum hemorrhage. BJOG. 2016;124(5): e106-e149.
• Roberge S, et al. Tranexamic acid during the postpartum period: A systematic review. BJOG. 2016;123(13):1997-2004.
• Sibai BM. Eclampsia and HELLP syndrome. Obstet Gynecol. 2004;103(1):181-192.
• Dovas A, et al. Cerebral Venous Thrombosis in Obstetrics: Diagnosis and Management. Clin Appl Thromb Hemost. 2020;26:1076029620940260.