Two Pregnant Patients Develop Severe Brain Swelling From Hypertension

A case series published in Clinical Case Reports details the clinical trajectories of two pregnant patients who developed posterior reversible encephalopathy syndrome, a rare but severe neurological complication of hypertensive disorders of pregnancy. The study, authored by clinicians at Nanjing Maternal and Child Health Hospital, highlights the critical importance of early identification, timely radiological evaluation, and multidisciplinary management in improving maternal and neonatal outcomes. By analyzing these two distinct cases, the authors emphasize that treatment success for hypertensive disorders depends not only on the selection of appropriate antihypertensive medications but also on structured follow-up and timely dose adjustments. Without these measures, persistent uncontrolled blood pressure allows adverse outcomes to accumulate, potentially leading to eclampsia, stroke, or maternal and fetal death.

Hypertensive disorders of pregnancy affect approximately 10% of all pregnancies and include chronic hypertension, gestational hypertension, and preeclampsia. Poorly controlled blood pressure significantly increases the risks of hypertensive crisis, eclampsia, stroke, and mortality for both mother and fetus. Oral antihypertensives such as methyldopa, labetalol, and nifedipine are key to prolonging gestation and reducing these complications. However, the authors note that a critical but often overlooked issue is that treatment success depends on structured follow-up and timely dose adjustment. Without these, persistent uncontrolled blood pressure allows adverse outcomes to accumulate, highlighting the need for vigilant monitoring throughout the gestational period.

Posterior reversible encephalopathy syndrome is characterized by headache, seizures, visual disturbances, and altered mental status. Imaging typically shows vasogenic edema in the bilateral parieto-occipital regions, a pattern that is distinctive on magnetic resonance imaging. The syndrome was first described by Hinchey et al. in 1996 and is associated with acute neurological symptoms that often develop rapidly over a few hours. Symptoms typically reach their most severe form within 12 to 48 hours and usually resolve within one week, although they may persist longer in some cases. Studies have shown that autoimmune diseases, severe hypertension, organ transplantation, cytotoxic drugs, sepsis, and immunosuppressive therapy are all associated with the development of this condition.

The first case involved a 27-year-old woman who presented at 27 weeks and 5 days of gestation with acute onset of headache, seizures, and visual impairment. These symptoms lasted approximately two hours following 27 weeks and 5 days of amenorrhea. The patient had undergone in vitro fertilization, with two frozen Day-5 blastocysts transferred on September 29, 2024. Post-transfer, she received fenmetramide, dexamethasone, progesterone, and other medications for luteal support. At 12 weeks and 1 day of gestation, she was hospitalized for severe pregnancy-related vomiting and received blood pressure monitoring, intravenous fluid therapy, antiemetic treatment, potassium supplementation, and antihypertensive therapy. During this hospitalization, her blood pressure ranged from 122 to 140 systolic and 81 to 99 diastolic millimeters of mercury.

Following discharge, home blood pressure monitoring revealed values fluctuating between 130 to 140 systolic and 90 to 100 diastolic millimeters of mercury. At 18 weeks and 5 days of gestation, routine antenatal examination revealed proteinuria and suboptimal blood pressure control. Consequently, her antihypertensive regimen was adjusted to include labetalol 150 mg three times daily, while aspirin was continued at the previous dose. Subsequent self-monitored blood pressure measurements ranged from 110 to 120 systolic and 95 to 99 diastolic millimeters of mercury. Despite these pharmacological interventions, the patient reported generalized edema for nearly three days prior to the current admission. At 27 weeks and 5 days of gestation, she experienced sudden visual disturbance upon awakening, accompanied by severe headache and a single generalized seizure lasting approximately one minute, as reported by family members.

Upon arrival at the emergency department, the patient’s blood pressure was measured at 218 systolic and 128 diastolic millimeters of mercury. Immediate management included oral nifedipine, intravenous magnesium sulfate for seizure control, continuous electrocardiographic monitoring, fetal heart rate monitoring, and oxygen supplementation. Despite treatment, her blood pressure remained markedly elevated, prompting the initiation and continuation of intravenous urapidil infusion. Cranial computed tomography demonstrated symmetrical patchy low-density areas in both occipital lobes with indistinct margins and mildly blurred adjacent sulci, suggestive of posterior reversible encephalopathy syndrome. Mild thickening of the posterior nasopharyngeal wall soft tissue was also noted, indicating the severity of the neurological presentation.

Following multidisciplinary consultation, a diagnosis of eclampsia was established, and given the risk of further neurological deterioration, emergency cesarean delivery under general anesthesia was recommended. The procedure was performed uneventfully, resulting in the live birth of a male infant weighing 1050 grams. The one-minute Apgar score was 2, with one point each for heart rate and reflex irritability. Immediately after umbilical cord clamping, the neonate received warmth, airway clearance, and endotracheal intubation, and was connected to a transport ventilator before being transferred to the neonatology department. The neonate was treated with mechanical ventilation, caffeine for respiratory stimulation, intratracheal instillation of pulmonary surfactant, anti-infective therapy, vitamin K1, plasma transfusion, red blood cell transfusion, and nutritional fluid support.

After eight days of treatment, cranial ultrasonography indicated intraparenchymal hemorrhage, and the condition was critical. At the family’s request, the patient was transferred to a higher-level hospital for further diagnosis and treatment. On follow-up, a drainage procedure for hydrocephalus was performed at the higher-level hospital. At seven months of age, the infant visited the pediatric department for treatment of bronchopneumonia and post-hydrocephalus-surgery status, and was cured and discharged. Currently, the infant is under follow-up, with a generally good condition. Postoperatively, the mother exhibited blurred vision, drowsiness, sluggish pupillary light reflexes, and mild cyanosis of the lips and mucous membranes. She was transferred to the intensive care unit for close monitoring, and comprehensive laboratory evaluations revealed no significant autoimmune abnormalities.

Management included airway maintenance, oxygen therapy, magnesium sulfate, urapidil infusion, mannitol for intracranial pressure reduction, prophylactic antibiotics, albumin infusion for hypoalbuminemia, and correction of electrolyte imbalances. Over subsequent days, the patient demonstrated gradual clinical improvement. Magnetic resonance imaging and magnetic resonance angiography performed on postoperative day 4 revealed symmetrical abnormal signals in both occipital lobes consistent with posterior reversible encephalopathy syndrome. Follow-up ophthalmologic examination identified bilateral exudative retinal detachment involving the macula, further illustrating the multisystem nature of the condition. The patient was discharged on postoperative day 9 in stable condition, and at 42-day postpartum follow-up, all clinical and laboratory parameters had normalized. Repeat cranial magnetic resonance imaging at 52 days postpartum showed complete resolution of previous abnormalities.

The second case involved a 27-year-old primigravida at 37 weeks and 3 days of gestation who presented with a 24-hour history of intermittent epigastric pain, progressive dizziness, headache, and visual disturbance. During her pregnancy, the patient underwent regular and standard antenatal care at the institution, with consistently normal blood pressure recordings. She did not receive any medication throughout the gestation, and no pregnancy-associated complications were observed. On admission, blood pressure was 165 systolic and 106 diastolic millimeters of mercury, and oxygen saturation was 91%. Immediate management included oral nifedipine, intravenous magnesium sulfate, and continuous maternal-fetal monitoring. Cranial computed tomography showed no acute intracranial abnormalities, but given the progression of severe preeclampsia with neurological symptoms, emergency cesarean delivery was performed following multidisciplinary consultation.

Postoperative laboratory findings revealed severe anemia, thrombocytopenia, leukocytosis, and hypoalbuminemia, consistent with a HELLP-syndrome variant. Brain magnetic resonance imaging subsequently demonstrated parieto-occipital subcortical hyperintensities characteristic of posterior reversible encephalopathy syndrome. The patient received comprehensive supportive treatment and was discharged on postoperative day 7. At 6-week postpartum follow-up, laboratory parameters had returned to normal. The patient declined repeat neuroimaging despite medical advice, highlighting a limitation in confirming radiological resolution in this case. The authors note that divergent follow-up outcomes, such as imaging resolution in the first case versus patient refusal in the second, highlight that clinical recovery does not guarantee radiological reversibility. Postpartum magnetic resonance imaging at 6 to 12 weeks is advisable to ensure complete resolution of neurological abnormalities.

The discussion emphasizes that eclampsia is often associated with severe fetal-maternal circulatory imbalance, impaired placental perfusion, preterm birth, intrauterine growth restriction, and an increased risk of intrauterine fetal death. It is considered a major cause of preterm birth, low birth weight, and increased neonatal intensive care unit admission rates. Eclampsia represents a critical progression involving central nervous system dysfunction and may result in severe maternal and neonatal complications. The authors argue that the pathogenesis of posterior reversible encephalopathy syndrome is not determined by absolute blood pressure alone. The first case had chronic hypertension, while the second was normotensive until acute onset at 37 weeks. Both developed the syndrome, suggesting that the rate of blood pressure rise and endothelial vulnerability outweigh chronic blood pressure levels in triggering blood-brain barrier disruption.

Assisted reproductive technology is identified as a potential predisposing factor for early-onset severe preeclampsia and posterior reversible encephalopathy syndrome, warranting intensified neurologic surveillance. Pharmacologically controlled diastolic blood pressure in the first case failed to prevent eclamptic seizure, cautioning against over-reliance on home blood pressure monitoring and emphasizing symptom-based vigilance. Both cases highlight persistent severe hypertension as a key precipitating factor for the syndrome. Early recognition, prompt neuroimaging, aggressive blood pressure control, seizure prophylaxis with magnesium sulfate, and timely delivery were essential in achieving favorable outcomes. Eclampsia and severe preeclampsia represent the most critical manifestations of hypertensive disorders in pregnancy. When complicated by posterior reversible encephalopathy syndrome, vigilant neurological monitoring, timely imaging evaluation, and coordinated multidisciplinary management are imperative for improved maternal and neonatal outcomes.

Subject of Research: Clinical management and outcomes of posterior reversible encephalopathy syndrome in hypertensive disorders of pregnancy

Article Title: Pregnancy‐Induced Hypertension Complicated by Posterior Reversible Encephalopathy Syndrome: A Case Series of Two Patients

Article References: Zhao, X., Yan, M., Long, F., Mumdzjans, A., & Song, R. (2026). Pregnancy‐Induced Hypertension Complicated by Posterior Reversible Encephalopathy Syndrome: A Case Series of Two Patients. Clinical Case Reports, 14(11), Article e73800. https://doi.org/10.1002/ccr3.73800

Image Credits: AI Generated

DOI: 10.1002/ccr3.73800

Keywords: posterior reversible encephalopathy syndrome, hypertensive disorders of pregnancy, eclampsia, preeclampsia, neuroimaging, maternal health, case series, blood pressure control, Pregnancy, Induced, Hypertension, Complicated