How to manage a post Lower Segment Caesarean Section (LSCS) patient with frontotemporal bleed and basal ganglia bleed in the setting of preeclampsia?

Management of Post-LSCS Frontotemporal and Basal Ganglia Hemorrhage in Preeclampsia

This patient requires immediate intensive care unit admission with aggressive blood pressure control targeting systolic BP <140-160 mmHg and diastolic BP <90-105 mmHg, continuation of magnesium sulfate for seizure prophylaxis and neuroprotection, multidisciplinary neurosurgical consultation, and strict fluid restriction to prevent worsening cerebral edema. 1, 2

Immediate Stabilization (First 24 Hours)

Blood Pressure Management

• Target BP <160/105 mmHg urgently to prevent hemorrhage expansion while avoiding hypotension that could worsen cerebral perfusion 1
• Use IV labetalol or nicardipine as first-line agents for severe hypertension (≥160/110 mmHg) in the postpartum setting 1
• Avoid hydralazine in the immediate post-hemorrhage period due to unpredictable BP drops and reflex tachycardia that may worsen intracranial pressure 1
• Monitor BP continuously or every 15 minutes until stable 2

Neuroprotection and Seizure Prophylaxis

• Continue magnesium sulfate infusion for at least 24-48 hours postpartum for both seizure prevention and potential neuroprotective effects 1, 2
• Magnesium provides dual benefit: prevents eclamptic seizures and may reduce secondary brain injury 2

Critical Monitoring

• Transfer to ICU or high-dependency unit immediately 1, 2
• Continuous monitoring: BP, oxygen saturation, ECG, neurological status (Glasgow Coma Scale hourly) 1, 2
• Insert urinary catheter for strict hourly urine output monitoring (target >30 mL/hour) 1
• Consider central venous catheter for fluid management in critically ill patients 1, 2

Neurological Assessment and Imaging

Immediate Neurosurgical Consultation

• Obtain urgent neurosurgical evaluation for hemorrhage size, location, and need for surgical intervention 3
• Frontotemporal and basal ganglia bleeds may require surgical evacuation if causing mass effect or neurological deterioration 3

Imaging Protocol

• Repeat CT head within 6-12 hours to assess for hemorrhage expansion 4
• Consider MRI brain to evaluate for posterior reversible encephalopathy syndrome (PRES), which commonly accompanies preeclamptic hemorrhages and may be reversible with BP control 4
• Serial imaging if neurological status deteriorates 4

Hematologic Management

Coagulation Correction

• Check platelet count, PT/PTT, fibrinogen immediately 1, 5
• **Transfuse platelets if count <50,000/mm³** to reduce bleeding risk, targeting >80,000/mm³ in setting of intracranial hemorrhage 1, 5, 2
• Administer fresh frozen plasma if coagulopathy present (INR >1.5) 1, 5
• Monitor complete blood count and coagulation profile every 6-12 hours initially 2

HELLP Syndrome Surveillance

• Check liver enzymes, LDH, peripheral smear for hemolysis 5, 2
• The degree of thrombocytopenia correlates with liver dysfunction severity 5
• Monitor for hepatic complications (right upper quadrant pain, epigastric pain) which increase mortality risk 5, 2

Fluid Management Strategy

Strict Fluid Restriction

• Limit fluids to avoid cerebral edema worsening - this is critical and often overlooked 2
• Avoid aggressive fluid resuscitation that would be reflexively given in other critically ill patients 2
• Target euvolemia, not hypervolemia: typically 80-100 mL/hour maintenance 2
• Monitor for pulmonary edema (chest X-ray, oxygen saturation) 1, 5

Laboratory Monitoring Protocol

Serial Testing Schedule

• Every 6-12 hours for first 48 hours: CBC with platelets, liver enzymes (AST, ALT), creatinine, LDH 2
• Twice weekly thereafter until normalized 1
• Monitor for worsening thrombocytopenia (<20×10⁹/L) which correlates with higher hemorrhage risk 2
• Check blood glucose regularly as hypoglycemia can occur in HELLP syndrome 1, 2

Specific Complications to Monitor

Neurological Deterioration

• Declining Glasgow Coma Scale score requires immediate repeat imaging and neurosurgical re-evaluation 3
• New focal deficits, worsening headache, or seizures mandate urgent CT head 4
• PRES can worsen before improving; MRI findings may lag clinical improvement by several days 4

Hepatic Complications

• Perform abdominal ultrasound if right upper quadrant pain, epigastric pain, or shoulder pain develops (suggests hepatic hematoma/rupture) 2
• Early transplant center referral if signs of hepatic failure emerge 2

Renal Function

• Monitor urine output hourly; oliguria (<400 mL/24h) indicates severe disease 1, 5
• Rising creatinine requires nephrology consultation 1

Common Pitfalls to Avoid

• Do NOT give corticosteroids - they do not improve maternal outcomes in HELLP syndrome despite historical use 2
• Do NOT aggressively fluid resuscitate - this significantly increases pulmonary edema and cerebral edema risk 2
• Do NOT lower BP too rapidly - maintain cerebral perfusion pressure; avoid drops >25% in first hour 1
• Do NOT delay neurosurgical consultation - basal ganglia hemorrhages can expand rapidly 3
• Do NOT stop magnesium sulfate prematurely - continue for minimum 24 hours postpartum, longer if ongoing risk 1, 2

Antihypertensive Regimen Post-Stabilization

Transition to Oral Agents

• Once BP stable, transition to oral labetalol, nifedipine long-acting, or methyldopa 1
• These agents are safe for breastfeeding 6
• Target diastolic BP 85 mmHg, systolic <140-160 mmHg 1
• Reduce or cease antihypertensives if diastolic BP <80 mmHg 1

Long-Term Considerations

Follow-Up Planning

• Counsel regarding increased recurrence risk in future pregnancies (up to 25%) 2
• Consider aspirin prophylaxis before 16 weeks gestation in future pregnancies 2
• Long-term cardiovascular follow-up required - preeclampsia increases lifetime cardiovascular disease risk 7, 6
• Repeat neuroimaging at 3-6 months to document hemorrhage resolution 4

Prognosis Discussion

• PRES-related changes are typically reversible with BP control, though recovery may take weeks 4
• Maternal mortality in severe preeclampsia with intracranial hemorrhage approaches 3-5% even with optimal care 1, 5
• Neurological outcomes depend on hemorrhage size, location, and rapidity of BP control 3