Question

A 38-year-old delivers twins by uncomplicated cesarean section at 37 weeks. The pregnancy, her first, was unremarkable. On day 3 following her delivery, she experiences an acute onset of what she describes as the worst headache of her life. The neurologist is called and discovers that she has a notable bitemporal hemianopsia, neck stiffness, a positive Kernig's sign, persistent hypotension, and a right third nerve palsy. The most likely diagnosis is:

A. Sheehan's syndrome
B. Cushing's disease
C. Subarachnoid hemorrhage
D. Acute bacterial meningitis
E. Familial hemiplegic migraine

Answer 1

The most likely diagnosis for the presented case is subarachnoid hemorrhage (C), evidenced by the sudden onset of a severe headache, neurological deficits, and the occurrence postpartum. The symptoms do not closely match those of Sheehan's syndrome, Cushing's disease, familial hemiplegic migraine, or acute bacterial meningitis.

Step-by-step explanation:

The most likely diagnosis for a 38-year-old woman who delivers twins by cesarean section and experiences an acute onset of a severe headache, bitemporal hemianopsia, neck stiffness, a positive Kernig's sign, persistent hypotension, and a right third nerve palsy on day 3 following delivery is subarachnoid hemorrhage (C). This condition is an emergency associated with a sudden and severe headache, often described as 'the worst headache of one's life,' and can cause neurological deficits such as cranial nerve palsies. The sudden onset of these symptoms, particularly following delivery, increases the suspicion for a vascular event like a subarachnoid hemorrhage rather than the other conditions listed.

Meningitis, another consideration, is an infection of the membranes covering the brain and spinal cord presenting with symptoms like fever, headache, and a stiff neck. However, the severe headache and other neurological signs such as the cranial nerve palsy seen in this case align more closely with subarachnoid hemorrhage.

While Sheehan's syndrome can occur after childbirth due to severe blood loss causing hypopituitarism, the acute neurological symptoms described are not typical of this condition. Cushing's disease, caused by excessive cortisol production, would not present acutely after delivery. Familial hemiplegic migraine could cause headache and neurological symptoms but would not typically present for the first time postpartum with such severity, and there is no mention of migraine history. Finally, Acute bacterial meningitis could cause neck stiffness and headache, but the other neurological signs and the timing post-delivery point towards a vascular cause.