“It’s not all about eclampsia”: Involuntary movements in the postpartum period

Objective: New onset movement disorders during pregnancy and the puerperium are rare, yet alarming. They present a diagnostic challenge due to a diverse differential, some of which are potentially life threatening. This case prompted multi-disciplinary team (MDT) problem-solving and highlights a paucity of easily accessible clinical guidance for diagnosis and management.

Case report: A 28-year-old primiparous woman without significant medical history presented in labour at term, following spontaneous rupture of membranes. Progressing well in labour, she was fully dilated immediately after insertion of an epidural block and achieved a vaginal delivery complicated by a postpartum haemorrhage of 1800 mls. Inadequately controlled with uterotonics alone (synctocinon, misoprostol, carboprost), she was transferred to theatre for an examination under anaesthesia. Following an epidural top-up, examination demonstrated an empty uterus with persistent bleeding arising from the lower uterine segment. A second dose of carboprost was administered with ondansetron for nausea. Haemostasis was subsequently achieved with a Bakri® balloon. Thirty minutes later, she developed uncoordinated jerking movements of her face and limbs, remaining alert throughout. The movements were classified as a “disorganised dystonia”; the remainder of the neurological examination was unremarkable.

Bedside tests revealed normotension with no proteinuria and a capillary blood glucose of 4.5mmol/L. After excluding eclampsia or seizure of unknown aetiology, concerns arose regarding local anaesthetic systemic toxicity. Given the risks of cardiotoxicity and neurotoxicity, empirical lipid emulsion treatment was administered.

Serum electrolytes, including magnesium and calcium were unremarkable and an MRI head revealed no features of oedema, haemorrhage, ischaemia, mass lesions or venous sinus thrombus. The involuntary movements resolved within an hour and MDT assessment by obstetricians, anaesthetists and physicians proposed a drug-induced reaction as the most likely diagnosis.

Discussion: Several medications, given routinely peripartum, can cause movement disorders. Myoclonus has been reported with fentanyl and “movement disorders” with Levobupivacaine, carboprost and ondansetron.

This case highlights the broad differential for involuntary movements seen in pregnancy and the puerperium, as well as the lack of relevant clinical guidance to diagnose and manage them. We propose the development of a decision tree to aid diagnosis. A drug-induced movement disorder was considered the most likely diagnosis, after exclusion and preventative treatment of more serious possibilities. Evaluating the risks, however uncommon, associated with routinely administered medicines in the peri-partum period is essential.



Conclusions: A systematic A-E approach with MDT support is key to optimally managing potentially life-threatening neuropathology in the assessment of acute and unfamiliar presentations.