Obstructive hydrocephalus masquerading as impending eclampsia in a 37-week pregnant woman: a case report

In preeclampsia, the neurologic symptoms, especially a lingering headache, can sometimes mimic more severe intracranial conditions, pushing doctors to quickly consider early delivery. Obstructive hydrocephalus during pregnancy is an uncommon but tricky diagnosis, one that could easily be missed when hypertension and proteinuria are already present, potentially delaying the identification of a neurosurgical emergency.

A 25-year-old first-time mother, 37 weeks and 1 day pregnant, presented with a month-long history of progressively worsening bilateral lower extremity edema and a two-day episode of intense occipital and bitemporal headache. Her blood pressure was elevated at 161/120 mmHg, accompanied by proteinuria (2+), hypoalbuminemia, hyperuricemia, and signs of potential fetal growth restriction, all meeting the criteria for severe preeclampsia. Despite treatment with antihypertensive medications and supportive care, the headache did not subside, prompting an emergency cesarean section. A healthy female infant was delivered, weighing 1960 g, with Apgar scores of 9 at 1 min and 10 at 5 min. Post-surgery, the ongoing neurological concerns led to imaging studies. A CT scan and MRI of the brain revealed significant ventriculomegaly in the supratentorial region, with marked dilation of the lateral and third ventricles, while the fourth ventricle remained unaffected-indicative of obstructive hydrocephalus. Her neurological exam was mostly unremarkable, except for a right-sided Babinski sign. A lumbar puncture showed clear cerebrospinal fluid with an opening pressure of 105 mmH₂O. Neurosurgeons advised close monitoring, and a brief course of mannitol completely alleviated the headache by the fourth postoperative day. She was discharged on day six in good condition.

This case represents a rare instance where obstructive hydrocephalus was diagnosed at term, coexisting with severe preeclampsia, and initially mistaken for impending eclampsia without the usual signs of increased intracranial pressure. Any persistent or unusual headache, particularly when accompanied by focal neurological symptoms, should prompt immediate neuroimaging in pregnant women with hypertension to rule out secondary intracranial causes.