Clinical Reasoning: A 28-year-old pregnant woman with encephalopathy

A 28-year-old woman at 37 weeks’ gestation became increasingly confused and forgetful. She slept 12 hours daily, mistook her apartment for previous residences, and forgot her children’s names. Her husband helped her eat and walk. She presented to the obstetrical service fully dilated after 2 days of leaking vaginal fluid, and delivered a healthy baby girl. A few hours later, she did not remember giving birth. She was transferred to the neurology service for evaluation. She had had a febrile seizure at age 4, and several brief convulsions as a teenager. A sleep-deprived EEG had been negative. She took phenytoin for a year, then stopped prior to her first pregnancy. She had no further convulsions. This was her fifth pregnancy. She had 2 healthy children, 1 abruption at 23 weeks, and 1 elective abortion. Her maternal grandmother had died from a ruptured cerebral aneurysm. She had no complaints but could not explain why she was in the hospital. She was afebrile with normal blood pressure. She appeared well and had a normal postpartum abdominal examination. She was inattentive and abulic with sparse but fluent speech. She recalled 2 of 3 words at 5 minutes, but had no memory for recent events, including her delivery. She could not describe cocktail ingredients, despite working as a bartender, but correctly recited old addresses. Cranial nerves were normal. Both optic discs had sharp margins by bedside funduscopic examination. Strength was full. Reflexes were brisk, with 3 beats of clonus at her right ankle. Toes were equivocal on the right and downgoing on the left. Sensation and coordination were normal. Gait was narrow-based and slightly unsteady, but she did not fall. ### Questions for consideration: 1. What can cause subacute mental status changes in the peripartum state? 2. What studies would you pursue? This 28-year-old peripartum woman has subacute onset encephalopathy …