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Seize the Dura: An Osteopathic Approach to Postictal Delirium

Journal: The AAO Journal Date: 2024/06, 34(2):Pages: 11. doi: Subito , type of study: case report

Full text    (https://meridian.allenpress.com/aaoj/article/34/2/7/500955/LBORC-NUFA-Poster-Abstracts-2024-Clinician-amp)

Keywords:

case report [705]
childbirth [54]
delirium [1]
female [594]
OMT [3746]
osteopathic manipulative treatment [3766]
postpartum [18]
women [550]

Abstract:

Introduction/Background: Delirium is common in patients with underlying conditions—affecting 30% of elderly hospitalized patients—but can affect anyone at any age. Here we describe a case of severe delirium following a postpartum seizure and how osteopathic manipulation targeting the reciprocal tension membrane (RTM) contributed to its resolution. Case: A 20yo G1P1001 with mild transaminitis early in pregnancy developed pre-eclampsia with severe features before term vaginal delivery. Despite intravenous magnesium through postpartum day one (PPD1), a seizure occurred and rash developed on PPD2. Intubation resulted due to severe postictal encephalopathy. Within 24 hours, liver enzymes increased significantly, platelets remained stable, but LDH rose and hemoglobin dropped consistent with early HELLP syndrome. CT head showed a prominent, superiorly displaced pituitary; MRI brain was delayed for inability to remain still. The Osteopathic Neuromusculoskeletal Medicine (ONMM) service was consulted on PPD3 to expedite extubation. Exam revealed spheno-basilar synchondrosis compression, bilateral sacral extension/superior shearing, and decreased cranial rhythmic impulse systemwide. Results: Following initial RTM treatment sacral motion was restored, patient was weaned off sedation and successfully extubated within 18hrs. Her rash faded, liver enzymes halved and trended down for the duration of hospitalization, and MRI showed a non-displaced appropriately enlarged pituitary. Five daily osteopathic treatments addressing diaphragmatic, mediastinal, hepatic, and core link restrictions followed until patient regained baseline mental and physical function. Discussion: Magnesium was restarted until PPD5 and patient was referred for outpatient follow up on acute fatty liver of pregnancy. A multi-specialty approach including ONMM allowed the patient to continue breastfeeding within 48hrs of postpartum pre-eclamptic seizure, spend minimal time sedated and intubated, avoid extensive endocrine work-up, and discharge home on PPD9. Non-physiologic RTM dysfunctions should be considered in such cases.


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