Great job! This patient had a rare cause of non-traumatic SAH, but one that was highly important to recognize early as it affected management of her pregnancy: urgent delivery was necessitated. Prompt recognition allowed for the correct early treatment of the patient as well as her baby, avoiding the development of further neurologic complications. Her preeclampsia/RCVS led to a brainstem infarct, but she was able to recover well.
Lead can be placed over the abdomen when the area of interest for the CT scan is just the head. Iodinated contrast is pregnancy category B; animal studies have not identified any deleterious effects of iodinated contrast on fetuses even though it can cross the placenta. Of course, this doesn't mean we should obtain CT scans in all pregnant patients with reckless abandon. The general principle is still that we must prioritize the care of the patient herself, which will also take care of the fetus. It remains paramount to have a thorough risk/benefit discussion with the patient before proceeding with these scans. As the patient in this case had an acute SAH with focal neurologic deficits that were at high risk of progressing, with potential etiologies that would be fatal if not intervened upon promptly, the risk/benefit profile clearly favored obtaining these studies.
The PRES/RCVS spectrum of disorders is known to occur in the peripartum period. For this patient, luckily, this occurred far enough along in her pregnancy such that delivery could be safely expedited as the fetus remained viable. However, RCVS can also occur even postpartum (usually within one week of delivery).
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