Reversible Neurological Manifestations Preceding Biochemical Deterioration in Postpartum HELLP Syndrome-A Case Report and Literature Review.

Posterior reversible encephalopathy syndrome (PRES) is a rare but severe neurological complication associated with hypertensive disorders of pregnancy and HELLP syndrome. We report a postpartum case in which neurological manifestations preceded the full biochemical expression of HELLP syndrome. A 22-year-old primigravida was admitted at 36 + 0 weeks for premature rupture of membranes and fetal growth restriction, presenting with mild thrombocytopenia and elevated lactate dehydrogenase but normal liver enzymes. On postpartum day 1, she developed headache, visual disturbances, hypertensive crisis, and a generalized tonic-clonic seizure. Brain magnetic resonance imaging revealed bilateral cortical-subcortical T2/FLAIR hyperintensities consistent with PRES. At that time, laboratory findings were not yet diagnostic of HELLP syndrome; however, by postpartum day 3, severe thrombocytopenia and elevated transaminases confirmed the diagnosis. The patient was treated with magnesium sulfate, antihypertensive therapy, corticosteroids, and plasmapheresis, achieving complete clinical and radiological recovery. A narrative review of the literature indicated that neurological manifestations typically occur within 48 h postpartum. This case highlights that PRES may precede the full laboratory expression of HELLP syndrome and underscores the importance of early recognition, prompt neuroimaging, and multidisciplinary management to ensure favorable maternal outcomes.