Convulsive Syncope as the Initial Presentation of Massive Postpartum Pulmonary Embolism Leading to Cardiac Arrest: A Case Report

Massive pulmonary embolism (PE) remains a leading cause of maternal mortality in the postpartum period, particularly following cesarean delivery. Atypical neurological presentations, including seizure-like activity, may represent convulsive syncope secondary to transient cerebral hypoperfusion rather than true epileptic events, potentially delaying diagnosis and management. We report the case of a 28-year-old multiparous woman (para 5, including two sets of twins) who presented three weeks post-cesarean section with sudden collapse and cardiac arrest. She initially developed abdominal pain followed by brief seizure-like episodes without post-ictal confusion, after which she transiently returned to baseline. During transport, she became unresponsive. On arrival, she was in cardiopulmonary arrest with an estimated downtime of 10 minutes. Advanced cardiac life support was initiated, and sustained return of spontaneous circulation was achieved after approximately one hour of resuscitation. Computed tomography pulmonary angiography demonstrated massive bilateral pulmonary emboli. Systemic thrombolysis with alteplase was administered during resuscitation at a dose of 100 mg over two hours. Despite aggressive critical care management, the patient developed severe hypoxic-ischemic brain injury with persistent myoclonus and ultimately progressed to brain death following a second cardiac arrest. This case highlights the diagnostic challenge of massive PE presenting with atypical neurological features. Seizure-like activity may reflect convulsive syncope due to transient cerebral hypoperfusion and should prompt early consideration of life-threatening cardiovascular etiologies. Heightened clinical suspicion during the high-risk postpartum period remains essential to improve timely diagnosis and outcomes.