Amniotic fluid embolism (AFE) is one of the most catastrophic obstetric emergency events. Estimated incidence is 1 in 40,000-80,000 deliveries [1,2]. AFE results from sudden entry of amniotic fluid or fetal material into the maternal circulation, triggering a profound inflammatory immunological response. This cascade can lead to abrupt cardiovascular collapse, respiratory distress, and disseminated intravascular coagulation (DIC), contributing to high maternal morbidity and mortality [3]. Obstetric embolic events remain an important cause of maternal mortality despite overall improvements in maternal outcomes in Korea [4]. Although stroke is not a primary manifestation of AFE, it can occur as a devastating secondary complication, particularly in the presence of DIC [1,5]. In such cases, stroke may result from multifactorial mechanisms, including paradoxical coagulopathy, which predisposes patients to both ischemic and hemorrhagic events, and hypoxic-ischemic brain injury caused by severe hemodynamic instability and cardiac arrest [6-9]. Owing to the extreme rarity of postpartum stroke associated with AFE and DIC, literature describing its clinical progression, long-term prognosis, and optimal management strategies is scarce. Most existing reports have focused on acute clinical presentations, diagnostic challenges, and immediate maternal outcomes, with little attention paid to subsequent neurological sequelae or rehabilitation measures, despite structured multidisciplinary rehabilitation offering the potential to significantly influence recovery trajectories even in cases of severe neurological injuries. Case reports that document survival and long-term functional recovery are thus essential to inform clinical practice and guide comprehensive care. This report presents the detailed clinical course and 2-year rehabilitation outcomes of a postpartum woman who developed ischemic stroke secondary to DIC triggered by AFE, highlighting the critical role of early and intensive rehabilitation in improving neurological and functional outcomes.

This case report was approved by the Institutional Review Board (IRB) of Jeju National University Hospital (IRB No: 2025-08-010). As the report contained no identifiable personal information, the IRB granted an exemption from the requirement for written informed consent.

A 38-year-old woman, gravida three and para two, with no known comorbidities, was admitted to the Obstetrics and Gynecology Department for a third elective cesarean section. Seven hours after surgery, she was found to be undergoing a seizure-like motion, and her blood pressure decreased to 66/38 mmHg. Her heart rate was 127 beats/minutes, respiratory rate was 20 breaths/minutes, and oxygen saturation level was 73%. Laboratory tests revealed the following: hemoglobin level was 5.1 g/dL, platelet count was 119,000/uL, prothrombin time was 19.4 sec, and activated partial thromboplastin time was 62 sec. Fibrinogen was 120 mg/dL, fibrinogen degradation products 131.4 ug/dL and D-dimer was >35.2 mg/L. These findings strongly indicated the presence of DIC, which likely developed as a secondary complication of AFE.

After resuscitation, her vital signs stabilized, but she remained comatose. Magnetic resonance imaging of the brain confirmed an acute infarction (Fig 1). Magnetic resonance angiography findings were normal.

She was transferred to the Department of Rehabilitation Medicine 30 days after stroke onset and participated in an intensive and comprehensive rehabilitation program for 3 months. Therapy was provided 5 days per week, typically consisting of approximately 2 hours of neurodevelopmental therapy and occupational rehabilitation with 1 hour of cognitive and speech therapy per session. The patient underwent ten repetitive transcranial magnetic stimulation sessions during rehabilitation.

At the time of transfer, the patient’s Glasgow coma scale score [10] was 8/15. Her motor power was grade 0 on the right side and between grade 0 and poor-minus grade on the left. Her Korean Mini-Mental State Examination, 2nd edition score was 0/30, and her Korean version Modified Barthel Index (K-MBI) [11] score was 0/100. Her Berg Balance Scale (BBS) score [12] was 0/56, indicating that she was unable to maintain a sitting posture. On her screening test for aphasia and neurologic-communication disorders [13], she scored 0/30, but precise evaluation was not possible due to severe cognitive impairment.

After 1 month of rehabilitation therapy, the patient showed improved consciousness, allowing for detailed language and cognitive evaluations. In the Korean version of the Western Aphasia Battery (K-WAB) [13,14], her Aphasia Quotient (AQ) was 17.1. Her Language Quotient (LQ) was 13.3, and her Cortical Quotient (CQ) was 13.23. Receptive language was scored at 39.5% and expressive language at 8.67%, consistent with features of Broca’s aphasia. In a Computerized Neurocognitive Function Test [15], severe impairments were noted across all domains, including attention, visual memory, auditory memory, visuospatial short-term memory, auditory- verbal learning, visual and motor exploration, categorization, and abstract thinking. Rehabilitation therapy improved speech production, comprehension, and cognitive function.

Three months after transfer, her bilateral lower extremity strength improved to grades 3-4, and her BBS score increased to 19/56, reflecting enhanced balance. The patient ambulated with minimal assistance. Her bilateral upper extremity strength also improved to grade 3, but in her right upper limb, delayed-onset post-stroke hand tremors and dystonia developed. Owing to impaired fine motor control of her dominant hand, she still required assistance in activities of daily living (ADLs). Nevertheless, her K-MBI score improved to 37. She also exhibited behavioral dysregulation, including decreased attention span, aggression, and depressive mood. Pharmacological treatment was initiated alongside cognitive and language rehabilitation therapies.

Two years after onset, her K-WAB showed further improvement, with an AQ of 26.6, an LQ of 29.1, and a CQ of 33.23. Receptive and expressive language improved to 56% and 12.67%, respectively. Other functional assessments demonstrated progress. Upper extremity muscle strength improved to grades 3-4, with handgrip power measured at 16.3 kg on the right and 18.1 kg on the left. Her tremor symptoms noticeably ameliorated. Her K-MBI score increased to 59/100, indicating greater independence in ADLs. Her BBS score improved to 40/56 and her Functional Ambulation Category score [16] was 4, suggesting that the patient was able to ambulate under supervision.

This case is notable in that it describes long-term rehabilitation outcomes spanning a 2-year period in a patient who experienced postpartum stroke secondary to DIC triggered by AFE, an exceptionally rare and underreported clinical scenario. Previous reports on AFE-associated DIC have primarily focused on acute-phase management and survival. To our knowledge, very little literature details long-term neurological and functional outcomes following comprehensive rehabilitation in such patients. Rehabilitation programs, including neurodevelopmental therapy, cognitive-linguistic rehabilitation, and repetitive transcranial magnetic stimulation, likely play key roles in facilitating neuroplasticity and restoring functional independence.

Despite these encouraging results, this report is limited by its nature as a single case study. Further research is required to determine whether similar benefits can be generalized to broader populations. Our findings emphasize the importance of integrating early and structured rehabilitation into the standard care pathway for postpartum stroke, particularly in cases with complex etiologies such as AFE and DIC. Multicenter observational studies are essential to validate these observations.

Although postpartum stroke is rare, it can be life-threatening if not promptly recognized and treated. In this case, early diagnosis and appropriate acute-phase medical management were achieved. The patient underwent intensive and comprehensive rehabilitation therapy, which contributed substantially to her recovery of independent functional abilities. This case underscores the critical role of timely and structured rehabilitation in optimizing outcomes for patients with postpartum stroke.