A confused woman
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HKCEM College Tutorial. A Confused Woman. AUTHOR DR WONG WAI-YIP AUGUST 2013. History. F/40 G1P0, Twin Pregnancy, Gestation: 32 weeks, FU MCHC Complained of increased headache in the morning. Her husband found that the patient had confusion in the afternoon.

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A Confused Woman

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HKCEM College Tutorial

A Confused Woman

AUTHOR

DR WONG WAI-YIP

AUGUST 2013


History

  • F/40

  • G1P0, Twin Pregnancy, Gestation: 32 weeks, FU MCHC

  • Complained of increased headache in the morning. Her husband found that the patient had confusion in the afternoon.

  • No leaking, No PV bleed. Mild epigastric pain

  • BP in triage: 150/105mmHg, Pulse 100/min

  • Temp 36.9

  • Triage: Cat II


What further history or information do you want to know?


History

  • She had headache, nausea and vomiting, and some epigastric discomfort for ~ 10 days

  • She had bilateral lower limb edema up to mid-calf

  • She had consulted GP and was given some panadol and antacids, no other medications were taken

  • Symptoms were partially improved

  • She had no recent head injury


Past history

  • Antenatal FU in MCH: unremarkable

  • Recent USG 2 weeks ago in private: twin pregnancy, mild small date for gestation for both twin

  • Patient enjoyed good past health


Physical examination

  • GCS E3V5M6

  • Rechecked BP 160/105mmHg

  • Bilateral ankle edema up to mid calf

  • There was mild tenderness over the epigastrium

  • Pupils: 3mm both sides, reactive to light

  • No scalp wound or swelling


What other physical sign(s) will you look for?

Jerks/Hyperreflexia/Clonus

http://www.youtube.com/watch?v=0mM4RZmGTb8


What bedside investigations are relevant to this case ?

  • H’stix

  • Urine multistix

  • Doptone/Transabdominal ultrasound


What other investigations will you request?

  • CBP

    • WCC 6, Hb 11.4, platelet 85,000cells/mm3

  • LFT

    • Bil normal, ALP ↑ 250, AST ↑ 60IU/L

  • RFT

    • Na 140, K3.4, urea 9.4, Cr 108

  • Urate ↑ 0.40

  • Glucose 9.8mmol/dL

  • Urine analysis

    • Albumin +++, RBC ++

  • H’stix 9.7mmol/dL

  • ECG showed normal sinus rhythm

  • USG showed single viable fetus with normal lie, no retroplacental bleeding


What is(are) your differential diagnoses?


Pre-eclampsia

  • Pre-eclampsia:

    • Hypertension and proteinuria occur after 20 week of gestation

    • Hypertension, BP >= 140/90mmHg (Korotkoff V) in 2 separate occasions

    • Proteinuria, urinary protein excretion in excess of 300 mg in 24 hours, or urine dipstick (semi-quantitive analysis) 1-2 +ve

    • Edema is not one of the diagnostic criteria but a common finding


Diagnostic criteria for hypertensive disorder in pregnancy

  • Chronic hypertension

    • Hypertension present before pregnancy or first diagnosed before 20 weeks’ gestation

  • Preeclampsia superimposed on hypertension

    • New onset or acutely worse proteinuria, a sudden increase in blood pressure, thrombocytopenia, or elevated liver enzyme after 20weeks’ gestation in a woman with preeclampsia with pre-existing hypertension


Severity of preeclampsia (1)


Severity of preeclampsia (2)


Diagnosis

  • Patient is suffering from severe pre-eclampsia with HELLP syndrome

  • She is at risk of multiple organ failure and poor outcome


HELLP syndrome

  • Multi-system disease

  • A form of severe pre-eclampsia

  • Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP)

  • Non-specific complaints,

    • Malaise, epigastric discomfort, nausea and vomiting

  • Treatment same as pre-eclampsia

  • http://www.youtube.com/watch?v=Gb0jDqWUJQ4


Laboratory evaluations for suspected pre-eclampsia or HELLP syndrome


Progress

The lady developed

generalized tonic-clonic convulsion in the resuscitation room


What are the Differential diagnosis ?

  • Eclampsia

  • Drug overdose

  • Electrolyte disturbance

  • Epilepsy

  • Cerebral tumors

  • Stroke


Eclampsia

  • Incidence

    • 1 in 2000 maternities in UK, More in developing countries

    • Major cause of maternal death, ~ 18%

    • Mortality rates are higher at early gestations, advanced maternal ages and amongst black women

      • Maternal fetal medicine, Myers, Jenny E, Baker, Philip N et al

  • Eclampsia

    • Generalised tonic-clonic convulsion during pregnancy, labor or within 7 days of delivery, not due to epilepsy or other convulsive disorder


  • What are your management ?

    • Summon help

    • ABC

    • Control the seizure

    • Control the Blood pressure

    • Urgent consult O&G for delivery

    • ICU & Neonatal ICU


    Airway, breathing and circulation

    • ABC

      • Secure the airway,

      • lie in Left lateral position

      • Maintain high flow of O2,

      • IVF resuscitation, check H’stix

      • Cardiac monitoring

      • Urinary catheterization: monitoring of urine output and protein


    How would you control the seizure?

    • Benzodiazepam

      • Diazepam 5-10 mg slow iv bolus

      • Lorazepam 2-4mg iv bolus

    • MgSO4

      • Loading 4-6gm intravenously over 15-20 minutes then continuous infusion 1-2gm/hr

      • Checked Serum blood level ideally 4.8-9.6 mg/dl

      • Titrated clinically by adjusting according to patellar reflex and urine output in previous 4 hour

      • Continued for 24 hours in postpartum period


    Magnesium Sulphate

    • Level I evidence for superiority of MgSO4 against phenytoin

  • Superior for treatment of recurrent seizure

  • Reduced the risk of maternal death

    • Compared with diazepam (RR 0.7)

    • Compared with phenytoin (RR0.5)

  • Reduced incidence of pneumonia, mechanical ventilation, ICU admission


  • Effects of Magnesium Sulphate

    • Reported beneficial effects

      • Vasodilatation in vascular bed

      • Increased renal blood flow

      • Increased prostacyclin release by endothelial cells

      • Decreased plasma renin activity

      • Decreased angiotensin converting enzyme levels

      • Attenuation of vascular response to pressor substances

      • Bronchodilation

      • Reduced platelet aggregation


    What are the Side Effects/Complications of MgSO4 ?

    On mother:

    • Flusing

    • Sweating

    • Hypotension

    • Depressed reflexes

    • Flaccid paralysis

    • Respiratory failure

      Antidote for toxicity:

      IV 10ml 10% of calcium gluconate/calcium chloride


    Detrimental Effects of MgSO4 therapy

    • Decreased uterine activity and prolonged labour

    • Decreased fetal heart rate variability

    • Excessive blood loss after delivery

    • Neonatal neuromuscular and respiratory depression

    • Low APGAR score


    Clinical findings associated with increasing maternal serum levels of magnesium


    What is the Target Blood Pressure?

    Goal:

    • SBP 140-150mmHg,

    • DBP 90-100mmHg

      What antihypertensive(s) would you choose?

    • Hydralazine

    • Labetolol


    Hydralazine

    • 5mg every 15-20 minutes

    • Onset of action 15 min; peak effect 30-60min; duration of action 4-6hr

    • Not to lower the BP too acutely or to DBP < 80mmHg

    • Direct arteriolar vasodilator that causes a secondary baroreceptor-mediated sympathetic discharge resulting in tachycardia and increased cardiac output

    • Helps to increase uterine blood flow and blunts the hypotensive response

    • It is metabolized in liver

    • Side effects:

    • Headache, tremor, nausea, vomiting, tachycardia


    Labetolol

    • A non-selective beta-blocking agent with additional anatgonist activity at vascular alpha-1 receptors

    • Would cause decrease in cardiac output to the uterus with consequent restriction of fetal growth

    • 10 mg slow iv bolus

    • Doubling every 10-20min to max 300mg total or 1-2mg/min iv infusion

    • Onset 5-10 min; peak effect 10-20min; duration 45min to 6hr

    • Side effects:

      • Bradycardia (fetal), maternal flushing, nausea


    Can ACEI be used?

    • ACEI and angiotensin receptor blockers are contraindicated as they were associated with fetal malformation (oligohydraminos, fetal artery stenosis, fetal death)


    Management of eclampsia (Summary)

    • ABC

    • Control seizure

      • MgSO4

      • Diazepam

    • Control of blood pressure

      • Hydralazine

      • Labetolol

    • Fluids

      • crystalloid 1-2ml/kg/hr with monitoring of urine output

    • Early delivery of fetus within 4 hours after maternal stabilization

    • MgSO4 is continued for 24 hr after delivery or, if postpartum, 24hr after the last convulsion, in some cases, the infusion may be continuefor longer


    Take Home Message

    • Blood pressure measurement is very important in the assessment of a pregnant woman

    • Headache may be a serious symptom in a pregnant woman


    Thank You


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