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

HKCEM College Tutorial

A Confused Woman

AUTHOR

DR WONG WAI-YIP

AUGUST 2013


History

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


A confused woman

What further history or information do you want to know?


History1

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

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

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

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

What bedside investigations are relevant to this case ?

  • H’stix

  • Urine multistix

  • Doptone/Transabdominal ultrasound


A confused woman

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

What is(are) your differential diagnoses?


Pre eclampsia

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

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 (1)


Severity of preeclampsia 2

Severity of preeclampsia (2)


Diagnosis

Diagnosis

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

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


Hellp syndrome

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

Laboratory evaluations for suspected pre-eclampsia or HELLP syndrome


Progress

Progress

The lady developed

generalized tonic-clonic convulsion in the resuscitation room


What are the differential diagnosis

What are the Differential diagnosis ?

  • Eclampsia

  • Drug overdose

  • Electrolyte disturbance

  • Epilepsy

  • Cerebral tumors

  • Stroke


Eclampsia

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

    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

    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

    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

    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

    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

    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

    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

    Clinical findings associated with increasing maternal serum levels of magnesium


    What is the target blood pressure

    What is the Target Blood Pressure?

    Goal:

    • SBP 140-150mmHg,

    • DBP 90-100mmHg

      What antihypertensive(s) would you choose?

    • Hydralazine

    • Labetolol


    Hydralazine

    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

    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

    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

    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

    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

    Thank You


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