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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 midcalf ▪ 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? 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 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 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) mild severe SBP <=150mmHg >=160mmHg DBP <=100mmHg >=100mmHg proteinuria >300mg in 24 hours >5000mg in 24 hour headache absent present Visual disturbance absent present Upper abdominal pain absent present oliguria absent Present <500ml/24hr seizures absent Present in eclampsia Serum Creatinine level Abnormal, >=1.0mg/dl Normal to mildly ↑ <=1.0mg/dl Normal to mildly ↑<=70U/L elevated >=70U/L AST Severity of preeclampsia (2) mild severe bilirubin Normal to mildly ↑, <=1.2mg/dl >=1.2mg/dl urate Normal to mildly ↑, <=6mg/dl >=6mg/dl LDH Normal to mildly ↑, <600U/dl >600U/dl Platelet count Normal to mildly ↓, >100,000cells/mm3 <100,000cells/mm3 Pulmonary edema absent present Fetal growth restriction absent present oligohydraminos absent present Diagnosis Patient is suffering from severe preeclampsia 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 preeclampsia or HELLP syndrome CBP and PBS Platelet count Liver function test, AST, ALT RFT Coagulation profile schistocytes <100,000 but suspicious if <150,000 Elevated but below levels usually seen in viral hepatitis (<500IU/L) Normal or elevated urea and creatinine level abnormal 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 1. 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 Serum magnesium levels (mg/dl) 1.5-2.5 4-8 9-12 15-17 30-35 Clinical findings Normal level Therapeutic range for seizure prophylaxis Loss of patellar reflex Muscular paralysis, respiratory arrest Cardiac arrest 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 continue for 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