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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