A Confused Woman

1. HKCEM College Tutorial A Confused Woman AUTHOR DR WONG WAI-YIP AUGUST 2013

2. 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

3. What further history or information do you want to know?

4. 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

5. 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

6. 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

7. What other physical sign(s) will you look for? Jerks/Hyperreflexia/Clonus http://www.youtube.com/watch?v=0mM4RZmGTb8

8. What bedside investigations are relevant to this case ? • H’stix • Urine multistix • Doptone/Transabdominal ultrasound

9. 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

10. What is(are) your differential diagnoses?

11. 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

12. 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

13. Severity of preeclampsia (1)

14. Severity of preeclampsia (2)

15. Diagnosis • Patient is suffering from severe pre-eclampsia with HELLP syndrome • She is at risk of multiple organ failure and poor outcome

16. 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

17. Laboratory evaluations for suspected pre-eclampsia or HELLP syndrome

18. Progress The lady developed generalized tonic-clonic convulsion in the resuscitation room

19. What are the Differential diagnosis ? • Eclampsia • Drug overdose • Electrolyte disturbance • Epilepsy • Cerebral tumors • Stroke

20. 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

21. What are your management ? • Summon help • ABC • Control the seizure • Control the Blood pressure • Urgent consult O&G for delivery • ICU & Neonatal ICU

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Clinical findings associated with increasing maternal serum levels of magnesium

29. What is the Target Blood Pressure? Goal: • SBP 140-150mmHg, • DBP 90-100mmHg What antihypertensive(s) would you choose? • Hydralazine • Labetolol

30. 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

31. 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

32. Can ACEI be used? • ACEI and angiotensin receptor blockers are contraindicated as they were associated with fetal malformation (oligohydraminos, fetal artery stenosis, fetal death)

33. 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

34. 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

35. Thank You