Rosen & Barkin's 5-Minute Emergency Medicine Consult (322 page)

• History and physical exam with attention to symptoms of abdominal pain, nausea, vomiting, and headache
  
• Obstetric history:
  
  • Parity
    
  • Deliveries
    
  • History of hypertensive disorder during pregnancy
    
  • Estimated gestational age
    
  • Prenatal care
    
• May present with flulike symptoms, such as fatigue or malaise
  
• Nausea, usually with vomiting
  
• Right upper quadrant or epigastic pain:
  
  • Pain increases with severity of disease
    
• Headache, often with visual changes
  
• Symptoms which carry higher morbidity:
  
  • Dyspnea and/or fluid overload to suggest cardiogenic/noncardiogenic pulmonary edema
    
  • Dyspnea associated with pulmonary embolus
    
  • Chest pain suggestive of myocardial ischemia
    
  • Altered mental status, seizures of focal neurologic deficit:
    
    • Hypertensive encephalopathy
      
    • Cerebral edema
      
    • Hemorrhagic cerebrovascular accident
      
  • Peripheral edema
    
  • Ascites
    
  • Hematuria
    
  • Low urine output
    

• Vital signs with attention to BP
  
• May not have systolic or diastolic HTN
  
• Many patients will have right upper quadrant pain, concern for liver subcapsular hematoma
  
• Evidence of fluid overload
  
• Careful neurologic exam
  
• Fetal heart tones
  

• Immediate CBC with platelet count and smear, BUN, creatinine, LFTs, coagulation profile, and magnesium level
  
• Urinalysis for protein; screen for UTI
  
• Weigh patient to determine recent weight gain
  

• CBC:
  
  • Anemia
    
  • Thrombocytopenia
    
  • Peripheral smear demonstrates microangiopathic hemolytic anemia (burr cells or schistocytes)
    
  • Other hemolysis markers are elevated lactate dehydrogenase (LDH) levels, increased reticulocyte count, and elevated bilirubin levels
    
• Platelet count and smear:
  
  • <100,000 platelets/μL
    
• Disseminated intravascular coagulation screen
  
• Coagulation profile:
  
  • PT
    
  • PTT
    
• BUN, creatinine, and magnesium levels
  
• LFTs to assess hemolysis markers and hepatic dysfunction:
  
  • Elevated aspartate aminotransferase level: >40 IU/L
    
  • Elevated alanine aminotransferase level: >40 IU/L
    
  • Elevated LDH: >600 IU/L
    
  • Elevated serum bilirubin: >1.2 mg/dL
    

• CXR:
  
  • Suspected pulmonary edema
    
• CT of head:
  
  • Mental status changes or focal neurologic deficit
    
• US of the pelvis (transabdominal or transvaginal):
  
  • Image fetus and placenta
    

• GI:
  
  • Cholecystitis
    
  • Cholelithiasis
    
  • Biliary colic
    
  • Pancreatitis
    
  • Hepatitis
    
  • Ulcer disease
    
  • Acute fatty liver of pregnancy
    
  • Acute gastritis
    
  • Hiatal hernia
    
  • Severe gastroesophageal reflux
    
• Hematologic:
  
  • Preeclampsia-associated thrombocytopenia
    
  • Gestational thrombocytopenia
    
  • Idiopathic thrombocytopenic purpura
    
  • Thrombotic thrombocytopenic purpura
    
  • Hemolytic uremic syndrome
    
• Neurologic:
  
  • Epilepsy
    
  • Encephalitis
    
  • Meningitis
    
  • Encephalopathy
    
  • Brain tumor
    
  • Intracranial hemorrhage
    
• Other:
  
  • Drug abuse
    
  • Pyelonephritis
    
  • Sepsis
    

TREATMENT

Cautions:

• Transport patient in left lateral decubitus position to prevent inferior vena cava syndrome
  
• Venous access for anticipated seizure activity
  
• Routine seizure management (preferably with magnesium sulfate) if the patient seizes
  

• ABC management
  
• Left lateral decubitus position to prevent inferior vena cava syndrome
  
• High-flow oxygen via face mask
  
• Maternal monitoring:
  
  • Cardiac
    
  • Pulse oximetry
    
  • Tocography
    
• Fetal monitoring
  

• Control HTN with antihypertensives (see Medication):
  
  • Avoid ACE inhibitors because of fetal side effects
    
• Heparin should be avoided because of bleeding complications
  
• Treat preeclampsia or eclampsia with IV magnesium sulfate:
  
  • Magnesium sulfate is not given to treat HTN
    
• Order type and screen for possible transfusion
  
• Call for emergent obstetric consult, consider neonatology consult:
  
  • Consider emergent delivery
    
  • Early plasma exchange therapy has shown promise in postpartum patients with severe disease
    
• Discuss administration of glucocorticoid with consultant:
  
  • Helps fetal lung maturity
    
  • IV dexamethasone more effective than IM betamethasone
    
  • Depends on gestational age of fetus
    
  • Does not reduce disease severity or duration, but improves platelet counts
    
• Limit IV fluid administration unless clinical evidence of dehydration:
  
  • Excess fluids promote further capillary leak
    
  • Lactated Ringers or NS at 60 mL/hr (no more than 125 mL/hr)
    
  • Monitor urine output with Foley catheter
    
• Correct thrombocytopenia by platelet transfusion in women with platelet counts <20,000 platelets/μL, even without active bleeding, as risk of postpartum bleeding is significantly increased
  
• Platelet counts >40,000 platelets/μL are safe for vaginal delivery
  
• Correct thrombocytopenia to platelet counts >50,000 platelets/μL if cesarean delivery planned
  
• If coagulation dysfunction is present, transfusion with fresh frozen plasma and packed RBCs in consultation with obstetrics
  
• Transfusion with packed RBCs for hemoglobin <10 g/dL
  

• Hydralazine: 2.5 mg IV, then 5–10 mg q15–20min:
  
  • Up to 40 mg total dose, to keep diastolic BP <110 mm Hg
    
  • IV drip 5–10 mg/hr titrated
    
• Labetalol: 10 mg IV, then 20–80 mg IV q10min:
  
  • Up to 300 mg total dose
    
  • IV drip 1–2 mg/min titrated
    

• Nitroprusside: 0.25 μg/kg/min as a drip:
  
  • Increase 0.25 μg/kg/min q5min
    
  • Use only if no response to hydralazine or labetalol
    
• Magnesium sulfate: 4–6 g in 100 mL IV over 15–20 min as loading dose:
  
  • Maintenance drip starting at 2 g/hr
    
  • Titrate to clinical effect
    
  • Watch for toxicity (antidote is calcium gluconate 10%, 10 mL IV over 3 min).
    
  • Measure magnesium sulfate level at 4–6 hr; adjust drip to achieve levels between 4 and 7 mEq/L.
    

FOLLOW-UP

• Admit all patients to obstetric service for continuous monitoring of mother and fetus
  
• ICU admission:
  
  • Pulmonary edema
    
  • Respiratory failure
    
  • Cerebral edema
    
  • GI bleeding with hemodynamic instability
    

Patients with HELLP syndrome should always be admitted. Discharge should be a decision of the OB Consultant

After stabilization in the ED, transfer to facility capable of managing high-risk obstetric conditions unless delivery is imminent.

Patients should be followed closely by OB:

• May develop HELLP after delivery, usually within 48 hr
  

• Hypertensive pregnant women with abdominal pain, elevated LFTs, and decreased platelets need emergent treatment and OB consultation
  
• Patients with HELLP syndrome may have a normal BP
  
• Transport to a facility capable of caring for these patients after stabilization is essential
  

• Ciantar E, Walker JJ. Pre-eclampsia, severe pre-eclampsia and hemolysis, elevated liver enzymes and low platelets syndrome: What is new?
  Women’s Health.
  2011;7(5):555–569.
  
• Deak TM, Moskovitz JB. Hypertension and pregnancy.
  Emerg Med Clin North Am.
  2012;30:903–917.
  
• Giannubilo SR, Bezzeccheri V, Cecchi S, et al. Nifedipine versus labetalol in the treatment of hypertensive disorders of pregnancy.
  Arch Gynecol Obstet.
  2012;286:637–642.
  
• Woudstra DM, Chandra S, Hofmeyr GJ, et al. Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy (Review).
  Cochrane Database Syst Rev
  . 2010; (9):CD008148.
  
• Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age.
  Am J Med
  . 2009;122:890–895.
  

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