Rosen & Barkin's 5-Minute Emergency Medicine Consult (570 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ETIOLOGY
  • Preeclampsia
    • Incomplete placental implantation and underperfusion
    • Leads to decreased angiogenic growth factor and increased maternal placental debris in circulation
  • Eclampsia
    • 1/3 of patients with eclampsia did not have hypertension prior to seizure
  • Risk factors:
    • Extremes of reproductive age
    • Primagravida
    • Multiple gestations
    • Molar pregnancy, hydatidiform mole
    • Smoking
    • Increased body mass index
    • Diabetes, collagen vascular diseases
    • Pre-existing hypertension or renal disease
    • History of preeclampsia with prior pregnancies (7.5–10% increased risk)
    • Independent risk factors for eclampsia
      • Nulliparity
      • Maternal age
      • GH
DIAGNOSIS
  • GH
    • Normotensive prior to 20 wk gestation
    • SBP >140 or DBP >90 on 2 separate measurements
    • Severe: SBP >160 and DBP >110
  • Preeclampsia
    • GH and proteinuria
    • 300 mg protein on 24 hr urine
    • 1+ protein on urinalysis
    • Mild:
      • SBP <160 mm Hg or
      • DBP <110 mm Hg
      • Normal platelets
      • Normal liver function tests
      • No cerebral symptoms
    • Severe:
      • SBP >160 or DBP >110
      • 5 g protein on 24 hr urine
      • 3+ proteinuria on 2 occasions
      • Oliguria
      • Thrombocytopenia
      • Right upper quadrant pain
      • Impaired liver function
      • Cerebral symptoms
      • Intrauterine growth restriction
      • Vision changes
      • Pulmonary edema
  • HELLP Syndrome
    • Hemolysis
    • Elevated liver enzyme
    • Low platelets
    • May present with:
      • Pulmonary edema
      • Renal failure
      • Liver failure
      • Sepsis
      • Pulmonary disease
      • Stroke
SIGNS AND SYMPTOMS
History
  • History of preeclampsia
  • Parity
  • Weight gain
  • Leg swelling
  • Abdominal pain
  • Nausea/vomiting
  • Shortness of breath
  • Headache
  • Visual changes
  • Jaundice
  • Stroke symptoms
Physical-Exam
  • Check serial BP
  • Palpate abdomen carefully, especially RUQ
  • Assess extremities for edema
  • Perform neurologic exam:
    • Deep tendon reflexes
    • Mental status changes
    • Visual acuity
ESSENTIAL WORKUP
  • Serial BP measurements
  • Urinalysis
  • CBC, LFTs, BUN/creatinine, uric acid
  • US
  • Fetal monitoring
  • Head CT depending on severity of presentation
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • Urinalysis:
    • Protein >1+ correlates to 30 mg/dL
    • >1+ requires 24 hr urine collection
    • Urine sediment for RBC, WBC, casts
  • CBC
  • LFTs
  • BUN/creatinine
  • Uric acid
  • LDH
  • d
    -dimer
  • Fibrinogen levels
  • Coagulation studies
Imaging
  • US:
    • Gestational age
    • Fetal viability/distress
    • Oligohydramnios
  • Fetal monitoring, nonstress test
  • Head CT: Rule out mass or hemorrhage
Diagnostic Procedures/Surgery
  • Lumbar puncture: Rule out infection or subarachnoid hemorrhage
  • Urine toxicology: Rule out substance abuse:
    • Cocaine
    • Methamphetamine
DIFFERENTIAL DIAGNOSIS
  • Essential hypertension
  • Renal or collagen vascular disease
  • Hydatidiform mole, hydrops fetalis
  • Drug abuse
  • Epilepsy
  • Encephalitis
  • Meningitis
  • Encephalopathy
  • Brain tumor
  • Intracranial hemorrhage
TREATMENT
PRE HOSPITAL
  • ABCs
  • Oxygen
  • Place patient in left lateral decubitus position
INITIAL STABILIZATION/THERAPY
  • ABCs
  • 100% oxygen
  • Left lateral decubitus position (reduces pressure on inferior vena cava, enhancing cardiac return/output)
  • Maternal cardiopulmonary monitoring
  • Magnesium sulfate (MgSO
    4
    ) for seizures
ED TREATMENT/PROCEDURES
  • Make arrangements for emergent C-section
  • MgSO
    4
    for seizure treatment and prophylaxis
  • Hydralazine or labetalol for BP control
    • Goal is to lower BP by 25% initially and then to <160/100 over subsequent hours
  • Mg toxicity:
    • Hypotension
    • Loss of patellar reflex
    • Respiratory depression
    • Decreased urine output
    • Elevated creatinine
    • Calcium gluconate to reverse
  • Intubate for airway protection/hypoxia or if seizures refractory to interventions
  • Tocographic and fetal monitoring
  • OB consult:
    • All cases along GH–preeclampsia–eclampsia spectrum
    • Expectant management if <30 wk gestation
    • Delivery >30 wk
    • Emergent delivery for severe symptoms: Induction vs. C-section
MEDICATION
First Line
  • MgSO
    4
    : 10 g IM or 4 g IV; followed by 1–2 g/hr IV infusion:
    • MgSO
      4
      bolus should not exceed 1 g/min
    • Serum Mg goal: 4–7 mEq/L
  • Hydralazine: 5–20 mg IV
  • Labetalol: 10 mg IV initially, then 5–10 mg increments for desired effect
Second Line
  • Valium: 5–10 mg IV if no response to MgSO
    4
  • Fosphenytoin: 15–20 mg phenytoin equivalents (PE) IV × 1 (max. 150 mg PE/min IV)
  • Phenytoin: 15–18 mg/kg IV, not to exceed 25–50 mg/min, for persistent seizure activity
  • Calcium gluconate: 1 g IV
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Preeclampsia
  • Eclampsia
  • HELLP syndrome
  • ICU, labor and delivery, OR
Discharge Criteria
  • Isolated hypertension with workup negative for preeclampsia
  • Asymptomatic
  • Close obstetric follow-up assured
FOLLOW-UP RECOMMENDATIONS
  • Follow-up with OB as above
  • Return to ED:
    • Headache
    • Abdominal pain
    • Leg swelling
    • Decreased urination
    • Shortness of breath
PEARLS AND PITFALLS
  • Delivery is the definitive treatment for preeclampsia and eclampsia
  • BP of 130/80 mm Hg in a pregnant woman requires investigation
  • Postpartum presentation: Consider preeclampsia/eclampsia in patient up to 30 days postpartum presenting with:
    • Edema
    • Shortness of breath
    • Headache
    • Seizure
  • Airway considerations in preeclamptic or eclamptic patients:
    • Reduced internal diameter of airways due to engorgement
    • Airway edema may be present
    • Use smaller-diameter endotracheal tube
    • Use fiberoptic guidance if available
    • High risk for aspiration
ADDITIONAL READING
  • Deak TM, Moskovitz JB. Hypertension and pregnancy.
    Emerg Med Clin N Am.
    2012;30:903–917.
  • Leeman L, Fontaine P. Hypertensive disorders of pregnancy.
    Am Fam Physician
    . 2008;78:93–100.
  • Podymow T, August P. Antihypertensive drugs in pregnancy.
    Semin Nephrol
    . 2011;31:70–85.
  • Sibai BM. Etilogy and management of postpartum hypertension-preeclampsia.
    Am J Obstet Gynecol
    . 2012;206:470–475.
  • Yancey LM, Withers E, Bakes K, et al. Postpartum preeclampsia: Emergency department presentation and management.
    J Emerg Med.
    2011;40;380–384.
  • 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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