Postpartum emergencies

Late Postpartum Eclampsia

Disposition

• 15% of all cases of eclampsia
• 40% have no history of HTN or proteinuria

• Symptoms
• headache,
• confusion,
• visual disturbances
• nausea, vomiting
• epigastric

pain.

Exam altered mental status focal neurologic deficits reduced visual acuity hyperreflexia right upper quadrant or diffuse abdominal tenderness, peripheral edema

Blood Pressure UA (proteinuria - absence does not rule out!

Treatment

control of blood pressure and prevention of progression to eclampsia

Brain damage due to intracranial hemorrhage or ischemia may result in permanent neurologic damage and is the most common cause of death in women with eclampsia

just as for the antepartum patient—the postpartum patient will benefit from careful, ongoing monitoring of blood pressure and lowering of blood pressures to 130 to 150 mm Hg systolic and 80 to 100 mm Hg diastolic.

Intravenous labetalol in an initial dose of 20 mg followed at 10-minute intervals by doses of 20 to 80 mg, to a total cumulative dose of 300 mg, is usually effective. Instead of intermittent therapy, an IV infusion of 1 to 2 mg/min may be used after the first dose. Hydralazine may also be used in a dose of 5 mg by slow IV push over 1 to 2 minutes; a repeat bolus of 5 to 10 mg can be given every 20 minutes to a total dose of 30 mg

One goal of therapy in the patient with postpartum preeclampsia is to prevent progression to eclampsia. Magnesium sulfate has been shown to be effective in this regard, reducing the risk of eclampsia by 50% compared with placebo.

Magnesium sulfate is given at a loading dose of 4 to 6 g IV over 15 minutes followed by 2 to 3 g IV per hour. Patients should be observed to detect any loss of reflexes and respiratory depression, both of which are signs of hypermagnesemia. If seizures recur at therapeutic doses of magnesium, other anticonvulsant drugs can be administered. At that point, consideration should also be given to other possible causes of seizures, such as intracranial hemorrhage or metabolic abnormalities.

HELLP Syndrome

• Presents in postpartum period in 30%
• usually within 48 hr of delivery
• 80% had no evidence of preeclampsia before delivery

40% to 90% of patients have right upper quadrant or epigastric pain, 86% to 100% have proteinuria, and 82% to 88% have hypertension

Patients may be seriously ill at presentation (or shortly thereafter) as a result of disseminated intravascular coagulation, acute renal failure, pulmonary edema, subcapsular liver hematoma, or retinal detachment

w/u

CBC w/ diff Chemistry Magnesium level UA Coags Fibrinogen (DIC)

MRI to evaluate PRES CT to evaluate for hepatic hematoma

When diagnosis of the HELLP syndrome is confirmed by pathognomonic laboratory abnormalities, efforts should be directed, as in eclampsia, toward controlling blood pressure and preventing seizures

Platelet transfusion may be indicated when counts are less than 20,000 cells/μL or if there is evidence of bleeding. Although dexamethasone was previously thought to enhance recovery, this drug has not been shown to be effective in large randomized trials

Evidence of abdominal distention or increasing abdominal girth is suggestive of a ruptured hepatic hematoma. Treatment should be aimed at maintaining adequate intravascular volume hemodynamically stable, percutaneous embolization of the hepatic artery can be done82; if not, operative management should be considered

Peripartum Cardiomyopathy

• Presentation similar to typical CHF
• ECG

DDX

• Respiratory tract infection
• PE
• MI
• Postpartum fluid overload