Postpartum emergencies: Difference between revisions

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=== Background ===
=== Background ===
=== Diagnosis ===
=== Work-Up ===
=== DDx ===
=== Treatment ===
=== Disposition ===
*15% of all cases of eclampsia
*15% of all cases of eclampsia
*40% have no history of HTN or proteinuria
*40% have no history of HTN or proteinuria


*Symptoms
=== Diagnosis ===
*headache,
Hypertension
*confusion,
*Sys >140 or dia > 90 AND
*visual disturbances
* Proteinuria > 0.3g in 24-hr
*nausea, vomiting
**Urine dipstick of 1+ is suggestive
*epigastric
***Lack of proteinuria is not rule-out!
 
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
 
<br/>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
 
<br/>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.
 
<br/>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
 
<br/>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.
 
 
 


*History
**Headache
**Confusion
**Visual disturbances
**Nausea/vomiting
**Epigastric pain


*Physical
**AMS
**Focal neurologic deficits
**Visual symptoms
**Hyperreflexia
**RUQ or diffuse abdominal tenderness
**Peripheral edema


=== Work-Up ===
*UA


=== Treatment ===
*Control blood pressure
**Lower to Sys 130-150, dia 80-100
*Labetalol
**Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
**Option 2: Initial 20mg; then IV infusion of 1-2mg/min
*Hydralazine
** 5mg IV over 1-2min; repeat bolus of 5-10mg q20min PRN to total of 30mg
*Prevent eclampsia
** Magnesium: Load 4-6g IV over 15min followed by 2-3g per hr
***Observe for loss of reflexes, respiratory depression
**If seizures recur:
***Consider other anticonvulsant drugs
***Consider alternative diagnosis


== HELLP Syndrome ==


HELLP Syndrome
=== Background ===
 
*Presents in postpartum period in 30%
*Presents in postpartum period in 30%
*usually within 48 hr of delivery
**Usually within 48 hr of delivery
*80% had no evidence of preeclampsia before 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
=== Diagnosis ===
 
*Signs/Symptoms
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
**RUQ or epigastric pain - 40-90%
 
**Proteinuria - 86-100%
w/u
**Hypertension - 82-88%
 
*Labs
CBC w/ diff Chemistry Magnesium level UA Coags Fibrinogen (DIC)
**CBC w/ diff
 
***Microangiopathic hemolytic anemia
MRI to evaluate PRES CT to evaluate for hepatic hematoma
***Plt count <100
 
**LFT
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
***AST > 70, bilirubin > 1.2
 
**LDH > 600
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
 
<br/>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
 


=== Work-Up ===
*CBC w/ diff
*Chemistry
*LFT
*LDH
*PT/PTT/INR
*FDP, fibrinogen, D-Dimer
*CT to evaluate for hepatic hematoma (if needed)


=== Treatment ===
*Same as for eclampsia




=== Complications ===
* DIC
* Acute renal failure
* Subcapsular liver hematoma
**Abdominal distention
**Mainttain adequate intravascular volume
***If unstable consider embolization vs surgery




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*Presentation similar to typical CHF
*Presentation similar to typical CHF
*ECG
*ECG
Development of heart failure in the last month of pregnancy or
within 5 months of delivery
• Absence of an identifiable cause for the heart failure
• Absence of recognizable heart disease prior to the last month of
pregnancy
• Left ventricular systolic dysfunction


DDX
DDX

Revision as of 05:05, 27 March 2011

Late Postpartum Eclampsia

Background

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

Diagnosis

Hypertension

  • Sys >140 or dia > 90 AND
  • Proteinuria > 0.3g in 24-hr
    • Urine dipstick of 1+ is suggestive
      • Lack of proteinuria is not rule-out!
  • History
    • Headache
    • Confusion
    • Visual disturbances
    • Nausea/vomiting
    • Epigastric pain
  • Physical
    • AMS
    • Focal neurologic deficits
    • Visual symptoms
    • Hyperreflexia
    • RUQ or diffuse abdominal tenderness
    • Peripheral edema

Work-Up

  • UA

Treatment

  • Control blood pressure
    • Lower to Sys 130-150, dia 80-100
  • Labetalol
    • Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
    • Option 2: Initial 20mg; then IV infusion of 1-2mg/min
  • Hydralazine
    • 5mg IV over 1-2min; repeat bolus of 5-10mg q20min PRN to total of 30mg
  • Prevent eclampsia
    • Magnesium: Load 4-6g IV over 15min followed by 2-3g per hr
      • Observe for loss of reflexes, respiratory depression
    • If seizures recur:
      • Consider other anticonvulsant drugs
      • Consider alternative diagnosis

HELLP Syndrome

Background

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

Diagnosis

  • Signs/Symptoms
    • RUQ or epigastric pain - 40-90%
    • Proteinuria - 86-100%
    • Hypertension - 82-88%
  • Labs
    • CBC w/ diff
      • Microangiopathic hemolytic anemia
      • Plt count <100
    • LFT
      • AST > 70, bilirubin > 1.2
    • LDH > 600

Work-Up

  • CBC w/ diff
  • Chemistry
  • LFT
  • LDH
  • PT/PTT/INR
  • FDP, fibrinogen, D-Dimer
  • CT to evaluate for hepatic hematoma (if needed)

Treatment

  • Same as for eclampsia


Complications

  • DIC
  • Acute renal failure
  • Subcapsular liver hematoma
    • Abdominal distention
    • Mainttain adequate intravascular volume
      • If unstable consider embolization vs surgery






Peripartum Cardiomyopathy

  • Presentation similar to typical CHF
  • ECG

Development of heart failure in the last month of pregnancy or within 5 months of delivery • Absence of an identifiable cause for the heart failure • Absence of recognizable heart disease prior to the last month of pregnancy • Left ventricular systolic dysfunction


DDX

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

Background

Diagnosis

Work-Up

DDx

Treatment

Disposition

See Also

Source




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