Postpartum emergencies

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

Background

• Presentation similar to typical CHF

Diagnosis

• Development of heart failure in ast month of pregnancy or w/in 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

Treatment

• Treat like usual heart failure

Source

EBM, Volume 12, Number 8, Aug 2010. Postpartum Emergencies