HEADACHE IN PREGNANCY
A 17-year-old girl is admitted to the labour ward by ambulance because of a severe headache and reduced fetal movements. This is her first pregnancy. She did not discover she was pregnant until very late and was uncertain of her last menstrual period date so was dated by ultrasound scan at 23 weeks. According to that scan she is now 37 weeks.
When she was first booked in the antenatal clinic her blood pressure was 120/68 mmHg and urinalysis negative. The blood pressure was last checked 1 week ago and was 132/74 mmHg and urine was negative again. Booking blood tests were all normal.
This morning she woke with a frontal headache which has persisted despite paracetamol. She says that her vision is a bit blurred but she cannot be more specific about this. She also reports nausea and epigastric discomfort, but has not vomited. She denies leg or fin- ger swelling.
The blood pressure is 164/106 mmHg. This is repeated twice at 15 min intervals and is found to be 160/110 mmHg and 164/112 mmHg. She is apyrexial and her heart rate is 83/min. Her face is minimally swollen and fundoscopy is normal. Cardiac and respiratory examinations are normal. Abdominally she is tender in the epigastrium and beneath the right costal margin, but the uterus is soft and non-tender. The fetus is cephalic and 3/5 palpable.
The legs and fingers are mildly oedematous and lower limb reflexes are very brisk, with clonus.
· What is the diagnosis?
· How would you manage this patient?
The woman has pre-eclampsia with rapid onset and severity of symptoms and signs sug- gesting severe or ‘fulminant’ disease. She is at high risk of developing eclampsia.
The headache and visual disturbance are typical features of cerebral oedema; the right upper quadrant pain of subcapsular liver swelling and the proteinuria occurs from renal involvement.
The blood tests show typical features of severe pre-eclampsia:
· elevated liver transaminases
· elevated urate
· elevated creatinine.
The platelet count is at the lower end of the normal range for pregnancy and if reduced further, with raised bilirubin would suggest development of HELLP syndrome (haemoly- sis, elevated liver enzymes and low platelets).
This is an obstetric emergency and the senior midwife, anaesthetist and senior obstetrician should be informed immediately. The only definitive treatment for pre-eclampsia is deliv- ery of the baby, but the maternal status must be stabilized first. In this case she should be admitted and have an intravenous cannula inserted. Blood should be sent for coagulation and for group and save. A urinary catheter should be inserted and fluid input and output carefully monitored for oliguria as a sign of impending renal failure.
In pre-eclampsia although the extracellular fluid is increased (third space), the intravas- cular volume is generally depleted, so fluid input should be managed carefully with the help of an anaesthetist, balancing adequate renal perfusion with the risk of overload and pulmonary oedema. Where the urine output is decreased, a central venous line may be needed for more accurate assessment of volume status.
The woman should be given an antihypertensive to reduce her blood pressure (thus redu- cing the risk of cerebral haemorrhage). If initial oral antihypertensives are not effective, a titrated intravenous infusion should be used.
Magnesium sulphate infusion reduces the risk of an eclamptic fit in women with severe pre-eclampsia and should be commenced.
The CTG shows reduced variability and occasional variable decelerations. This suggests that the reduced fetal movements may be due to fetal distress, probably from uteroplacen- tal insufficiency. Caesarean section would therefore be the mode of delivery of choice, but only when the maternal blood pressure is under control and the coagulation screen result is available.
Postnatally the condition may not improve for 48 h or more, and the woman should be nursed in a high-dependency setting until the blood pressure is under control, renal out- put is normal, symptoms have settled and blood results are returning to normal.