The Real-World Boards: Question #13
A 40-year-old pregnant woman presents with headache and hypertension
These are the Real-World Boards. As in the real world, there is often no “right” answer, and you are only competing against yourself. Upgrade to the Lifelong Learner level for full access to all the questions and unlimited CME credits with an included Learner+ account.
You are working in a small rural hospital without obstetric services. A 40-year-old woman presents to the ED with a persistent, mild-to-moderate headache, which is unusual for her. She states she hasn’t been drinking enough water and feels dehydrated.
She is pregnant at 34 weeks’ gestation. This is her first pregnancy.
Her blood pressure is 154/88 mm Hg. She has no prior history of hypertension. She has 1+ proteinuria on urinalysis, which is unchanged from 2 months ago. Her serum creatinine is 1.3 mg/dL, from a baseline of 1.0 mg/dL.
Platelets and liver enzymes are normal. Neurologic exam is nonfocal. She has 2+ bilateral leg edema of unknown chronicity. Fetal heart rate is 150 bpm (normal).
Oral labetalol and acetaminophen are provided. One liter of LR is infused. After 5 hours, her blood pressure is 145/88. Her headache has improved, but is still present.
You activate your hospital’s processes to transfer to a higher level of care. There are multiple candidate hospitals within a three-hour drive.
She asks you what is most likely going to happen next.
This woman has preeclampsia, defined by new-onset hypertension in pregnancy after 20 weeks and (in this case) an increase in creatinine to >1.1 mg/dL and persistent headache.
Along with SBP ≥140 and/or DBP ≥90 persistent over >4 hours, any one or more of the following as new findings define preeclampsia:
Proteinura (protein/creatinine ratio ≥0.3 in random urine, or ≥300 mg in 24 hours, or 2+ on UA if no quantitative testing available)
New onset headache unrelieved by analgesics
Pulmonary edema*
Visual symptoms*
Platelets <100K*
Creatinine >1.1 mg/dL or doubling from baseline*
AST/ALT ≥2x ULN*
*These are “severe features” (any one of which results in the diagnosis of “preeclampsia with severe features”, formerly “severe preeclampsia”; other severe features are SBP ≥160 or DBP ≥110 or severe or progressive headache.
HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) may be a form of severe preeclampsia (this is debated).
Eclampsia is preeclampsia with seizures.
Delivery of the baby generally resolves preeclampsia. Vaginal delivery is preferable, if feasible.
Patients with preeclampsia (including severe preeclampsia) are commonly managed in the labor and delivery unit. ICU transfer is appropriate if life-threatening complications develop (e.g., pulmonary edema, multi-organ failure).
The decision to induce labor (if it does not occur spontaneously) is driven by both the degree of fetal development and the severity of preeclampsia, with the dual goals of maximizing fetal development and minimizing maternal and fetal complications.
Common scenarios for prompt induction of labor include:
Preeclampsia with severe features (including HELLP) at ≥34 weeks’ gestation
Preeclampsia without severe features at ≥37 weeks
When maternal and fetal status permit, “expectant management” can be provided in a high-risk OB unit to buy as much time as possible for maximal fetal development before delivery. This should ideally be provided in a tertiary center with NICU (for the newborn) and ICU (for the mother) capacities.
Emergent C-section is reserved for maternal or fetal instability.
Two days later, you are rotating on the critical care service at a tertiary hospital and are consulted on the same patient.
She is in early labor and progressing slowly. This morning, her blood pressure rose to 161/102 despite repeated doses of IV hydralazine. She received magnesium sulfate in a 4 g IV loading dose followed by 1 g per hour IV; the previous serum level was 4 mEq/L. Her blood pressure remains unchanged.
Platelets are 98K, and creatinine is 1.5 g/dL with adequate urine output. She appears uncomfortable. She is alert and oriented. The obstetrician says the fetus is not overly stressed and vaginal delivery is planned, if feasible.
During your examination, after you confirm patellar reflexes are present, she experiences a generalized tonic-clonic seizure.
You note in her family history that her mother has myasthenia gravis.
