Case 86: Headache in pregnancy

 CASE 86: HEADACHE IN PREGNANCY

History

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 finger swelling.

Examination

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.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 11.6 g/dL 11–14 g/dL

Packed cell volume 42.2% 31–38%

Mean cell volume 79 fL 74.4–95.6 fL

White cell count 5×109/L 6–16×109/L

Platelets 126×109/L 150–400×109/L

Sodium 141 mmol/L 130–140 mmol/L

Potassium 4.0 mmol/L 3.3–4.1 mmol/L

Urea 3.8 mmol/L 2.4–4.3 mmol/L

Creatinine 92 mmol/L 34–82 mmol/L

Alanine transaminase 189 IU/L 6–32 IU/L

Alkaline phosphatase 74 IU/L 30–300 IU/L

Gamma glutamyl transaminase 34 IU/L 5–43 IU/L

Bilirubin 12 mmol/L 3–14 mmol/L

Albumin 24 g/L 28–37 g/L

Urate 0.46 mmol/L 0.14–0.38 mmol/L

Urinalysis: protein ++++

Cardiotocograph (CTG): baseline 140/min, reduced variability (5–10/min). Variable decelerations, occasional accelerations.

Questions

• What is the diagnosis?

• How would you manage this patient?100 Cases in Obstetrics and Gynaecology

244

ANSWER 86

The woman has pre-eclampsia with rapid onset and severity of symptoms and signs suggesting 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 occur 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 (haemolysis,

elevated liver enzymes and low platelets).

Management

This is an obstetric emergency and the senior midwife, anaesthetist and senior obstetrician

should be informed immediately. The appropriate definitive treatment for pre-eclampsia is

delivery 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 intravascular

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 reducing

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 preeclampsia 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 uteroplacental 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 output

is normal, symptoms have settled and blood results are returning to normal.

KEY POINTS

• Pre-eclampsia causes widespread endothelial dysfunction, with effects on all

of the body systems. Death can occur from cerebral haemorrhage, eclampsia,

pulmonary oedema, renal failure or hepatic rupture.

• Immediate stabilization of the mother should precede delivery of the baby.