Case of eclampsia in your resus bay

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Diagnosis:

  • new-onset tonic-clonic, focal, or multifocal seizures in the absence of other causative conditions (eg, epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage, drug use), 

  • typically but does not have to be present in the presence of preexisting hypertensive disorder of pregnancy (preeclampsia, gestational hypertension, HELLP syndrome)



Presentation:

  • Hypertension 

  • Headache (persistent frontal or occipital headaches or thunderclap headaches)

  • Visual disturbances (scotomata, loss of vision [cortical blindness], blurred vision, diplopia, visual field defects [eg, homonymous hemianopsia], photophobia)

  • Right upper quadrant or epigastric pain 

  • Asymptomatic 



Management:

  • Start with ABCs

  • Consider alternative causes of seizures based on additional information other than eclampsia: hyponatremia, ICH, hypoglycemia, etc.

  • Usually eclamptic seizures subside on its own

  • If pt is seizing => administer Mg Loading dose 4-6 g IV over 15 to 20 minutes. An alternative dose/route is magnesium sulfate 5 g intramuscularly into each buttock for a total of 10 g

  • Followed by Maintenance dose – magnesium sulfate 2 g/hour as a continuous IV infusion to women with good renal function.

  • If pt is in status => in cases refractory to magnesium sulfate (patient is still seizing at 20 minutes after the bolus or more than two recurrences), administer sodium amobarbital (250 mg IV over three minutes), thiopental, or phenytoin (1250 mg IV at a rate of 50 mg/minute). In this case pt will need to be intubated.

If need to consider intubation:

  • Medications:

    • Induction - consider propofol (category B)

      • You want to avoid: Etomidate - lowers seizure threshold and Ketamine - worsens HTN

 

    • Paralytics - rocuronium or succinylcholine, yet both of the medications are category C so use minimal dose to reach the desired effect, avoid additional doses

pregnancy medications.jpg



Next consider hypertensive control if BP diastolic pressures greater than 105 to 110 mmHg or systolic blood pressures ≥160 mmHg:

  • Labetalol - 20 mg IV gradually over 2 minutes.

  • Hydralazine - 5 mg IV gradually over 1 to 2 minutes.

  • Nifedipine immediate release - 10 mg orally.

  • Nicardipine (parenteral) - The initial dose is 5 mg/hour intravenously by infusion pump and can be increased to a maximum of 15 mg/hour.

Proceed with labs, consider HELLP syndrome labs, type and screen, fluids. 

Call OB/GYN early

The definitive treatment for eclampsia is prompt delivery.  



POTD: Young woman with upper abdominal pain clinical vignette

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25-year-old woman presents with RUQ abdominal pain she has had for 1 week. She denies fever and vomiting. She also describes some vague pelvic pain for the past month. She is unsure if her vaginal discharge is abnormal. She thinks she was treated for an STI a few years ago, also unsure. No urinary symptoms.

Examination reveals tenderness to palpation in the right upper quadrant, negative murphy’s sign. You do a bedside u/s that does not show GS/cholecystitis. LFTs/lipase are nl. GI cocktail doesn’t help. Being a thorough emergency physician you decide to do a pelvic exam and find +purulent discharge with an erythematous cervix and mild cervical tenderness to palpation. No adnexal ttp b/l.

Dx? Management?

Fitz-Hugh-Curtis syndrome (FHCS).

FHCS is a relatively rare secondary infection of the perihepatic region following pelvic inflammatory disease (PID). Patients generally have mild to moderate PID findings on pelvic examination. Most infections are chlamydial; gonococci are another infectious etiology. Because the infection does not affect the liver or biliary system itself, liver function test results and ultrasound examination results are normal. Abdominal CT can be diagnostic for FHCS; perihepatic inflammation will be noted.

Outpatient treatment for Fitz-Hugh-Curtis syndrome is similar to that for PID: ceftriaxone, 250 mg IM once, and doxycycline, 100 mg PO twice daily for 14 days, with or without metronidazole, 500 mg PO twice daily for 14 days. Patients who are hemodynamically stable may be discharged home with OBGYN f/u.

Although this is a rare diagnosis just keep it in the back of your mind. Chlamydia and gonorrhea are often asymptomatic in women, undiagnosed and lead to infertility (vs men where they tend to have symptoms).  So if the clinical scenario fits, do the pelvic exam.

Sources: Peer IX, uptodate

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POTD: Cerebral Venous Sinus Thrombosis (CVST)

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Clinical Presentation:

An 18-year-old female student presented with a 7-day history of worsening frontal headache and 1 day history of vomiting. The patient described marked photophobia, but no fever or history of seizure. She was taking a combined oral contraceptive and had no other medical history. Physical examination showed no focal neurology, but fundoscopy revealed bilateral papilledema. 


Today, let’s learn about cerebral venous sinus thrombosis.

What is it?

Clot that forms within the major cerebral veins, such as the dural sinuses (super sagittal sinus, straight sinus, and transverse sinuses), cortical veins, vein of Galen, and jugular veins.

MRV-of-Cerebral-Venous-System-Saposnik-2011.png

What causes it?

Thrombosis of either the cerebral veins or of the major cerebral sinuses.

Epidemiology

  • More common in younger patients (median age = 38)

  • More common in women

  • Mortality of 10-30%

  • Risk factors: 

    • Acquired: infections (otitis, mastoiditis), surgery, pregnancy, trauma, cancer, exogenous hormones

    • Genetic: inherited thrombophilia

Presentation

  • Non-specific stroke-like symptoms: severe HA (90% of patients) that can be gradual in onset, weakness, paresthesias, blurred or double vision

  • If increased ICP, can see mental status changes, lethargy, decreased consciousness, papilledema 

  • If focal brain injury, can have seizures or focal neurological defecits

Diagnosis

  • Variety of imaging modalities for diagnosis, typically can start with a non-contrast CT head and then progress to CT venogram (if MRI unavailable), or perform MR venography, MRI, or cerebral angiography

Management

  • Manage seizures or herniations 

  • Start anticoagulation

    • Unfractionated heparin (UFH)

    • Low molecular weight heparin (LMWH): 1 mg/kg SQ Q12 hours

  • Other treatment modalities: systemic thrombolytics, cather-based interventions (thrombolytics and thrombectomy), decompressive craniectomy

CVT-Algorithm-Saposnik.png
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