Snapshot A 20-year-old woman at 30 weeks gestation presents to the emergency room with malaise, headache, and nausea. On physical exam, she is alert and oriented. She is noted to have bilateral lower extremity edema. A urine dipstick shows 2+ proteinuria and her blood pressure is 150/96 mmHg. Her other laboratory values are within normal limits. She is discharged home. The next day, she returns with a worsening headache and found with elevated blood pressure again at 163/100 mmHg. She is admitted and started on magnesium sulfate for seizure prophylaxis. Introduction Overview hypertension during pregnancy can be chronic hypertension, gestational hypertension, preeclamspia, or eclampsia some consider HELLP syndrome to be a form of preeclampsia/eclampsia although this is controversial Diagnosis of preeclampsia hypertension (> 140/90 mmHg on 2 separate occasions or 160/110 mmHg) and proteinuria can also be diagnosed without proteinuria if one of the following signs of severe preeclampsia blood pressure > 160/110 mmHg hepatic dysfunction renal insufficiency visual/cerebral disturbances pulmonary edema thrombocytopenia Spectrum of Hypertensive Disorders in PregnancyChronic HypertensionGestational HypertensionPreeclampsiaEclampsiaHELLP SyndromeHistory of hypertension(> 140/90 mmgHg) before pregnancy or before 20 weeks of gestationHypertension persists after deliveryHypertension after 20 weeks of gestationHypertension returns to baseline by 6 weeks post-partumCommon in multiple gestationsHypertension (> 140/90 mmHg on 2 separate occasions, or >160/110 mmHg) plusproteinuriaPreeclampsia plus seizuresHemolysisElevatedLiver enzymesLowPlatelets Epidemiology Incidence 2-6% Risk factors nulliparity multiple gestations hyatidiform mole diabetes chronic hypertension chronic renal disease Etiology Pathogenesis mechanism impaired vasodilation of spiral arteries causes placental ischemia this results in increased vascular tone, increased vasoconstriction, and decreased vasodilation other factors considered to contribute include maternal immunologic intolerance, inflammatory changes, and abnormal placental implantation Presentation Symptoms common symptoms danger signs headache epigastric pain visual changes pulmonary edema oliguria water retention Physical exam inspection hypertension > 140/90 mmHg tonic-clonic seizures hyperreflexia periorbital and extremity edema altered mental status Studies Serum labs proteinuria 1-2+ on dipstick > 300 mg on 24-hour urine protein/creatinine ratio > 0.3 best confirmatory test is a spot urine protein to creatinine ratio thrombocytopenia hemoconcentration Differential Acute fatty liver of pregnancy key distinguishing factor primarily characterized by fulminant liver failure HELLP syndrome key distinguishing factor characterized by hemolysis, elevated liver enzymes, and low platelets Treatment Medical antihypertensive medication indications blood pressure > 160/100 mmHg risk of decreased utero-placental blood flow drugs labetalol methyldopa hydralazine intravenous magnesium sulfate or diazepam indications seizure prophylaxis and treatment magnesium toxicity can occur hyporeflexia presents before bradypnea treatment calcium gluconate Surgical delivery indications the only definitive treatment if mild preeclampsia, can monitor for progression to severe preeclampsia if severe preeclampsia or eclampsia, deliver immediately preeclampsia can still occur postpartum and still should be managed with IV magnesium Complications Maternal cerebral hemorrhage Disseminated intravascular coagulopathy Acute respiratory distress syndrome Abruptio placentae Recurrence of preeclampsia Prognosis Maternal mortality 14% Most resolve after delivery
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OB.14.121) A 32-year-old G1P0 woman presents to the emergency department at 34 weeks gestation. She complains of vague upper abdominal pain and nausea which has persisted for 2 weeks, as well as persistent headache over the past several days. Her temperature is 99.0°F (37.2°C), blood pressure is 164/89 mmHg, pulse is 88/min, respirations are 19/min, and oxygen saturation is 98% on room air. Hemoglobin: 10 g/dLHematocrit: 30%Leukocyte count: 7,800/mm^3 with normal differentialPlatelet count: 25,000/mm^3 Serum:Na+: 139 mEq/LCl-: 100 mEq/LK+: 4.3 mEq/LHCO3-: 25 mEq/LBUN: 20 mg/dLGlucose: 99 mg/dLCreatinine: 1.1 mg/dLCa2+: 10.2 mg/dLAST: 199 U/LALT: 254 U/LUrine:Color: YellowProtein: PositiveBlood: PositiveThe patient begins seizing. Which of the following is the most appropriate definitive treatment for this patient? QID: 104761 Type & Select Correct Answer 1 Betamethasone 0% (0/19) 2 Cesarean section 32% (6/19) 3 Lorazepam 26% (5/19) 4 Magnesium 32% (6/19) 5 Platelet transfusion 11% (2/19) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (M2.OB.14.6) A 20-year-old woman presents to the emergency department with painful abdominal cramping. She states she has missed her menstrual period for 5 months, which her primary care physician attributes to her obesity. She has a history of a seizure disorder treated with valproic acid; however, she has not had a seizure in over 10 years and is no longer taking medications for her condition. She has also been diagnosed with pseudoseizures for which she takes fluoxetine and clonazepam. Her temperature is 98.0°F (36.7°C), blood pressure is 174/104 mmHg, pulse is 88/min, respirations are 19/min, and oxygen saturation is 98% on room air. Neurologic exam is unremarkable. Abdominal exam is notable for a morbidly obese and distended abdomen that is nontender. Laboratory studies are ordered as seen below.Serum:hCG: 100,000 mIU/mLUrine:Color: AmberhCG: PositiveProtein: PositiveDuring the patient's evaluation, she experiences 1 episode of tonic-clonic motions which persist for 5 minutes. Which of the following treatments is most appropriate for this patient? QID: 105176 Type & Select Correct Answer 1 Lorazepam 2% (1/45) 2 Magnesium 20% (9/45) 3 Phenobarbital 76% (34/45) 4 Phenytoin 0% (0/45) 5 Propofol 0% (0/45) M 7 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (M2.OB.13.5) A 25-year-old pregnant woman at 28 weeks gestation presents with a headache. Her pregnancy has been managed by a nurse practitioner. Her temperature is 99.0°F (37.2°C), blood pressure is 164/104 mmHg, pulse is 100/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for a comfortable appearing woman with a gravid uterus. Laboratory tests are ordered as seen below.Hemoglobin: 12 g/dLHematocrit: 36%Leukocyte count: 6,700/mm^3 with normal differentialPlatelet count: 100,500/mm^3 Serum:Na+: 141 mEq/LCl-: 101 mEq/LK+: 4.4 mEq/LHCO3-: 25 mEq/LBUN: 21 mg/dLGlucose: 99 mg/dLCreatinine: 1.0 mg/dLAST: 32 U/LALT: 30 U/LUrine:Color: AmberProtein: PositiveBlood: NegativeWhich of the following is the most likely diagnosis? QID: 103368 Type & Select Correct Answer 1 Acute fatty liver disease of pregnancy 2% (1/41) 2 Eclampsia 0% (0/41) 3 HELLP syndrome 39% (16/41) 4 Preeclampsia 17% (7/41) 5 Severe preeclampsia 37% (15/41) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (M2.OMB.4876) A 23-year-old woman presents to labor and delivery at 40 weeks gestation with abdominal contractions and leakage of fluid from her vagina. She subsequently undergoes an uncomplicated vaginal delivery. The child is healthy and is heated, suctioned, and stimulated. While holding her newborn, the mother endorses a headache, blurry vision, and abdominal pain. Her temperature is 98.0°F (36.7°C), blood pressure is 194/104 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable woman. There is blood in her vagina and her uterus is contracted. Her cranial nerve exam is unremarkable and she has normal strength and sensation. Laboratory studies and a urinalysis are pending. Which of the following is the most appropriate next step in management? QID: 216512 Type & Select Correct Answer 1 CT head 0% (0/0) 2 Labetalol 0% (0/0) 3 Magnesium 0% (0/0) 4 MRV head 0% (0/0) 5 Ondansetron and morphine 0% (0/0) M 11 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
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