A 25-year-old woman, gravida 1 para 0, at 29 weeks gestation comes to the emergency department due to a headache. The patient has a history of migraines but has not had one during the pregnancy until today. She has no other chronic medical conditions. This morning, the patient woke with a left-sided frontal headache and blurry vision in the left eye. She took a dose of acetaminophen, but the headache did not improve and now is in the bilateral frontal region. The patient has no sick contacts but has had increased stress at work and is working longer hours. Her caffeine consumption has increased to 2-3 cups of coffee a day. Blood pressure is 156/92 mm Hg and pulse is 84/min. Fetal heart rate is 155/min. Repeat blood pressure a few hours later is 150/94 mm Hg. Cranial nerves are intact. There is no nuchal rigidity. The abdomen is soft, gravid, and nontender. Deep tendon reflexes are normal. The remainder of the examination is unremarkable. Which of the following is the most likely diagnosis in this patient?

Question

A 25-year-old woman, gravida 1 para 0, at 29 weeks gestation comes to the emergency department due to a headache.  The patient has a history of migraines but has not had one during the pregnancy until today.  She has no other chronic medical conditions.  This morning, the patient woke with a left-sided frontal headache and blurry vision in the left eye.  She took a dose of acetaminophen, but the headache did not improve and now is in the bilateral frontal region.  The patient has no sick contacts but has had increased stress at work and is working longer hours.  Her caffeine consumption has increased to 2-3 cups of coffee a day.  Blood pressure is 156/92 mm Hg and pulse is 84/min.  Fetal heart rate is 155/min.  Repeat blood pressure a few hours later is 150/94 mm Hg.  Cranial nerves are intact.  There is no nuchal rigidity.  The abdomen is soft, gravid, and nontender.  Deep tendon reflexes are normal.  The remainder of the examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d97f_7b64_bc81_af55fd5b0536_MD0003_00 Headaches are common in pregnancy, particularly in patients with a history of headaches outside of pregnancy. Most cases of headache are benign, but women at ≥20 weeks gestation or with atypical headache symptoms require evaluation for preeclampsia. Although this patient has a history of migraines, which can present with unilateral, frontal pain and visual aura (eg, seeing bright shapes, vision loss), another etiology for her headache should be suspected because pregnant patients usually have either resolution (as in this patient) or increasing severity of migraines, not a sporadic pattern (Choice C). In addition, this patient's new-onset hypertension (ie, systolic blood pressure ≥140 or diastolic ≥90 mm Hg) at ≥20 weeks gestation plus headache with vision changes (eg, blurry vision, scotoma) are consistent with preeclampsia with severe features (eg, preeclampsia with visual or cerebral symptoms, indicating CNS dysfunction). Preeclampsia causes headaches due to high blood pressure, which creates acute elevations in cerebral perfusion pressure and dysregulated cerebral blood flow. Patients often describe preeclampsia headaches as "the worst of my life," and these headaches are typically refractory to acetaminophen or nonsteroidal anti-inflammatory drugs. Patients with preeclampsia, especially those with severe features, are at increased risk for seizure and stroke; therefore, management includes magnesium sulfate and blood pressure control (eg, labetalol, nifedipine). (Choice A) Increased caffeine consumption can cause mild hypertension and tachycardia; caffeine withdrawal can cause headaches. However, neither caffeine use nor withdrawal results in vision changes, making this diagnosis unlikely. (Choice B) Cluster headaches typically present with unilateral orbital or temporal pain with associated autonomic symptoms (eg, ptosis, miosis, lacrimation). Blurry vision is uncommon, and patients typically have relatively quick resolution of symptoms (<3 hr), making this diagnosis unlikely. (Choice E) Tension-type headaches are often worsened by stress and typically present with bilateral, band-like pain; however, they do not cause visual changes. Educational objective: Preeclampsia with severe features commonly presents in women at ≥20 weeks gestation with new-onset hypertension (ie, systolic blood pressure ≥140 or diastolic ≥90 mm Hg) and headache with vision changes (eg, blurry vision). References: Preeclampsia: association with posterior reversible encephalopathy syndrome and stroke. (http://www.ncbi.nlm.nih.gov/pubmed/29438078)

A 25-Year-Old Woman, Gravida 1 Para 0, at 29 Weeks