A 21-year-old woman, gravida 1 para 1, comes to the emergency department for abdominal pain and a severe headache. The pain started 2 days ago in the epigastrium and now radiates to the right upper quadrant. The pain was initially responsive to acetaminophen but has become increasingly severe. The patient also reports an occipital headache accompanied by blurry vision. A week ago, she had an uncomplicated vaginal delivery at 39 weeks gestation and, after a normal postpartum course, was discharged on day 2. The patient has a history of migraines for which she typically takes daily prophylactic medication. She stopped the medication when she became pregnant. Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, and pulse is 94/min. The visual fields are normal and there is no nuchal rigidity. Abdominal examination reveals tenderness to palpation over the epigastrium and right upper quadrant, and there is hepatomegaly. Bilateral lower extremities have 2+ pitting edema to the knees. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 21-year-old woman, gravida 1 para 1, comes to the emergency department for abdominal pain and a severe headache.  The pain started 2 days ago in the epigastrium and now radiates to the right upper quadrant.  The pain was initially responsive to acetaminophen but has become increasingly severe.  The patient also reports an occipital headache accompanied by blurry vision.  A week ago, she had an uncomplicated vaginal delivery at 39 weeks gestation and, after a normal postpartum course, was discharged on day 2.  The patient has a history of migraines for which she typically takes daily prophylactic medication.  She stopped the medication when she became pregnant.  Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, and pulse is 94/min.  The visual fields are normal and there is no nuchal rigidity.  Abdominal examination reveals tenderness to palpation over the epigastrium and right upper quadrant, and there is hepatomegaly.  Bilateral lower extremities have 2+ pitting edema to the knees.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c029_38f1_8f63_cd2cdba5a4e0_MD0005_00 This patient has Hemolysis, Elevated Liver enzymes, and a Low Platelet count (≤100,000/mm³), a presentation consistent with HELLP syndrome, a variant of preeclampsia. HELLP syndrome typically occurs at >20 weeks gestation but can also occur during the postpartum period. Presenting signs and symptoms of HELLP syndrome include malaise, headache, visual changes, nausea and/or vomiting, epigastric/right upper quadrant pain, hypertension, and proteinuria. Patients with HELLP syndrome are at risk for seizures; magnesium sulfate is first-line therapy for seizure prophylaxis. Other complications of HELLP syndrome include abruptio placentae, disseminated intravascular coagulation, renal failure, pulmonary edema, and hepatic hematoma. For this reason, treatment also includes supportive care, serial laboratory evaluations, and (for patients who are still pregnant) delivery. (Choice A) In HELLP syndrome and preeclampsia, intravenous antihypertensives (eg, labetalol, hydralazine) are typically indicated for acute control of blood pressure ≥160/110 mm Hg. This patient's blood pressure is 150/90 mm Hg. (Choice C) N-acetylcysteine is an antidote for acetaminophen overdose. Acetaminophen overdose presents with right upper quadrant pain, transaminitis, and an elevated total bilirubin. However, the transaminitis is usually markedly elevated (>3,000 U/L) and there is no associated hypertension. (Choice D) Plasma exchange is indicated when HELLP syndrome is complicated by fulminant hepatic disease (eg, aspartate aminotransferase >2,000 U/L or lactate dehydrogenase >3,000 U/L). (Choice E) Sumatriptan is used in the treatment of migraine headaches. Although migraines are associated with visual symptoms and nausea, there is no associated abdominal pain, hypertension, or laboratory abnormalities. Educational objective: HELLP syndrome, a variant of preeclampsia, presents with abdominal pain, hypertension, Hemolysis, Elevated Liver enzymes, and Low Platelets. Antepartum or intrapartum presentation is most frequent but postpartum presentation is also common. Treatment includes magnesium sulfate for seizure prophylaxis and delivery. References: Thrombotic microangiopathies (TTP, HUS, HELLP). (http://www.ncbi.nlm.nih.gov/pubmed/25060255) HELLP syndrome: understanding and management of a pregnancy-specific disease. (http://www.ncbi.nlm.nih.gov/pubmed/23654309)

A 21-Year-Old Woman, Gravida 1 Para 1, Comes to the Emergency