A 38-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the emergency department due to sudden-onset visual changes and headache. The patient reports "spots" in her vision for the past few hours and an occipital headache. She took a dose of acetaminophen, but it did not improve her symptoms. The patient's pregnancy has been complicated by gestational diabetes mellitus requiring insulin. Blood pressure is 168/114 mm Hg and pulse is 90/min. The pupils are equal and reactive to light. Extraocular movements are intact. Visual field testing shows partial loss of vision bilaterally. Which of the following is the most likely cause of this patient's symptoms?

Question

A 38-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the emergency department due to sudden-onset visual changes and headache.  The patient reports "spots" in her vision for the past few hours and an occipital headache.  She took a dose of acetaminophen, but it did not improve her symptoms.  The patient's pregnancy has been complicated by gestational diabetes mellitus requiring insulin.  Blood pressure is 168/114 mm Hg and pulse is 90/min.  The pupils are equal and reactive to light.  Extraocular movements are intact.  Visual field testing shows partial loss of vision bilaterally.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3b22_0860_9249_ad9e7de7b094_MD0001_00 This patient has preeclampsia, defined as new-onset hypertension (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) at ≥20 weeks gestation with proteinuria and/or signs of end-organ dysfunction. Preeclampsia likely occurs due to abnormal placental development that results in high-resistance, low-perfusion vessels and subsequent placental ischemia. Placental ischemia triggers widespread endothelial dysfunction, which causes dysregulated vascular tone (eg, vasospasm, vasoconstriction), increased vascular permeability, and decreased end-organ perfusion. Therefore, a classic presentation of preeclampsia is hypertension with headache and visual changes: Headaches are typically severe and throbbing in nature. They occur due to dysregulated cerebral blood flow, brain ischemia, and/or capillary leakage resulting in cerebral edema. Visual changes include blurry vision, photopsia (seeing "sparks"), and scotomata (partial vision loss [blind spots]) and are due to retinal artery vasospasm and optic nerve ischemia. Eye movement and the pupillary light reflex typically remain intact. Symptoms usually resolve after delivery, which is curative for preeclampsia. However, in rare cases, patients with severe retinal ischemia or retinal detachment may have permanent vision loss. (Choice A) Choroidal neovascularization, abnormal vessel growth beneath the retina, causes age-related wet macular degeneration. However, it presents with painless vision loss (no associated headache) and onset of symptoms is typically unilateral (ie, one eye affected first). (Choice B) A decreased anterior chamber angle (ie, angle-closure glaucoma) can cause headache and visual changes due to increased intraocular pressure. However, patients typically have a painful red eye and a dilated pupil that reacts poorly to light. (Choice C) Vitreous hemorrhage is associated with eye injury, anticoagulation, and diabetic retinopathy. It typically causes monocular vision loss associated with floaters/photopsia, not bilateral scotomata. (Choice D) Inflammatory optic nerve demyelination (ie, optic neuritis) causes monocular vision loss and eye pain with extraocular movement. This patient has bilateral visual changes and normal extraocular movement. Educational objective: Preeclampsia causes widespread endothelial dysfunction, resulting in dysregulated vascular tone, increased vascular permeability, and decreased end-organ perfusion. Therefore, a common presentation is headache with visual changes (eg, scotomata) due to dysregulated cerebral blood flow and retinal artery vasospasm. __________ References: The eye and visual system in the preeclampsia/eclampsia syndrome: What to expect? (http://www.ncbi.nlm.nih.gov/pubmed/23964188)

A 38-Year-Old Woman, Gravida 3 Para 2, at 35 Weeks