A 36-year-old primigravid woman at 34 weeks gestation arrives at the emergency department after being found unresponsive on the floor by her husband. She was found unconscious about 30 minutes ago and became gradually responsive over a few minutes. The husband reports the patient has had increasing nausea and vomiting over the past few hours and a severe frontal headache. Currently she has no symptoms other than the headache. Medical history is significant for migraines, and the patient takes no daily medications. Temperature is 36.7 C (98.1 F), blood pressure is 138/98 mm Hg, pulse is 78/min, and respirations are 20/min. Cranial nerves are intact, and the neck is supple. Funduscopic examination is normal. The lungs are clear to auscultation bilaterally. Cardiac examination demonstrates normal heart sounds. The abdomen is nontender, and the uterine fundus measures 34 weeks gestation. There is minimal pretibial edema, and deep tendon reflexes are 3+. Motor examination is normal. Laboratory results are as follows: Urine drug screen is negative. CT scan of the head reveals bilateral frontal lobe edema but no mass lesions or bleeding. Which of the following is the best next step in management of this patient?

Question

A 36-year-old primigravid woman at 34 weeks gestation arrives at the emergency department after being found unresponsive on the floor by her husband.  She was found unconscious about 30 minutes ago and became gradually responsive over a few minutes.  The husband reports the patient has had increasing nausea and vomiting over the past few hours and a severe frontal headache.  Currently she has no symptoms other than the headache.  Medical history is significant for migraines, and the patient takes no daily medications.  Temperature is 36.7 C (98.1 F), blood pressure is 138/98 mm Hg, pulse is 78/min, and respirations are 20/min.  Cranial nerves are intact, and the neck is supple.  Funduscopic examination is normal.  The lungs are clear to auscultation bilaterally.  Cardiac examination demonstrates normal heart sounds.  The abdomen is nontender, and the uterine fundus measures 34 weeks gestation.  There is minimal pretibial edema, and deep tendon reflexes are 3+.  Motor examination is normal.  Laboratory results are as follows:  Urine drug screen is negative.  CT scan of the head reveals bilateral frontal lobe edema but no mass lesions or bleeding.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d981_ec69_bc81_1f84c4b60bcb_MD0003_00 This pregnant patient was found unconscious and gradually became more responsive, suggestive of a postictal state. Given her hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg in pregnancy) and headache, consistent with preeclampsia with severe features, this presentation is most consistent with eclamptic seizure. Patients with preeclampsia are at risk for developing generalized tonic-clonic seizures (eclampsia) due to preeclampsia-induced cerebrovascular dysfunction (eg, vasospasm with subsequent brain ischemia). Although eclampsia classically presents with seizure activity, many patients are found in the postictal state because eclamptic seizures are usually brief (<1 minute), as in this patient. The postictal confusion and unresponsiveness typically resolve in 10-20 minutes, but patients continue to have signs of preeclampsia with severe features, such as severe headache, nausea, vomiting, hyperreflexia, and elevated creatinine levels. Eclampsia is usually a clinical diagnosis. However, CT scan of the head is performed in patients with atypical or prolonged symptoms and usually reveals bilateral frontal or occipital lobe edema, as seen in this patient. Because eclamptic seizures can cause brain injury and increased risk for stroke, eclampsia requires emergency treatment with magnesium sulfate infusion to prevent seizure recurrence. Fetal delivery is required for definitive cure. (Choice A) CT venography can diagnose cerebral venous thrombosis (CVT), which may present with severe headache and seizure. However, CVT typically causes papilledema and focal neurologic deficits, which are not seen in this patient. (Choice B) Lumbar puncture can diagnose CNS infection, idiopathic intracranial hypertension, or subarachnoid hemorrhage (particularly when CT scan of the head appears benign). However, these diagnoses are unlikely in this patient with no fever, nuchal rigidity, or signs of elevated intracranial pressure (eg, no papilledema on funduscopic examination). (Choice D) Triptan abortive therapy can treat migraines but is not used during pregnancy due to risks of fetal growth restriction and preterm labor. In addition, migraines typically cause unilateral (not bilateral) throbbing pain; however, loss of consciousness, hyperreflexia, and frontal lobe edema are not usually present. (Choice E) Video EEG may be used to diagnose patients with suspected psychogenic nonepileptic seizures; however, this management is inappropriate and potentially life-threatening in this patient with an emergent, medical cause of seizure. Educational objective: Eclampsia, generalized tonic-clonic seizures, can develop in patients with preeclampsia with severe features (eg, hypertension with elevated creatinine). Patients may present in a postictal state with persistent headache and hyperreflexia. Treatment is with magnesium sulfate infusion. References: Magnesium sulfate treatment for the prevention of eclampsia: a brief review. (http://www.ncbi.nlm.nih.gov/pubmed/19211496)

A 36-Year-Old Primigravid Woman at 34 Weeks Gestation Arrives at the Emergency