Postpartum Emergencies

It’s that time again. Another issue of EBMedicine‘s Emergency Medicine Practice is about to roll out.

Sixsmith D (2010). Postpartum Emergencies: Headache, Hypertension, Eclampsia, and Cardiomyopathy. Emergency Medicine Practice, 12(8). [Abstract and subscription link]

What’s covered in the review?

This month’s article focuses on the most commonly seen and important postpartum emergencies:

• headache
• hypertension and preeclampsia
• late postpartum eclampsia (LPPE) and HELLP
• cardiomyopathy

The simple to follow and pragmatic flowcharts to guide decision-making in the management of postpartum hypertension and preeclampsia deserve special mention.

Top tips from this month’s review

It is always difficult to summairse these Emergency Medicine Practice reviews because they are packed with pearls and useful facts. Having offered this feeble excuse, I now offer my top ‘take home’ tips, facts and insights on each of the major topics featured in this month’s review:

Headache

• Postpartum patients with headache, or even mildly elevated blood pressure, should be triaged as emergent cases.
• Do an appropriate review of symptoms of postpartum patients presenting to emergency departments — the serious causes can have disparate and unexpected manifestations… and don’t forget to check for hyperreflexia!
• Trying to diagnose the causes of a headache in a woman who is in the prothrombotic postpartum period and is sleep-deprived, anxious about motherhood, not eating well, has a history of preclampsia, is experience drastic hormonal fluctuations, and had recent spinal anesthesia for a caesarean section may result in an even bigger headache for the doctor!
• Fortunately, the review has a handy table briefly describing the key features of the different types of commonly headache seen postpartum.
• Pregnancy and the puerperium are risk factors for cerebral venous thrombosis — watch out!

Hypertension and Preeclampsia

• Definintion of hypertension —
  • SBP >140 mm Hg or a DBP > 90 mm Hg without proteinuria, with readings taken preferably on at least 2 occasions, 6 hours apart.
    However, there are other definitions…
• Definition of postpartum preclampsia —
  • SBP≥ 140 mm Hg or DBP ≥ 90 mm Hg
    and Proteinuria ≥ 0.3 g in a 24-hour urine specimen.
• Postpartum hypertension can be a continuation of a gestational disorder, or occur de novo. Furthermore, the enormous number of suggested etiologies and pathogenic mechisms that have been suggested for preclampsia/ eclampsia strongly suggests that no one has the faintest idea of why these conditions occur…
• Labetolol, hydralazine and appropriate referral are the mainstays of management of postpartum hypertension in the emergency department.
• Magnesium is a wonderful thing — it both prevents eclampsia in the preeclamptic and reduces seizure recurrence following an eclamptic seizure.

• Magnesium sulfate 4-6 g IV over 15 minutes or 2-3 g IV per hour; then benzo’s and phenytoin for refractory seizures.

LPPE and HELLP

• Definition of LPPE
  • eclamptic seizures (seizures in association with hypertension and proteinuria) occurring more than 48 hours after delivery but within 4 weeks postpartum.
• Definition of HELLP
  • Microangiopathic hemolytic anemia
  • Schistocytes (helmet cells) on peripheral smear
  • Platelet count ≤ 100,000/m3
  • Elevated liver enzymes (LDH ≥ 600 IU/L, AST ≥ 70 IU/L, bilirubin ≥ 1.2 mg/dL)
• LPPE is on the rise, and now accounts for about 15% of all cases of eclampsia.
• Bad things can happen even in the absence of hypertension or preeclampsia:

• About a third of LPPE cases occur in women with no history of hypertension or proteinuria!
• 30% of HELLP occurs in the 48h immediately postpartum, although it may occur up to 1 week after delivery — 80% have no history of preeclampsia!

• Patients with LPPE may have few or no symptoms and rapidly progress to seizures. Some experts consider evidence of PRES (posterior reversible encephalopathy) to be diagnostic of LPPE even in the absece of seizures.

Peripartum or postpartum cardiomyopathy

• Diagnostic criteria:
  • Development of heart failure in the last month of pregnancy or within 5 months of delivery
  • Absence of an identifiable cause for the heart failure
  • Absence of recognizable heart disease prior to the last month of pregnancy
  • Left ventricular systolic dysfunction
• The incidence in Nigeria is a whopping 1:100 deliveries! Its 1:15,000 in the US.
• Although dyspnoea is the most common presenting complaint of postpartum cardiomyopathy it may mimic a humble URTI early in its course.
• Risk factors include:

• Maternal age above 30
• Multiple fetuses
• Preeclampsia, eclampsia, or postpartum hypertension
• Maternal cocaine abuse
• Long-term tocolytic therapy
• Selenium deficiency

• Investigation and management is much the same as any other form of heart failure.

As always these highlights are just the tip of the iceberg. Check out the full article to find out a whole lot more.