A 29-year-old woman, gravida 1 para 1, is evaluated in the emergency department for a headache. Three days ago, she had an uncomplicated vaginal delivery with neuraxial anesthesia. This morning, the patient developed an occipital headache that has not improved with acetaminophen. The headache has become progressively worse, and the patient cannot sit without becoming nauseated and vomiting. The patient has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 162/96 mm Hg, pulse is 98/min, and respirations are 18/min. On examination, heart sounds are normal with no rubs or murmurs, and the lungs are clear to auscultation. Cranial nerves are intact and deep tendon reflexes are 3+. There is 5/5 strength in the right lower extremity and 3/5 strength in the left. Which of the following is the best next step in management of this patient?
Preeclampsia | |
Risk factors |
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Definition |
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Severe features |
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Management |
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*On 2 measurements ≥4 hr apart. DBP = diastolic blood pressure; IV = intravenous; PO = by mouth; SBP = systolic blood pressure; SLE = systemic lupus erythematosus. | |
This postpartum patient with worsening headache and severe hypertension (eg, systolic ≥160 or diastolic ≥110 mm Hg) has preeclampsia with severe features, which can present up to 6 weeks after delivery. The most common presenting symptom is a severe headache in the bilateral occipital or frontal regions that does not improve with acetaminophen or nonsteroidal anti-inflammatory drugs.
Patients with preeclampsia are at increased risk of hemorrhagic and ischemic stroke due to acute elevations in cerebral perfusion pressure and vessel rupture (hemorrhagic), as well as preeclampsia-mediated vascular endothelial damage and microthrombi formation (ischemic). To decrease this risk, preeclamptic patients with severe-range blood pressures require aggressive antihypertensive therapy (eg, labetalol, nifedipine) and magnesium sulfate, which helps prevent eclamptic seizures that can worsen stroke symptoms.
Most preeclamptic patients do not require imaging; however, in those with focal neurologic deficits, such as this patient with asymmetric motor deficits (strength right > left), CT scan of the head should be performed to evaluate for possible stroke and help guide management.
(Choices A and E) Oxygen administration is used to alleviate cluster headaches, which typically present with a short-lived, unilateral, orbital headache with autonomic symptoms (eg, ptosis, lacrimation). Triptans (eg, sumatriptan) are used to treat migraines, which can present as occipital headaches with nausea, vomiting, and occasionally motor aura (eg, hemiplegic migraine). However, CT scan should be performed in this patient prior to attempting symptomatic therapy in order to exclude life-threatening causes of neurologic deficit.
(Choice C) An epidural blood patch is used to treat postdural puncture headaches, which can occur after neuraxial anesthesia and may present as an occipital headache that worsens with sitting or standing due to cerebrospinal fluid (CSF) leakage. However, this type of headache is not associated with hypertension or focal neurologic deficits.
(Choice D) Lumbar puncture can evaluate for CSF infection (eg, meningitis, encephalitis), which may present with headache after neuraxial anesthesia. This patient is afebrile, making this diagnosis less likely. In addition, lumbar puncture is usually performed after CT scan to exclude a brain mass because there is a risk of herniation with mass effect.
Educational objective:
Preeclampsia can present up to 6 weeks postpartum with headache and hypertension. Patients with preeclampsia are at increased risk of stroke, and those with focal neurologic deficits should be evaluated with CT scan of the head.