achilles
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a 23 yr old primigravida woman at 32 weeks gestation comes to the maternity ward because of headache. BP-150/90mmhg. phy exam shows swelling of both hands and feet(2+ pitting edema) and also the face.CVS, resp, abd, fundoscopic and neurological exams are WNL. fetal heart tracing is reassuring. lab studies how elevated BUN and creatinine. urinalysis shows 2+ protenuria. amniotic fluid analysis shows immature fetal lungs. which is the most apt next step ?
1) salt restricted diet and steroids
2) salt reduced diet, steroids and rapid vaginal delivery
3) anti-HT's and steroids
4) IM mgso4 and steroids
5)scheduled CS
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| msyamp
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I go with 1
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| drk1980
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i agree wth MSYAMP....acc. to diagnostic criteria its mild preeclampsia...so conservative Mx.
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| infliximab
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BECAUSE OF HEADACHE, THERE IS MATERNAL JEOPARDY, SO I LL GO WITH ANY OPTION WITH RAPID DELIVERY AND MEASURE TO MATURE FETAL LUNG
ie OPTION 2
NOTE, IF 5 WAS EMERGENCY NOT SCHEDULED, WOULD HAVE BEEN A BETTER OPTION
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| dr_lashari
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i,ll go with ans no 1
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| infliximab
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REMAIN WITH OPTION 2
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| achilles
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well guys the correct answer is 1.the explanation given was that this is mild preeclampsia.
i got this one wrong. i choose 3.
to me it looked like severe pre-eclampsia and that wss because she had headache and elevated BUN and creatinine. aren't these two signs that mild pre-eclampsia has now converted into severe pre-eclampsia or we should only go by the BP, which should be more than 160/110 to classify it as severe preeclampsia.
msyamp, Drk1980, Dr lashari...could you pls help me with this confusion. i thought that she has headache and elevated BUN and creatinine so she had severe pree-eclampsia. i know there is something i am missing here.
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| Rasul
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If it's only IV MgSO4, I's go with 4.
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| achilles
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thanks babli...you helped me figure it out...i went back to the text and there it was ...right there !!
this patient had headache only as a symptom and all other examination was normal and hemoconcentration is present in mild preeclampsia also but it is just more marked in severe preeclampsia. but babli...BUN and creat do not rise in pregnancy....if they do then there is a prob...either it is due to preeclampsia or there is a prob with perfusion of the kidneys. so now it is clear.thanks again.
rasul, the answer is 1-salt restriction and steroids.
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| babli
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thanks achilles for corresting me.you are right BUN & CREATININE are not elevated in normal pregnancy.
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| infliximab
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ACHILLES,
IN KAPLAN NOTES PG 63, IT SAYS;
DIAGNOSIS OF SEVERE PREECLAMPSIA IS MADE WITH THE FINDING OF ATLEAST "MILD PREECLAMPSIA" WITH ANY ONE OF THE FF;
-SUSTAINED BP>160/110
-PROTEINURIA ON DIPSTICK 3-4+
-EVIDENCE OF MATERNAL JEOPARDY; SYMPTOMS INCLUDE HEADACHE ETC
WHICH MEANS THE FINDING OF THE BP >160/110 IS NOT A MUST FOR SEVERE HYPT
ACHILLES I THINK U NEED TO REVIEW UR ANS, DONT AGREE WITH U ON THIS ONE!
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| babli
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just found useful concerning above discussion
Indications for Delivery in Preeclampsia
Fetal indications
Severe intrauterine growth restriction
Nonreassuring fetal surveillance
Oligohydramnios
Maternal indications
Gestational age of 38 weeks or greater*
Platelet count below 100 X 103 per mm3 (100 X 109 per L)
Progressive deterioration of hepatic function
Progressive deterioration of renal function
Suspected placental abruption
Persistent severe headache or visual changes
Persistent severe epigastric pain, nausea, or vomiting
Eclampsia
*-Delivery should be based on maternal and fetal conditions as well as gestational age.
Adapted from National High Blood Pressure Education Program. Working Group on High Blood Pressure in Pregnancy. Working group report on high blood pressure in pregnancy. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 2000; NIH publication no. 00-3029. Accessed online July 19, 2004, at http://www.nhlbi.nih.gov/health/prof/heart/hbp/hb....
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| babli
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Signs of severe preeclampsia in the mother — As outlined above, these signs include: - Blood pressure greater than 160 to 180/110 (a risk for stroke)
- Platelet count <100,000 (a risk for bleeding)
- Elevated liver enzyme tests or persistent liver pain (a risk for liver rupture)
- Rising creatinine or severely decreased urine output (a risk for kidney failure)
- Shortness of breath from fluid in the lung spaces (a sign of weakening of the heart)
- Persistent severe headache (a risk for seizure)
- Abruption of the placenta (a risk for bleeding and harm to baby).
Signs of severe preeclampsia affecting the baby — The baby should be delivered in response to the following:
- Nonreassuring tests of fetal well-being (nonstress test or ultrasound)
- Suboptimal fetal growth (an ultrasound estimate that the baby's weight is less than expected for the gestational age)
- Decreased amount of amniotic fluid around the baby noted on ultrasound
- Decreased blood flow through the umbilical cord noted on Doppler tests.
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| infliximab
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babli wats ur conclusion?
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| babli
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infliximab i will go with 1 because severe persistent headache/visual changes would classify it as severe preeclampsia or indication for delivery.in above case both mom & baby looks fine after examination.
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| achilles
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thanks babli for all the effort. i really appreciate it.
infliximab, the symptom of headache in this patient was the point of confusion for me too and thats why i answered it wrong too...but looking back at the question,and many other questions on the usmle that deal with severe preeclampsia, the rest of the examination is wnl and there are none of the other symptoms that will shift the opinion in favour of severe preeclampsia...usually there are other symptoms also in the patient when she has severe preeclampsia(thats how they describe it in questions on severe preeclampsia on the usmle)...and on examination the mother is fine and the baby too is fine.
this was a question from uw...the given answer is 1-salt restricted diet and steroids. but yes the symptom of headache was confusing and thats what made me choose the wrong answer too and thats why the question is here so that we could discuss about it and i'll know what i was missing in this question.
as far as i am concerned, the answer is 1-salt restricted diet.
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| achilles
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but it sure was a valid point of discussion infliximab cause thats what the text said...any one of the symptoms (headache et all) will shift the diagnosis in favour of severe preeclampsia...but i guess the question will be more clear about the symptoms when they want you to think of severe preeclampsia.
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" i have miles to go before i sleep "
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