Postpartum Pre-Ecclampsia Education

Charlotte Reich, MD FACEP

The Case- 38y/o female lifelong asthmatic with one remote admission, no intubation, on no maintenance therapy, BIBEMS as notification for asthma exacerbation, found tachypneic with wheeze and a room air saturation in the low 90s, given decadron 12mg, duoneb x 3, MgSO4 2 gm, refused cpap.

BTW 10 days postpartum

On arrival sitting up speaking in broken sentences, reports much improvement but tachypneic/still in some distress, HR 120s BP 169/119 RR 26 satura3on 98% on nebulizer HEENT: NC/AT, perrla, conjunctivae pink, sclerae anicteric

Neck: supple

Cor: tachycardic, regular, no murmur

Lungs: +end expiratory wheeze in upper lung fields with coarse rales and diminished breath sounds at bases L>>R

Abd: soft, nontender

Extremi3es: 1+ b/l lower extremity edema, calves nontender

Neuro: nonfocal

Is this just status asthmaticus?

Given one additional neb as she says this helped

Further history:

G4P1021 s/p NSVD at 36w5d

No prenatal care as she did not realize she was pregnant until 7 months gestation +intrapartum cocaine/alcohol/tobacco use (not disclosed)

Questionable elevated BP with prior pregnancy, 140s/90s in L&D Eloped on postpartum day 1

Had been feeling short of breath for the last few days, +orthopnea, +leg swelling, +mild headache, since resolved

No abdominal pain, chest pain, or visual disturbance; no cough, no fever, lochia resolved

Differential diagnosis:

Status asthmaticus

Postpartum cardiomyopathy

PPCM with preserved ejection fraction

Pulmonary embolism

Amniotic fluid embolism

Severe anemia

Acute renal failure

SCAD (spontaneous coronary artery dissec3on)

Postpartum preeclampsia

HELLP syndrome

Initial diagnosics:

EKG- sinus tachycardia 117 normal axis and intervals no st/t wave changes

POCUS- no pericardial effusion, no RV dila3on, grossly normal EF; B lines with pleural effusions CXR: CHF with bilateral pleural effusions L>R

Duplex: negative for DVT

Labs: WBC 19 H/H 10.9/32.3 Plt 679; Na 141 K 4.1 Cl 106 CO2 24 BUN 8 creatinine 0.7 Glucose 108 Ca 9; total protein 6.6/albumin 3.7, AP 106. T bili 0.7, AST 16/ALT 17pH 7.34 CO2 44 lactate 0.9 (venous); troponin 20, bnp 3373

uric acid 3.8 LDH 277 fibrinogen 438 ddimer 309

Clinical course:

Agreed to bipap a\er decompensa3ng when gently reclined for POCUS

Given Lasix, vital signs improved with improved respiratory mechanics and did not require aggressive BP control

Transferred North a.er discussion with OB

CTA negative for PE

Received MgSO4 4gm load and 2gm/hr for the next 24 hours, hydralazine/labetalol prn, Ativan ciwa protocol

LeftAMA after 2 days prior to official echo

Diagnosis- postpartum preeclampsia with severe features

Preeclampsia criteria:

After 20 weeks gesta:on up to 6 weeks postpartum

Blood pressure >140/90 for 2 measurements 4 hours apart OR >160/110 PLUS proteinuria (>300mg in 24 hrs or >1+ dipstick)

OR other end organ involvement (dyspnea, headache, visual changes, peripheral edema, upper abdominal/shoulder pain, nausea/vomi3ng, sudden weight gain)

Proteinuria not required to make diagnosis Other signs/symptoms may precede elevated BP

Diagnostics:

CBC (platelets <100) with smear, LFTs (AST>70, indirect bilirubin >1.2), BMP (crea3nine >1.1 or double baseline), uric acid (>5.6, highly specific), LDH (>600), PT/PTT (elevated), fibrinogen (decreased), ddimer (elevated)

EKG, CXR, abdominal ultrasound (if pain/abnormal LFTs), CTH (if seizure/headache/visual complaints/focal neuro findings), CTA chest, echocardiogram

Management:

Seizure prophylaxis-

MgSO4 4 gm load, 1-2gm/hr for 24 hours

BP control-

labetalol 20mg IVP q10 minutes (40, 80, 80, 80, max 300mg) hydralazine 5-10mg IVP q20min (max 30mg) nifedipine10mg po q15-30 min (3 doses max)

may consider sodium nitroprusside Pulmonary edema-

Diuretics, NIPPV

Take home points:

21% of preeclampsia is postpartum

Postpartum preeclampsia associated with significant morbidity and mortality

Seizure prevention, blood pressure control and suppor3ve care are mainstays of treatment Diagnosis is key!!!

If it’s not on your differential you won’t diagnose it

Mothers are not routinely evaluated until 2-6 weeks postpartum, therefore any encounter with the healthcare establishment for any reason (eg the emergency department) is an opportunity to detect and treat a potentially life threatening condi3on

Do not blow off an elevated blood pressure in a patient in her first 6 weeks postpartum VITAL SIGNS ARE VITAL!!!

References:

Hauspurg et al. Postpartum preeclampsia/eclampsia: Defining its place and management among the hypertensive disorders of pregnancy. Am J Obstet Gynecol, 2022 Feb:226(2 Suppl);S1211-1221

Deshmukh et al. Acute postpartum heart failure with preserved systolic func3on. J Am Coll Cardiol case report, 2020 Jan, 2(1) 82-85

Fehr et al. (April 8, 2024) Clinical analysis of postpartum preeclampsia a\er an uncomplicated pregnancy. Cureus 16(4):e57834