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Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams

Emergency Medical Minute

Release Date: 09/12/2024

Episode 942: Acute Mountain Sickness and High Altitude Cerebral Edema show art Episode 942: Acute Mountain Sickness and High Altitude Cerebral Edema

Emergency Medical Minute

Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly May develop more severe symptoms at higher altitudes The pathophysiology involves cerebral vasodilation Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms The reduced...

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Emergency Medical Minute

Contributor: Meghan Hurley, MD Educational Pearls: Gastroenteritis clinical diagnoses: Diarrhea with or without vomiting and fever Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest Treatment for mild to moderate dehydration: oral or IV rehydration Begin orally to avoid unnecessary IV in a pediatric patient Administer ODT Ondansetron...

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Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best? A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and...

info_outline Episode 939: Serotonin Syndrome show art Episode 939: Serotonin Syndrome

Emergency Medical Minute

Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs Examples of unexpected monoamine oxidase inhibitors Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia Other medications that can interact with SSRIs to cause serotonin syndrome Dextromethorphan - primarily an...

info_outline Episode 938: AHA Policy on Management of Elevated Blood Pressure (BP) in the Acute Care Setting show art Episode 938: AHA Policy on Management of Elevated Blood Pressure (BP) in the Acute Care Setting

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Many patients present to the ED with elevated BP Many are referred from outpatient surgery centers or present after an elevated measurement at home Persistent questions on the best way to treat these patients The AHA published a scientific statement on the management of elevated BP in the acute care setting Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage Includes aortic dissection or subarachnoid hemorrhage  Require aggressive treatment Asymptomatic...

info_outline Episode 937: Pneumomediastinum show art Episode 937: Pneumomediastinum

Emergency Medical Minute

Contributor: Megan Hurley MD Educational Pearls: What is the mediastinum? The thoracic cavity is separated into different compartments by membranes The lungs exist in their own pleural cavities, and the mediastinum is everything in between The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves. What is a pneumomediastinum? Air in the mediastinum How can pneumomediastinum be categorized? Traumatic Ex. Stab wound to the trachea Ex. Boerhaave’s...

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Emergency Medical Minute

Contributor: Ricky Dhaliwal MD Educational Pearls:  Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% ...

info_outline Episode 935: Pregnancy Extremis - TOLDD show art Episode 935: Pregnancy Extremis - TOLDD

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side O: Administer high-flow...

info_outline Episode 934: Subendocardial Ischemia show art Episode 934: Subendocardial Ischemia

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).  It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST...

info_outline Episode 933: Benign Convulsions with Gastroenteritis show art Episode 933: Benign Convulsions with Gastroenteritis

Emergency Medical Minute

Contributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or...

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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

  • Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.

  • Hypertension (HTN) complicates 2-8% of pregnancies

  • The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart

  • There is a range of HTN disorders

    • Chronic HTN which could have superimposed preeclampsia (preE) on top

    • Gestational HTN in which there are no lab abnormalities

    • PreE w/o severe features

      • Protein in urine

      • Urine protein >300 mg in 24 hours

      • Urine Protein to Creatinine ratio of .3

      • +2 Protein on urine dipstick

    • PreE w/ severe features

      • Systolics above 160 mmHg

      • Diastolics above 110 mmHg

      • Headache, especially not going away with meds, or different than previous headaches

      • Visual changes, anything that lasts more than a few minutes

      • RUQ pain, which could present as heartburn

      • Pulmonary edema

      • Low platelets, if <150 perk up ears, <100 definitely look into

      • Renal insufficiency, creatinine 1.1 or higher or doubling of baseline

      • Impaired liver function

      • Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to

  • Treatment

    • Labetalol, IV

      • Avoid in bradycardia, asthma, or myocardial disease

      • Quick up titrate, with dosing regimens such as 20-20-40 or 20-40-80 (mg)

    • Hydralazine, IV

      • 5 mg starting, then another 5 mg then 10 mg if not working

    • Nifedipine, Oral

      • Can cause a headache

    • Goal is not to normalize BP but bring it down slowly

  • How to give magnesium

    • Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function

    • Follow with 2 g per hour or 1 g per hour

    • Don’t give in myasthenia gravis

  • What should you do if the patient progresses to eclampsia (seizures)

    • Magnesium is the best drug

    • Can use phenytoin or benzos IV as an alternate

    • Diazepam is available PR which is a good option if you don’t have IV access

    • IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks

  • Facts about post-partum PreE

    • 20% of women will have HTN post-partum

    • Most resolve by 6 weeks

    • If it lingers past 6 months this is chronic HTN

    • If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor

    • Post-partum is the most common time for strokes

    • Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed

    • Enalapril is safe in breast feeding

    • Some patients might need to give up breast feeding to be on even more aggressive HTN therapy

    • Are NSAIDs safe while breastfeeding?

      • Motrin is pretty safe

    • Pulm edema is a risk, be careful with fluids

  • Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea

 

References

  1. Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6

  2. Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276

  3. Reed, B. (2020, May 2). ‘They didn’t listen to me’: Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death

  4. Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330

  5. Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008

  6. Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653

 

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII