Discussion


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The radiograph depicts a small right pleural effusion. The next best step in treatment would be to treat the patient for pre-eclampsia and refer for obstetrical/gynecologic consultation.

Pre-eclampsia, also known as pregnancy-induced hypertension, is a multiorgan condition thought to be triggered by endothelial cell damage or dysfunction occurring between 20 weeks’ gestation and 4 weeks’ post-partum. Although it represents a minority of overall cases, postpartum pre-eclampsia is the type most likely to be diagnosed by nonobstetrical providers.  Symptoms are mostly neurologic, cardiopulmonary, and hepatic. 

The diagnosis of pre-eclampsia is made by consistent blood pressure measurements >140/90 mm Hg; symptoms include edema or effusion of the lung, cerebral symptoms (ie, headache and vision loss), elevated liver function tests, azotemia, proteinuria, and platelet count >100 with a recent or current pregnancy past 20 weeks. The mnemonic ECLAMPSIA can be helpful to remember these symptoms. Severe forms of pre-eclampsia may include massive proteinuria, seizures, blood pressure >160/110 mm Hg, or ascites. 

Management of pre-eclampsia involves delivery of the fetus if possible, as well as high-dose intravenous magnesium sulfate plus various antihypertensive agents to achieve a target blood pressure of approximately 145/95 mm Hg. Diuretics should be avoided. If seizures occur despite magnesium, phenytoin and/or benzodiazepines may be added. Imaging is not universally required but should be targeted to the clinical presentation and blood values, especially if symptoms do not improve with standard therapy.

Case Conclusion

The patient was admitted for pre-eclampsia and treated with magnesium. Computed tomographic (CT) imaging of the chest was negative for pulmonary embolism or liver pathology but did reveal small bilateral pleural effusions. CT of the head was negative for bleeding or venous sinus thrombosis. Blood pressure and headache improved with treatment; AST and ALT increased slightly on day 1 of treatment but then improved.

Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Reference

Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. EMresource.org. 2017;5.