Interesting Case Rounds

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Interesting Case Rounds

• Mark Boyko
• EM Resident

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REDIS Reason For Visit

• Penis caught in the net

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CASE

• 30-year old middle-eastern woman presents to the
  ER with complaints of a bilateral, throbbing
  headache, located in the occipital region.
• Heart rate 34 on REDIS.
• Stable when you see her
• Difficult history because of language barrier.
  Baby is present in stroller by bed.

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CASE

• VITALS
• HR 34, regular
• BP 170/105 right arm
• RR 18
• O2 96 on RA
• Temp 37.3

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CASE

• It came on gradually 2 days earlier, was 10/10
  but now is 8/10.
• Unresponsive to Tylenol, worried about taking
  anything else because shes breastfeeding.
• No visual changes, no photophobia, no dizziness
• Has some neck stiffness, has been nauseated but
  has not vomited
• H/A worse when she lies down, has not been able
  to sleep
• Has not been very mobile since delivery, still
  quite sore in the abdomen
• Denies chest pain, dizziness, shortness of breath
• Denies bleeding per vagina
• Please just make the headache stop

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Past Med Hx

• Born in Saudi Arabia
• Denies any medical conditions
• Denies previous heart problem
• Mostly inactive
• No medications
• No drugs/EtOH

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Pregnancy Hx

• First baby, no previous pregnancy
• Spent first 6 months of pregnancy in Saudi
  Arabia, then moved to Canada
• Denies any complications during pregnancy
• Blood pressure was always low
• Carried baby 40 weeks, delivered at PLC
• SROM but failed to dilate beyond 5cm, was taken
  for c-section, baby was out under 24hrs from ROM.
  No fever for mom or baby
• Had epidural but took them a few tries, it was
  painful near my lower back
• Stayed in hospital 4 days, they were checking
  out my heart

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Phx

• HR fluctuating between 32-40 BPM
• General Sweaty, but A/O
• CNS
• PERL, EOM normal, fields normal
• able to flex/extend neck, not objectively stiff
• no pronator drift
• symmetrical movements UL LL, power 5
• reflexes 1 in UL LL

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Phx (cont)

• CVS
• JVP not elevated
• N S1 S2, II/VI mid-systolic murmur LUSB
• pulses equal R L radial
•  
• RESP
• normal A/E, equal, no crackles
•  
• ABDOMEN
• incision looks okay
• bulky mass left side of midline just above
  incision, very tender
• Otherwise no peritoneal signs
•  
• BACK
• 4 puncture wounds near site of epidural, tender
  near area, no cellulitis or mass
• LEGS
• no calf tenderness or swelling
• pedal pulses present

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Thoughts So Far?

• About that heart rate

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Blood Work

• Na 142
• K 3.8
• Cl- 105
• HCO3- 2.3
•  
• WBC 8.0
• Hgb 143
• Plts 211
• Hct 0.45
• Glucose 7.6
•  
• Cr 50
• BUN 3.1

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Old Charts Come Down

• Cardiology saw her post-op day 1 after nurse
  noticed low HR in the morning, and ECG showed
  2nd degree heart block Mobitz II
• Holter done, untypable 2nd degree block
  possibly Mobitz I
• ECHO was done, results normal
• discharged home with follow-up in 1 month

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What do you want to do right now?

• BP control
• Hydralazine 10mg IV x 1
• Pain control
• Morphine 5mg IV now

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Reassess

• HR 40, BP 154/92
• Headache slightly improved but still there

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Imaging

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Imaging Results

• Non-contrast CT Head
• Normal
• CT Venogram
• Normal

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More Blood Work

• ALT normal
• Bili normal
• Mg2 normal
• Ca2 normal
• Alb 34
• Uric Acid 410 (140-360)
• LDH 336 (100-235)
•  
•  
• Urinalysis I dont have to pee

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She Finally Pees

• Leuks Neg
• Nitr Neg
• Protein 1
• RBCs 20/HPF

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What to do

• Treat as pre-eclampsia !!
• Mg2 IV
• Consult MTU
• They are puzzled by heart rate
• Consult Cardio OB
• You go home and watch a Whos the Boss re-run

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Late Post Partum Pre-eclampsia

• Does this actually exist?
• --gt YES
• Pre-eclampsia symptoms in a woman 48hrs to 4
  weeks post-partum
• Overall incidence of pre-eclampsia is declining,
  but incidence of post partum pre-eclampsia is
  rising (likely from early d/c out of hospital)
• Up to 25 of pre-eclampsia cases are post-partum
• 50 of these cases are beyond 48hrs
• 70 of these cases develop convulsions
• HEELP syndrome and more classic pre-eclampsia lab
  work is appreciated only in a minority of late
  post partum pre-eclampsia, thus have a lower
  threshold for treating these patients.

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Late Post Partum Pre-eclampsia Treatment

• Treat the same as you would regular
  pre-eclampsia, but you dont have a baby to
  deliver at the end
• Mg Sulfate 4g loading dose over 15minutes, then
  2g/hr infusion for 24-48 hrs while monitoring
• Mg2 levels
• reflexes
• urine output (Mg2 is excreted by the KIDNEYS)
• Blood work 2-3x daily

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• Post-Partum Headache Is Your Work-Up Complete?
• American Journal of Obstetrics and Gynecology -
  Volume 196, Issue 4 (April 2007)

• Primary Headache
• vs
• Secondary Headache
• Dural Venous Thrombosis
• Post Puncture Headache
• SAH
• Post Partum Cerebral Angiopathy
• Sheehans Syndrome

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What about Post LP Headache?

• Post partum incidence roughly 2-22
• 90 present within first 3 days of procedure, 66
  within first 2 days, but can develop up to 14
  days after procedure
• An increase of the headache upon standing is the
  sine qua non symptom ? Unless a headache with
  postural features is present, the diagnosis of
  post-dural puncture headache should be
  questioned. By definition, it worsens within 15
  min of standing, improves within 30min of lying
  down.
• Diagnosis ? is for the most part CLINICAL.

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What About Dural Venous Thrombosis?
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Dural Venous Thrombosis

• Incidence in North America 10-20 cases per
  100,000 deliveries, much higher in developing
  nations
• Most often occurs post-partum versus during
  pregnancy
• Mortality rate 4
• Intracranial venous congestion and damage to
  vessel endothelium secondary to mechanics of
  labour, in combination with the increased
  hypercoagulability that occurs postpartum
• Women remain hypercoagulable 2 weeks post
  partum!

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Whats the deal with the heart block?

• Why did cardiology say it was untypable 2nd
  degree block?

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Which Mobitz izit?

• Mobitz I block within the AV Node, progressive
  lengthening of PR interval
• Mobitz II block below the AV Node, presumed to
  be healthy. Most often, QRS is wide. A narrow QRS
  essentially excludes infra-nodal heart block.
• Our patient was a perfect 21 block with a narrow
  QRS hard to figure out!
• Only way to truly differentiate is intra-cardiac
  EPS. All Mobitz Type IIs get a pacemaker,
  regardless of whether or not they are
  asymptomatic.

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Hows Our Patient Doing?

• BP controlled, oral long-acting Ca2 blocker
  (Dihydropyridine!)
• Was on IV Mg 2 infusion for 48hrs, had 2
  proteinuria next urine check, now zero
• Never had elevated liver enzymes
• No seizures
• U/S showed 5cm fibroid, no retained POC
• Cardiology will do EPS study

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Any link between heart block and labour?

• Case report following Ergot alkaloids
• Case report mom with Listeriosis during pregnancy
• Congenital? A small percentage present late in
  life

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It could be worse
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Take Home Points

• Late Post Partum Pre-eclampsia can happen up to
  28 days after delivery
• Lower threshold to treat
• CT Venogram is the first choice to look for dural
  thrombosis
• Lots of confounders, stick to the big things you
  need to rule out given the context