Postpartum Preeclampsia—A Diagnosis Not to Be Missed

Abstract

Thank you to King et al.1King NM, Roberts M, Nabavizadeh P, Bennett S, Louis LB 4th, Cook JL. Extracorporeal Life Support for Cardiorespiratory Collapse After Delayed Diagnosis and Related Complications of Postpartum Preeclampsia [epub ahead of print]. J Cardiothorac Vasc Anesth. 2022:S1053-0770(22)00775-3. doi: 10.1053/j.jvca.2022.10.021Google Scholar for presenting this important case report of a parturient who necessitated mechanical circulatory support after decompensating postpartum. The patient was a healthy 26-year-old woman, a patient the authors would not predict would necessitate a mechanical assist device. She had an uncomplicated vaginal delivery and was discharged home 2 days later. However, as known from studies on maternal mortality, the postpartum period, sometimes called the fourth trimester, can be a dangerous time, with >50% of pregnancy-related maternal deaths occurring after delivery.2Kassebaum NJ Bertozzi-Villa A Coggeshall MS et al.Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2014; 384: 980-1004Abstract Full Text Full Text PDF PubMed Scopus (981) Google Scholar Although mortality is rare, postpartum morbidity is much more common and is a concern after delivery.3ACOG Committee Opinion No. 736Optimizing postpartum care.Obstet Gynecol. 2018; 131: e140-e150Crossref PubMed Scopus (396) Google Scholar Such complications include but are not limited to the following: severe postpartum hemorrhage; infections of the uterus, cesarean wound, breasts, or urinary tract; and thromboembolic events. Other less severe but still important concerns for the patient during this period include postpartum blues or depression, hemorrhoids, constipation, contraception options, weight retention, decreased libido, and breastfeeding difficulties.4Paladine HL Blenning CE Strangas Y. Postpartum care: An approach to the fourth trimester.Am Fam Physician. 2019; 100: 485-491PubMed Google Scholar Many of these events are treatable, but some may be harbingers for health issues later in the patient's life. For example, women who experience adverse pregnancy outcomes, such as gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm delivery, and low birth weight, may be at increased risk for developing cardiovascular disease later in life, independent of traditional cardiovascular disease risk factors.5Lane-Cordova AD Khan SS Grobman WA et al.Long-term cardiovascular risks associated with adverse pregnancy outcomes: JACC review topic of the week.J Am Coll Cardiol. 2019; 73: 2106-2116Crossref PubMed Scopus (103) Google Scholar Of greater concern, patients may not be aware of how these pregnancy-related conditions contribute to their long-term cardiovascular risk.6Beussink-Nelson L Baldridge AS Hibler E et al.Knowledge and perception of cardiovascular disease risk in women of reproductive age.Am J Prev Cardiol. 2022; 11100364Crossref PubMed Google Scholar The patient presented in this case developed postpartum preeclampsia, a diagnosis not as well-recognized as its counterpart, preeclampsia. Patients who present postpartum with new-onset hypertension, defined as a blood pressure of >140/90 mmHg, in conjunction with 1 other symptom, such as proteinuria, heart failure symptoms, neurologic symptoms, or other serum abnormalities, are diagnosed with postpartum preeclampsia. If the patient's blood pressure is >160/110 mmHg, then no other symptom is necessary for the diagnosis, and the patient is automatically diagnosed with postpartum preeclampsia. As one can see, proteinuria is not necessary for the diagnosis.7Hauspurg A Jeyabalan A. Postpartum preeclampsia or eclampsia: Defining its place and management among the hypertensive disorders of pregnancy.Am J Obstet Gynecol. 2022; 226: S1211-S1221Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar What was striking with this case is that the patient presented 3 times to the emergency department during her first week postpartum with various symptoms, including hypertension and headache. The emergency medicine physicians did not diagnose postpartum preeclampsia, perhaps because they were unaware of preeclampsia occurring postpartum or perhaps because they thought proteinuria was necessary to make that diagnosis. In 2013, the American College of Obstetricians and Gynecologists changed the guidelines for hypertension in pregnancy. One of the largest paradigm shifts was that proteinuria was no longer needed to diagnose preeclampsia.8Gestational hypertension and preeclampsia. ACOG practice bulletin summary, Number 222.Obstet Gynecol. 2020; 135 (1492-15)Google Scholar Therefore, a clinician can diagnose preeclampsia if hypertension occurs with any of the following: thrombocytopenia, impaired liver function, new-onset renal insufficiency, pulmonary edema, or new development of cerebral or visual disturbances.8Gestational hypertension and preeclampsia. ACOG practice bulletin summary, Number 222.Obstet Gynecol. 2020; 135 (1492-15)Google Scholar Without seeing the emergency room records or laboratory studies, it would be difficult to know for certain if the patient's clinicians were aware of this change. However, the patient's blood pressure on postpartum Day 7 was 182/95 mmHg, a dangerously high blood pressure for someone recently pregnant, a range that could lead to hemorrhagic stroke, pulmonary edema, or systolic dysfunction, all of which seemed to happen on postpartum Day 8 when the patient collapsed. This case underscores the importance of emergency medicine physicians and other clinicians being well-versed in common and serious postpartum pathologies. Clinicians must remember to ask patients about their recent pregnancy status. After pregnancy, many women are unsure of whom to contact with medical problems. They often do not think to contact their obstetrician because they are no longer pregnant. Instead, many patients present to urgent care or emergency rooms, unsure of where else to go. Postpartum patients are at risk for depression, peripartum cardiomyopathy, and headaches, some of which may have life-threatening causes, such as intracranial hemorrhage, central venous thrombosis, cervical artery dissection, and preeclampsia.9Wheaton N Al-Abdullah A Haertlein T. Late pregnancy and postpartum emergencies.Emerg Med Clin North Am. 2019; 37: 277-286Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar It is essential that all clinicians, not just obstetric-related professionals, familiarize themselves with postpartum pathologies to minimize the high level of maternal morbidity and mortality in this country. For example, a commonly missed diagnosis is spontaneous coronary artery dissection, a phenomenon that occurs mostly in young, otherwise healthy women without conventional risk factors of atherosclerosis. Spontaneous coronary artery dissection typically occurs postpartum when related to pregnancy, most commonly within the first week after delivery. Some patients are asymptomatic, but others may experience sudden cardiac death before reaching a healthcare professional. Patients who present to a doctor's office or emergency room typically present with chest pain. Other symptoms may include a rapid heartbeat or fluttery feeling in the chest, pain in the arms, shoulders, or jaw, or vague symptoms like shortness of breath, sweating, unusual, extreme tiredness, nausea, and dizziness. Because clinicians do not consider ischemic heart disease in young, healthy women, these symptoms typically are attributed to panic, anxiety, or extreme exhaustion postpartum. Often, electrocardiograms are not even ordered, and patients are sent home.10Hayes SN Kim ESH Saw J et al.Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the.American Heart Association. Circulation. 2018; 137: e523-e557Google Scholar Being aware that pregnancy or postpartum status is a large risk factor for spontaneous coronary artery dissection may prompt the clinician to order an electrocardiogram and check cardiac enzymes. In this patient's clinical course, the diagnosis of postpartum preeclampsia led to the patient's numerous complications. It is important to understand that preeclampsia is not simply hypertension in a pregnant woman after 20 weeks of gestational age but rather multiorgan damage and, if untreated, failure. Complications include but are not limited to heart failure, pulmonary edema, renal dysfunction or failure, seizures, posterior reversible encephalopathy syndrome (PRES), blindness, respiratory failure, liver failure, thrombocytopenia, disseminated intravascular coagulation, and even death. Research is being done to better understand the underlying mechanisms contributing to preeclampsia's development and progression. It appears that during implantation of the fertilized egg, a patient with preeclampsia has impaired trophoblast invasion and defective spiral artery remodeling, which lead to placental ischemia. The placental ischemia stimulates a cascade of activation and/or dysfunction of the maternal vascular endothelium and a release of antiangiogenic factors with eventual multiorgan failure.11Ives CW Sinkey R Rajapreyar I et al.Preeclampsia-pathophysiology and clinical presentations: JACC state-of-the-art review.J Am Coll Cardiol. 2020; 76: 1690-1702Crossref PubMed Scopus (140) Google Scholar The patient presented in this case conference had untreated postpartum preeclampsia that led to persistent hypertension and progressed to eclampsia with a tonic-clonic seizure. It appeared that she aspirated, and her emergent intubation was difficult, leading to hypoxic respiratory failure and cardiac arrest with pulseless electrical activity. Magnetic resonance imaging (MRI) done 3 days after the seizure revealed PRES and vertebral artery dissection, all of which could be attributed to the patient's preeclampsia. Posterior reversible encephalopathy syndrome is a syndrome of vasogenic brain edema that typically presents with a headache and seizures, but can be associated with other focal neurologic deficits. It is most often sudden in onset brought on by the rapid development of hypertension, leading to hyperperfusion and increased cerebral perfusion pressure causing vasogenic edema.12Gewirtz AN Gao V Parauda SC et al.Posterior reversible encephalopathy syndrome.Curr Pain Headache Rep. 2021; 25: 19Crossref PubMed Scopus (24) Google Scholar There is considerable overlap between PRES and eclampsia, suggesting they actually may be the same disease process. In one study, 98% of patients with eclampsia had radiographic evidence of PRES on MRI.13Zambrano MD Miller EC. Maternal stroke: An update.Curr Atheroscler Rep. 2019; 21: 33Crossref PubMed Scopus (25) Google Scholar Laboratory findings are unnecessary for the diagnosis, but neuroimaging is necessary. Most often, computed tomography (CT) scanning is usually the first neuroimaging modality of a parturient with neurologic deficits because of its speed and ability to diagnose intracranial hemorrhage. However, vasogenic edema is not always seen on a CT scan and was not seen in this patient's CT. Instead, an MRI is most often needed to confirm the diagnosis, as was seen in this patient's hospital course. The treatment for PRES is the same as eclampsia, and includes magnesium sulfate to treat the eclamptic seizure and gradual blood pressure reduction if the patient is hypertensive. Another interesting finding in the CT angiogram of the head and neck demonstrated a vertebral artery dissection. Dissections, whether they affect the vertebral arteries, coronary arteries, or aorta, may occur more often during pregnancy because of how the cardiac physiology is altered during pregnancy, with increased plasma volume, stroke volume, heart rate, cardiac output, etc. In addition, the pregnant body experiences numerous fluctuations in estrogen and progesterone, which can alter the arterial wall and cause decreased elasticity and increased arterial wall thickness, making the arteries more susceptible to dissection.14Bons LR Roos-Hesselink JW. Aortic disease and pregnancy.Curr Opin Cardiol. 2016; 31: 611-617Crossref PubMed Scopus (15) Google Scholar Furthermore, patients diagnosed with hypertensive disorders of pregnancy have a higher risk of developing a cervical artery dissection.15Salehi Omran S Parikh NS Poisson S et al.Association between pregnancy and cervical artery dissection.Ann Neurol. 2020; 88: 596-602Crossref PubMed Scopus (21) Google Scholar Clinicians should have a low threshold for sending high-risk patients, such as patients with preeclampsia, to be evaluated for a cervical artery dissection if they develop headaches or focal neurologic deficits, as it can be a potential cause of stroke. Of course, not all headaches during pregnancy or postpartum are dangerous. Still, headaches in patients with hypertensive disorders of pregnancy can be worrisome, as they can indicate a deadly hemorrhagic stroke, cerebral vein thrombosis, impending eclampsia, or PRES, as in this patient's case. There are no formal guidelines on managing headaches during labor and delivery or immediately postpartum, but to avoid missing a potential catastrophic cause of headaches, it is reasonable to further evaluate headaches accompanied by a focal neurologic deficit or those headaches resistant to over-the-counter analgesics. Clinicians should be particularly concerned about patients diagnosed with hypertensive disorders of pregnancy. More studies have been published citing arterial dissections, especially in cervical arteries, are more common than what was previously thought and should be considered in the postpartum headache differential diagnosis.16Shanmugalingam R Reza Pour N Chuah SC et al.Vertebral artery dissection in hypertensive disorders of pregnancy: A case series and literature review.BMC Pregnancy Childbirth. 2016; 16: 164Crossref PubMed Scopus (26) Google Scholar In conclusion, King et al.1King NM, Roberts M, Nabavizadeh P, Bennett S, Louis LB 4th, Cook JL. Extracorporeal Life Support for Cardiorespiratory Collapse After Delayed Diagnosis and Related Complications of Postpartum Preeclampsia [epub ahead of print]. J Cardiothorac Vasc Anesth. 2022:S1053-0770(22)00775-3. doi: 10.1053/j.jvca.2022.10.021Google Scholar presented a very interesting patient who underscored the danger and catastrophic complications of preeclampsia and eclampsia. This patient's postpartum preeclampsia made the diagnosis particularly challenging for the emergency room staff, and should be an important reminder that patients can present with preeclampsia and eclampsia for up to 6 weeks after delivery. One systems-based intervention that may reduce missed diagnoses, such as this one, would be to ask all patients who present to the emergency room if they have been pregnant in the last year.17Illinois Department of Public HealthIllinois Maternal Morbidity and Mortality Report. Illinois. Department of Public Health, 2018https://dph.illinois.gov/content/dam/soi/en/web/idph/files/publications/publicationsowhmaternalmorbiditymortalityreport112018.pdfGoogle Scholar The emergency room team could then activate the hospital's cardio-obstetric team, should one exist, and, therefore, have the multidisciplinary team guide the initial management and counsel the patient about her long-term risk. Awareness of pregnancy status is critical, as it is the first step in diagnosing common postpartum pathologies. Accurate diagnosis and treatment could only help mitigate our rising maternal morbidity and mortality rates in the United States. None. Extracorporeal Life Support for Cardiorespiratory Collapse After Delayed Diagnosis and Related Complications of Postpartum PreeclampsiaJournal of Cardiothoracic and Vascular AnesthesiaPreviewAS CLINICIANS PUSH FORWARD into the future of obstetrical care and mechanical circulatory support, they will increasingly find these 2 seemingly separate environments intersecting as complexity grows within the obstetric population. Care for these challenging patients brings to light the present systemic biases that are integrated into the very medical infrastructure from which care is provided. The case presented here highlights these facts, and demonstrates a need for clinical and systemic growth and improvement regarding the recognition of peripartum complications and the need to mitigate the morbidity and mortality associated with potential bias. Full-Text PDF