Interesting Case Rounds

Mark BoykoEM Resident

REDIS ‘Reason For Visit’

“Penis caught in the net”

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.

CASE

• VITALS:

HR 34, regular

BP 170/105 right arm

RR 18

O2 96% on RA

Temp 37.3

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 she’s 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”

Past Med Hx

• Born in Saudi Arabia

• Denies any medical conditions

• Denies previous heart problem

• Mostly inactive

• No medications

• No drugs/EtOH

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”

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

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

Thoughts So Far?

About that heart rate…

Blood WorkNa+ 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

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

What do you want to do right now?

• BP control– Hydralazine 10mg IV x 1

• Pain control– Morphine 5mg IV now

Reassess

• HR 40, BP 154/92

• Headache slightly improved but still there

Imaging

Imaging Results• Non-contrast CT Head

– Normal

• CT Venogram– Normal

More Blood WorkALT normal

Bili normal

Mg2+ normal

Ca2+ normal

Alb 34

Uric Acid 410 (140-360)

LDH 336 (100-235)

 

 

Urinalysis – “I don’t have to pee”

She Finally Pees…

• Leuks Neg

• Nitr Neg

• Protein 1+

• RBC’s 20/HPF

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 ‘Who’s the Boss’ re-

run

Late Post Partum Pre-eclampsia• Does this actually exist?

--> 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.

Late Post Partum Pre-eclampsia Treatment

• Treat the same as you would regular pre-eclampsia, but you don’t 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

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

•Sheehan’s Syndrome

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.

What About Dural Venous Thrombosis?

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!

What’s the deal with the heart block?

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

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 2:1 block with a narrow QRS… hard to figure out!

*Only way to truly differentiate is intra-cardiac EPS. All Mobitz Type II’s get a pacemaker, regardless of whether or not they are asymptomatic.

How’s 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

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

It could be worse…

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