This traditional view is becoming less stringent,

however, and many hospitals now use cuffed endotracheal

tubes in all ages (decreasing air leak and improving ventilation efficiency).

The pediatric skeleton and surrounding ligaments and

tissues are also more flexible and less protective than the

adult. The pediatric head is proportionately larger than in

adults, increasing the relative force of head and neck injuries. In addition, greater white matter content in the brain

increases the risk of injury secondary to axonal shearing

and cerebral edema. Infants also have open fontanelles in

their skull until about 18 months of age. Older children

have open growth plates in their long bones for many years

until they close in late adolescence; these are the weakest

portions of the bone and the most prone to injury. Injury

to the growth plates is commonly classified by the

Salter-Harris scoring system (Figure 47-1). Tenderness at

the growth plate without evidence of fracture is indicative

of a Salter-Harris type 1 fracture and generally should be

splinted for patient comfort, improved healing, and

medicolegal protection for the physician.

CHAPTER 47

Normal Type I Type II

Type Ill Type IV Type V

.A Figure 47·1. Salter-Harris classification. Reprinted with permission from Simon RR, Sherman sc,

and Koenigsknecht SJ. Emergency Orthopedics: The Extremities. 5th ed. New York: McGraw-Hill, 2007.

Infants and children are at increased risk of hypothermia

because of their high surface area to volume ratio. Pediatric

patients are at risk for spinal cord injury without

radiographic abnormalities (SCIWORA), because the

horizontal alignment of vertebral facet joints and more

elastic intervertebral ligaments predispose to subluxation

without bony injury. Finally, children overall are at an

increased risk for injury or disease because they are

unable to communicate, are dependent on their parent(s)

or guardian(s), and (especially when very young) are

immunologically immature. Take seriously a parent's report

of a significant change in behavior of his or her child.

DIAGNOSTIC STUDIES

..... Laboratory

Laboratory testing in children is performed much less

frequently than in adult patients. There are few instances in

which laboratory testing is part of the standard of care in

treating pediatric patients in the ED. These instances

include febrile neonates, diabetic ketoacidosis, sickle cell

crises, altered mental status, and neutropenic patients with

fever. Laboratory testing, generally, should be reserved for

confirming a diagnosis that is already suspected clinically,

or for assisting in the final disposition of the patient.

.... Imaging

In certain cases ( eg, trauma, altered mental status, and

suspected intraabdominal pathology), imaging tests such

as radiographs, ultrasound, computed tomography (CT),

and magnetic resonance imaging (MRI) may be necessary.

Plain radiographs are usually well-tolerated by pediatric

patients, as they are performed very fast and parents can be

close by with lead shielding. CT scans are somewhat less

tolerated, especially in younger children, as the patient is

required to leave his or her parent and lie flat on a

hard surface. This is even more pronounced in MRis for

these same reasons, in addition to the anxiety caused by

claustrophobia and loud noises made by the MRI. Anxiety

with imaging is often treated with short-acting sedatives

and/or pain medications (eg, midazolam, chloral hydrate,

and/or fentanyl).

THE PEDIATRIC PATIENT

Pediatric patient presents to ED

History obtai ned from child and parents

Exami nation performed with attention to patient's

developmental stage

Develop a differential diag nosis with consideration given to

age of patient

Discuss plan with parents and child

Figure 47-2. The pediatric patient diagnostic algorithm.

PROCEDURES

The general approach to procedures in children, j ust as in

the physical exam, is less anxiety-provoking by having the

parent participate as much as possible. Discussing the

procedure ahead of time with the parent(s)-especially

taking the time to mention key points during the procedure

and important actions the parents can take to help make

the procedure more comfortable for their child-can be

very helpful. For example, tell parents to hold the child

close, talk to the child, and help keep him or her still while

using sutures to repair a laceration, and tell parents how

doing so will help the child have a better experience (and

cosmetic outcome).

 

When performing a procedure, attempts should be

made to minimize pain and suffering in children through

the use of anesthetic, sedative, and/or pain medications.

Not only will the patient be happier, but the parents will be

more satisfied with their child's care. Use of topical

anesthetics during laceration repair, suprapubic bladder

tap, lumbar puncture, or intravenous access is recommended. During complex laceration repair or fracture

reduction, consider using procedural sedation. These pro ­

tocols use stronger medications such as ketarnine, midazolam, morphine, or fentanyl. Adequate pain relief can

help reduce anxiety as well.

MEDICAL DECISION MAKING

In most pediatric cases, your history and physical exam

are sufficient to rule out serious pathology. However, if

more ominous diagnoses are suggested by the history and/

or physical, testing should move into laboratory, imaging,

and possibly procedures as necessary (Figure 47-2).

TREATMENT

Once treatment strategies are chosen or narrowed down to

a few alternatives, it is a good time to review the options or

plan with the parent(s). The parents can be very helpful in

supporting the clinician in explaining the plan to the

patient. If multiple alternatives are presented, the parents

can help choose an option most in line with their wishes,

preferences, and/or child's comfort.

Medication dosages and emergency equipment must be

appropriate for the patient's weight. Getting an accurate

weight as part of the initial vital signs can help speed

medication calculations at this stage of the ED visit. If a

directly measured weight is unavailable in an emergent

situation, using a resuscitation tape (previously called

Broselow tape) can be extremely helpful. The red arrow on

the tape is placed at the patient's head and the tape is

extended to his/her feet to measure length. There is an

CHAPTER 47

average weight listed on the tape for this length. It is this

weight that is used for medication dosing, etc. All

medication dosages must be calculated on a milligram per

kilogram basis. All treatment should be performed as

quickly and as gently as possible.

DISPOSITION

� Admission

Indications for admission in pediatric patients include

suspected or confirmed acute surgical diagnoses ( eg,

appendicitis), any medical condition requiring further

monitoring and treatment ( eg, asthma, dehydration with

intractable vomiting), and uncertain diagnoses requiring

further work-up. Also, patients with certain social issues,

including suspected abuse, neglect, and failure to thrive,

should be considered for admission pending social services

consultation.

� Discharge

Stable patients with good social supports and medical

follow-up are appropriate for discharge after medical

conditions have been diagnosed and treatment plans

initiated and/or completed. Chronic conditions and related

complex work-ups in otherwise stable patients can be completed by the patient's primary care provider. Because almost

all pediatric patients have regular primary care providers,

patients will benefit from contact between the emergency

medicine physician and the primary care provider to have

appropriate continuity of care after discharge from the ED.

The treatment of the pediatric patient presents unique

challenges and requires specialized training but is easily

achievable by maintaining good rapport and communica ­

tion and showing patience and empathy. These skills will

decrease the amount of anxiety for the patient and parent,

facilitate care, and improve compliance.

SUGGESTED READING

American Academy of Pediatrics Committee on Pediatric

Emergency Medicine, American College of Emergency

Physicians Pediatric Emergency Medicine Committee, O'Malley

P, Brown K, Mace SE. Patient- and family-centered care and the

role of the emergency physician providing care to a chlld in the

emergency department. Pediatrics. 2006;118:2242-2244.

Corrales 1\Y, Starr M. Assessment of the unwell chlld. Aust Pam

Physician. 201 0;39:270-275.

Goldman, RD, Meckler, GD. Pediatrics: Emergency care of children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 73 1-733.

Hamrn MP, Osmond M, Curran J, Scott S, Ali S, Hartling L,

 

tations can be frank breech (legs are at the fetal face with

the buttocks presenting), complete breech (the buttocks

are presenting, but the fetal hips and knees are flexed), or

incomplete or footling breech (one leg is the presenting

part). Breech presentation is dangerous because the buttocks and legs do not fully dilate the cervix. The fetal head

can become caught in the birth canal during delivery.

Likewise, the cervical opening is not completely occluded

by the buttocks, so cord prolapse can occur.

DISPOSITION

All mothers should be admitted to a postpartum unit, and

the infant should be admitted to a neonatal nursery.

SUGGESTED READING

Lazebnik N, Lazebnik RS. The role of ultrasound in pregnancyrelated emergencies. Radial Clin North Am. 2004;42:315-327.

Stallard TC, Burns B. Emergency delivery and perimortem

C-section. Emerg Med Clin North Am. 2003;2 1 :679-693.

VanRooyen MJ, Scott JA. Emergency delivery. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20l l, pp. 703-71 1 .

The Pediatric Patient

joseph Walli ne, MD

Katrina R. Wade, MD

Key Points

• Inherent differences exist between pediatric and adult

patients.

• Physicians have to treat both the parent and the child.

INTRODUCTION

Infants, children, and adolescents constitute approximately

a third of all visits to emergency departments (EDs) in the

United States. Of these pediatric visits, more than half are

for urgent/nonemergent problems such as otitis media,

respiratory and gastrointestinal infections (often viral),

asthma, fractures, sprains, soft tissue trauma, and minor

head trauma. The challenge of pediatric emergency

medicine is to prevent mortality or increased morbidity by

catching the few cases that need hospital admission or

emergent intervention and ensuring proper discharge of

less ill patients.

Children are considered minors up to their 1 8th birthday. Although no consent is needed for life-saving interventions, minors require their parent's or guardian's

consent for routine medical care and discharge. An exception to this rule is the emancipated minor. "Emancipated

minor" status allows a person less than 18 years of age to

consent for medical care without parental knowledge, consent, or liability. The exact legal terms of what makes a

minor "emancipated" varies slightly from state to state, but

generally includes one or more of the following: marriage

(including becoming divorced, separated, or widowed),

membership in the armed forces, becoming pregnant or

having children, living separately from parent(s) or

guardian(s), or, finally, demonstrating the ability to manage one's own financial affairs. Of the preceding criteria,

discovering a patient is pregnant is the most common

• The older the chi ld, the more reliable the clinical

impression.

• Disposition can be affected by unique family situations.

situation the authors' have encountered that leads to

emancipated minor status.

Another important legal issue for clinicians working

with children is our role as mandated reporters. We have a

duty to protect vulnerable young patients. If there is

reasonable cause to suspect that a child has been abused,

neglected, or placed in imminent risk of serious harm, we

are obligated to involve government agents such as child

protective services, police, etc.

There are many aspects of clinical pediatric emergency

medicine that differ from adult emergency medicine

practice. Not only must you vary your approach to each

patient based on their anatomic, physiologic, and

developmental status, you also have to establish an effective relationship with the patient and his or her caregiver.

In other words, physicians have to treat both the parent

and the child. We review some of these differences later in

this chapter.

CLINICAL PRESENTATION

..... History

Obtain as much information as possible from the child.

Questions should be direct and stated in terms the child

can understand. Further details and clarifications should

be sought from the parents, guardians, or caregivers. The

younger the child, the greater reliance on history obtained

from the parents, and the more the history may be

1 96

THE PEDIATRIC PATIENT

Table 47-1. Average quantity of feedings based on age.

Age

1-2 weeks

3 weeks-2 months

2-3 months

3-4 months

5-12 months

Volume/Feeding (every 3-4 hrs)

2-3 oz

4-5 oz

5-6 oz

6-7 oz

7-8 oz

influenced by the parent(s)' perception of symptoms.

When taking the history, children can become anxious

when separated from parents. Separate children from

parents only when absolutely necessary ( eg, in the case of

an adolescent patient when a sexual and/or illicit drug

history needs to be obtained) or in a younger patient

when abuse or neglect is suspected. Unusual complaints

such as weight loss, night sweats, headaches, or back pain

in a small child should prompt concern for more indolent

or life-threatening underlying pathology, particularly

malignancy.

Important historical information needed in all

pediatric patients includes birth history, immunizations,

prior medical problems, medications, allergies, develop ­

mental milestones,

  Women who are not able to easily access medical

care are not good candidates for outpatient management.

SUGGESTED READING

American College of Obstetricians and Gynecologists. Committee

on Practice Bulletins-Obstetrics. Diagnosis and management of

preeclampsia and eclampsia. Obstet Gynecol. 2002;99:1 59-167.

Echevarria MA, Kuhn GJ. Emergencies after 20 weeks of preg -

nancy and the postpartum period. I n: Tintinalli JE, Stapczynski

JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 695-702.

Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. 2003;1 02:1 8 1-192.

Sibai BM. Diagnosis, prevention, and management of eclampsia.

Obstet Gynecol. 2005;105:402-4 10.

E mergency Delivery

jessica Sime, MD

Key Points

• Assemble sufficient staff and supplies to care for both

the mother and newborn.

• When vaginal bleeding is present, defe r the pelvic

exami nation until placenta previa has been excluded.

INTRODUCTION

Less than 1% of all deliveries are in the emergency

department (ED) because most women in labor are

quickly triaged to the labor and delivery unit. However, if a

woman is going to precipitously deliver, or the hospital has

no obstetric services, it is up to the emergency physician to

be prepared to deliver the infant.

Moreover, deliveries in the ED are more likely to be

considered high risk. Women who deliver in the ED

more often have had little or no prenatal care, may have

substance abuse problems, do not know they are pregnant,

or have been victims of domestic violence. These women

may have higher frequencies of complications such as

premature rupture of membranes (PROM), preterm labor,

malpresentation, umbilical cord prolapse, placenta previa,

abruptio placentae, or postpartum hemorrhage. The

emergency medicine physician must be prepared to manage

these complications.

CLINICAL PRESENTATION

� History

Past medical, surgical, gestational age, and obstetric history

should be obtained, as well as history of prenatal care. It is

important to inquire about vaginal bleeding during labor.

Scant, mucoid bleeding is usually termed bloody show and

• Util ize bedside ultrasound to check feta l presentation.

• Be prepared for complications such as postpartum hemorrhage, shoulder dystocia, and breech

presentation.

occurs when the cervical mucus plug is expelled. Heavy

vaginal bleeding is a worrisome sign and can represent

placenta previa (painless vaginal bleeding from the placenta covering the cervical os) or abruptio placentae (painful bleeding owing to placental separation from the uterus).

The physician should also determine whether the patient

has had a spontaneous rupture of membranes (SROM).

Clear, blood-tinged, or meconium-stained vaginal fluid

suggests rupture of membranes.

� Physical Examination

As always, vital signs are the first step in examination.

Fetal heart rate can be assessed with handheld Doppler

or with electronic fetal monitoring, if available. The

abdomen should be palpated for tenderness and fundal

height. Gestational age can be estimated if the mother is

unsure. At 20 weeks' gestation, the uterus is at the umbilicus, and it grows approximately 1 em every week until

36 weeks.

Pelvic examination should begin with inspection of

the perineum to determine whether the delivery is imminent (crowning). If the patient reports vaginal bleeding,

examination should be deferred until an ultrasound can be

performed. It is important to identify placenta previa first,

as the bimanual and speculum examination can exacerbate

the bleeding.

1 92

EMERGENCY DELIVERY

The bimanual examination determines the position of

the fetus and readiness of the cervix. Sterile gloves should

be used to prevent infection. A normal cervix is thick, only

open at the entry to fingertip, and is firm to touch.

Gradually the cervix thins; this is termed effacement.

Dilation of the cervix progresses from closed to fully open

(10 em). Station indicates the location of the presenting

part relative to the ischial spines. A presenting part at the

ischial spines is at 0 station. If the presenting part is at the

introitus, it is at + 3 station. Position describes the relationship of the presenting part to the birth canal. Usually the

fetal occiput is anterior.

Speculum examination can help identify spontaneous

rupture of membranes. Pooling vaginal secretions should

be tested with Nitrazine paper to determine pH. A dark

blue color correlates to a pH of 7.0-7.4 and indicates the

presence of amniotic fluid. Normal vaginal secretions have

a pH of 4.5-5.5. Next, the cervical os is inspected. The

examiner should identify whether it is open slightly, has

bulging membranes, a visible fetal head, or other presenting part. If the examiner sees a prolapsed umbilical cord,

he or she should keep a hand in the vagina and elevate the

presenting part to prevent cord compression, while an

assistant contacts obstetric services for an emergency

cesarean section.

DIAGNOSTIC STUDIES

� Laboratory

If a patient is about to deliver, no laboratory studies are

necessary. A complete blood count, type and screen,

prothrombin time/partial thromboplastin time are useful

in the event of postpartum hemorrhage. Rh type should be

sent to determine the need for RhoGAM.

� Imaging

Bedside ultrasound is used to determine the fetal position,

 

 A slide for microscopy is prepared by mixing a sample

of discharge with 1-2 drops of normal saline and then

applying a coverslip. Vaginal secretions may also be

prepared with l Oo/o potassium hydroxide (KOH), often

producing a fishy odor, or positive whiff test, which may

provide evidence for a diagnosis (Table 44-l).

During the speculum exam, endocervical cultures

should be obtained by placing a swab l em into the cervix

and rotating it. DNA probe swabs have a high sensitivity

and specificity for both gonorrhea and chlamydia; however, the results of these tests are not immediately available

in the ED.

In patients with abdominal pain or toxic appearance,

blood tests may be helpful. An elevated white blood cell

(WBC) count, erythrocyte sedimentation rate (ESR), or

C-reactive protein (CRP) can support the diagnosis of

PID. Urinalysis should be part of the laboratory e valuation;

VAGINAL DISCHARGE

Table 44-1. Distinguishing ca uses of vagin itis.

however, a positive urinalysis finding does not exclude PID,

as inflammation in the pelvis can produce WBCs in the

urine. Testing for other STis such as human immunodeficiency virus, hepatitis, and syphilis may also be warranted.

Frequency

Discharge color

Quantity

pH (normal �4.5)

Amine/fishy odor

(discharge +

KOH prep)

Microscopy

(discharge +

normal saline

drops)

Treatment

Bacterial

Vaginosis

40-501\'o

Gray, white

Moderate

2:4.5

Positive

Clue cells

(epithelial

cells with

adherent

bacteria)

Metronidazole

500 mg BID

x 7 days

Candidiasis

20-25%

White, clumped

Scant to moderate

�4.5

Negative

Mycelia or

hyphae

with KOH

Fluconazole

1 50 mg x

1 dose

Vulvovaginal

discomfort

No cervical findings,

abdominal pain, CMT,

dnexal tenderness, or

History and microscopy

to determine between

infectious (BV, candida,

trichomonas), atrophic,

and chemical

Trichomonas

1 5-20%

Gray, greenyellow

Profuse

2:5

usually positive

Moti le trichomonads

Metronidazole

2g x 1 dose

OR

Metronidazole

500 mg BID X

?days

...,._ Imaging

Imaging may improve the accuracy of PID diagnosis.

Transvaginal pelvic ultrasound demonstrates thickened,

fluid-filled fallopian tubes or pelvic free fluid in severe PID.

Complex adnexal masses signifying tubo-ovarian abscesses

are seen on ultrasound as well. Abdominopelvic computed

tomography (CT) scans can also be used for patients with

toxic appearance, pain, and suspicion of tubo-ovarian

abscess. CT findings in PID include cervicitis, oophoritis,

salpingitis, thickening of uterosacral ligaments, simple or

complex pelvic fluid, or abscess collections.

MEDICAL DECISION MAKING

In patients presenting with vaginal discharge, use the history and pelvic exam to determine the cause (Figure 44-2).

Patients presenting with vulvovaginal discomfort, without

evidence of cervicitis on pelvic exam or concern for STI,

can be treated for vaginitis. The cause of vaginitis can be

determined based on historical factors as well as composition of vaginal discharge. If there is evidence of cervical

Vaginal discharge

History, exam, GU cultures, and

urine pregna ncy test

Cervical discharge and

erythema

No abdominal

pain/tenderness, CMT,

or toxic appearance

Cervi(itis

Figure 44-2. Vaginal discharge diagnostic algorithm. BV, bacterial vaginosis; CMT,

Cervical motion tenderness; GU, genitourinary.

CHAPTER 44

Table 44-2. Treatment of cervicitis: Treat for both

gonorrhea and chlamydia.

Gonorrhea

Chlamydia

First line

Ceftriaxone 250 mg IM

OR

Cefixime 400 mg PO

Azithromycin 1 g PO

Alternate

Cefpodoxime 400 mg PO

OR

Azithromycin 2 g PO

Doxycycline 1 00 mg PO

BID X 7 days

discharge or erythema without abdominal tenderness or

toxic appearance, the patient should be treated for cervicitis. It is important to rule out PID in these patients. Given

the difficulty of diagnosis and potential complications, the

20 10 Centers for Disease Control and Prevention guidelines recommend that providers maintain a low threshold

to treat PID. Empiric treatment for PID should be initiated

in sexually active young women and other women at risk

for STis if they are experiencing pelvic or lower abdominal

pain, if no other cause of pain can be identified, and if one

or more of the following minimum criteria are present on

pelvic exam: CMT, adnexal tenderness, or uterine tenderness.

 

 One or more of the following additional criteria can

be used to enhance the specificity and s upport a diagnosis

of PID: oral temperature >101°F, abnormal cervical or

mucopurulent discharge, presence of abundant WBCs on

microscopy of vaginal fluid, elevated ESR, elevated CRP,

or laboratory documentation of cervical infection with

N. gonorrhoeae or C. trachomatis.

TREATMENT

The treatment of vaginitis, cervicitis, and PID is outlined

in Tables 44-1, 44-2, and 44-3. All regimens used to treat

cervicitis and PID should be effective against N. gonorrhoeae

and C. trachomatis. The need to treat anaerobes has not

been completely studied. Gardnerella (BV) has been

present in many patients with PID, so many recommend

treatment regimens that include anaerobic coverage (ie,

metronidazole). For women with mild to moderate severity PID, parenteral and oral regimens appear to have

similar efficacy.

DISPOSITION

.... Admission

In women with mild or moderate PID, outpatient therapy

yields similar short and long-term outcomes.

Hospitalization is recommended when the patient meets

any of the following criteria: surgical emergencies cannot

Table 44-3. Treatment of PID.

Option 1 Option 2

Outpatient Ceftriaxone 250 mg IM Cefoxitin 2 g IM WITH

treatment PLUS Probenecid 1 g PO

Doxycycline 1 00 mg PO PLUS

BID X 14 days Doxycycline 1 00 mg PO

± BID X 14 days

Metronidazole 500 mg ±

PO BID x 14 days Metronidazole PO BID x

14 days

Inpatient Cefotetan 2 g IV q12hrs Clindamycin 900 mg IV

treatment OR q8hrs

Cefoxitin 2 g IV q6hrs PLUS

PLUS Gentamicin 2 mg/kg IV

Doxycycline 1 00 mg PO followed by 1 .5 mg/

or IV q12 hrs kg q8hrs

be ruled out (eg, appendicitis, tubo-ovarian abscess), pregnancy, nonresponse to oral antimicrobial therapy, unable

to tolerate oral regimen.

.... Discharge

Patient with vaginitis and cervicitis can be safely discharged. When an STI is suspected, patients should be

instructed to notify their partners. For PID, outpatient

therapy is initiated in patients who do not have any of the

criteria listed previously, appear nontoxic, and have reliable follow-up.

SUGGESTED READING

Buckley RG, Knoop KJ. Gynecologic and obstetric conditions.

In: Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas

of Emergency Medicine. 3rd ed. New York, NY: McGrawHill, 20 10.

Centers for Disease Control and Prevention. Sexually

Transmitted Diseases Treatment Guidelines, 20 10. http:// www.cdc.gov/std/treatrnent/20 10/toc.htm

Kuhn, JK, Wahl RP. Vulvovaginitis. In: Tintinalli JE, Stapczynski JS,

Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 20 11, pp. 71 1-16.

Shepherd SM, Shoff WH, Behrman AJ. Pelvic inflammatory

disease. ln: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 716-720.

Sweet RL. Treatment of acute pelvic inflammatory disease. Infect

Dis Obstet Gyneco/ 20 1 1;56 1-909.

Preeclampsia

and Eclampsia

Kathleen A. Wittels, MD

Key Points

• Gestational hypertension, preeclampsia, and eclampsia

represent a spectrum of potentially life-threatening

diseases that must be diagnosed and treated aggressively.

• Consider preeclampsia in any pregnant patient with an

elevated blood pressure.

INTRODUCTION

Hypertension in pregnancy occurs in approximately 10%

of pregnancies and can be associated with significant

maternal and fetal morbidity and mortality. The spectrum

of disease is divided into 3 main categories: gestational

hypertension, preeclampsia, and eclampsia. Preeclampsia

affects 2-6% of pregnancies in the United States, with a

higher incidence globally. Eclampsia occurs in <1% of

patients with preeclampsia.

Gestational hypertension is defined as a blood pressure

> 140/90 mmHg in a pregnant patient without preexisting

hypertension. The hypertension will resolve within

12 weeks postpartum. When proteinuria is also present, it

is defined as preeclampsia. Preeclampsia typically occurs

after 20 weeks' gestation. A subset of patients will develop

severe preeclampsia, which is associated with one of more

of the following: severe hypertension (> 1 60/110 mmHg on

2 separate occasions >6 hours apart), large proteinuria,

neurologic symptoms, epigastric/right upper quadrant

(RUQ) pain, pulmonary edema, or thrombocytopenia.

Eclampsia is preeclampsia with seizures. HELLP syndrome

affects some patients with preeclampsia and eclampsia and

is associated with hemolysis, elevated liver enzymes, and

low platelets.

Although the exact etiology of preeclampsia is unknown,

there are several factors that are thought to contribute.

• The degree of hypertension does not correlate with the

severity of preeclampsia.

• Delivery of the fetus is the definitive treatment of

preeclampsia and eclampsia.

These include maternal immunologic intolerance, abnormal

placental implantation, endothelial dysfunction, and genetic

factors.

CLINICAL PRESENTATION

..... History

Patients with gestational hypertension and preeclampsia may

be asymptomatic. Some women will report facial or extremity

edema, epigastric or RUQ pain, headache, or visual disturbances. Seizures in a woman with preeclampsia is pathognomonic for eclampsia and may occur in the postpartum

period. Risk factors for preeclampsia that should be screened

for during the history include nulliparity, advanced maternal

age, a multiple gestation pregnancy, diabetes, obesity, and

previous preeclampsia.

..... Physical Examination

It is critical to pay careful attention to the vital signs,

particularly the blood pressure. Edema of the face or

extremities may be appreciated. Examination of the lungs

may reveal rales suggestive of pulmonary edema. The

abdominal exam is important to assess for tenderness as

well as to estimate the gestational age of the fetus

(Figure 45-1). Listen for fetal heart tones with a Doppler or

1 89

-------

30

--24'

�

.r---...

20

16

"12'

CHAPTER 45