Case Study SOAP Note 2 -

Case Study #2 SOAP Note Lisa Case 8-2009 — A 36-Year-Old Woman with Headache, Hypertension, and Seizure 2 Weeks Post Partum. Aneesh B. Singhal, W. Taylor Kimberly, Pamela W. Schaefer, E. Tessa Hedley-Whyte The New England Journal of Medicine, Volume 360, Issue 11, Pages 1126 - 1137, 12 March 2009. https://www-nejm-org.libproxy.uccs.edu/doi/pdf/10.1056%2FNEJMcpc0809063 S : 36 y/o female 19 days postpartum admitted to Massachusetts General Hospital due to headaches, hypertension, and seizures. Pt delivered healthy twins at 35.6 weeks gestation via cesarean section for breech presentation at another hospital without complications during pregnancy. Brief associated medical history leading up to current admission to Mass Gen Hospital :  5 days postpartum : Pt was discharged.  10 days postpartum : Pt c/o intermittent, throbbing, bifrontal HA.  12 days postpartum : Pt saw her gynecologist with continued headaches with pain 8/10 and B/P 150/72; pt referred to internist the same day. Pt stated her HA resolved in waiting room of internal medicine clinic and went home without being seen. Pt reported to a different ER that evening c/o recurring HA. B/P was 190/80, CT and MRI of brain and laboratory testing did not show any significant findings. Pt administered oxycodone-acetaminophen for pain and discharged after B/P decreased to 168/70.  15 days postpartum : Pt saw internist c/o sudden onset HA’s that woke her from sleep early in the morning and in the late afternoons. Pt reported current HA in office as dull with pain 2/10; B/P 142/78. Trace peripheral edema present with rest of exam having normal results. Pt Rx furosemide and potassium chloride.  17 days postpartum : Pt returned to ER c/o severe HA with nausea, photophobia, and pain 10/10, B/P 204/96. Lab report showed complete blood count was normal other than hematocrit 34.7%. Additional normal Labs: serum electrolytes, magnesium, calcium, phosphorus, LFT and RFT. UA results = specific gravity 1.020, pH 6.0, protein 30 mg/dL, and 5-10 RBC. Shortly after IV hydromorphone was given, a generalized tonic-clonic seizure occurred with urinary incontinence and LOC x2 min. CT of head was normal. CSF lab results showed no cells, elevated protein level (64 mg/dL), low glucose level (54 mg/dL), and Gram staining and culture were negative. IV metoclopramide, lorazepam, and fentanyl given and oral oxycodone and methyldopa given; pt reported persistent frontal HA with pain 4/10. SBP ranged from 140-160. Continuous IV infusion of magnesium sulfate and hydralazine give, pt transferred from ER to ICU.  18 days postpartum : MRI with MRA and venography showed posterior white-matter changes on T 2 - weighted sequences and multifocal narrowing and dilatation of all the intracranial arteries. o Brain MRI showed hyperintense regions involving the posterior parietal–occipital lobes, the left frontal cortex, and the subcortical white matter. These areas had increased diffusion, indicating vasogenic edema. o MRA of circle of Willis showed multifocal stenoses in the proximal anterior, middle, and posterior cerebral arteries.  19 days postpartum : pt appeared confused with episode of difficulty word-finding and pronunciation x5 min and right hemiparesis. Aspirin administered. CT scan showed no acute infarction or hemorrhage evidence. Pt transferred to Mass Gen Hospital via ambulance, arriving 4 hours after aphasia episode. Current Medication prior to admission : furosemide, iron, multivitamins, oxycodone-acetaminophen. No oral contraceptives. NKDA. Social Hx : Pt lives with husband and their 3 children (2 y/o child and 19-day old twins).  Tobacco : denies use.  ETOH : denies use.  Recreational : denies use. PMHx : no HTN, HA’s, or exlampsia prior to or during pregnancies. Normal routine prenatal screening. FMHx : Mother – HTN. Father – cardiovascular disease. No eclampsia O : Vital Signs on Admission to Mass Gen 19 days postpartum: Temp : 36.8°C, B/P : 136/91 mmHg, HR : 95 bpm, RR : 24 bpm, SpO2 : 98% ambient air, G3P3. Physical Examination Findings :  19 days postpartum (day 1 Neuro ICU ): o Peripheral edema (1+), normal general physical examination. o SBP ranged from 110 to 120 mmHg. Page 1 of 5

Case Study #2 SOAP Note Lisa Neurological Examination :  19 days postpartum (PRIOR to Neuro ICU admission ): o Pt’s speech was fluent and clear, but responses were slow. The first cranial nerve was not tested; other cranial nerves were normal. Strength 4/5 on right, normal on left. Ataxia noted during rapid alternating movements and finger-to-nose and heel–knee–shin testing; pt was not able to touch her nose with her right forefinger. Gait was not tested. The remainder of the neurologic examination was normal.  19 days postpartum (AFTER admitted to Neuro ICU, day 1 ): o Pt’s level of alertness fluctuated and there was intermittent right hemiparesis.  20 days postpartum (day 2 Neuro ICU ): o During the day, pt developed weakness in the right arm and both legs, and LOC decreased. Pt did not seem to track gaze but moved her fingers on command, withdrew arms and legs on stimulation, and occasionally answered questions. At times she was unresponsive, with her eyes open.  21 days postpartum (day 3 Neuro ICU) : o neurologic deterioration noted with unresponsiveness, continuous lip smacking and chewing movements, and spasticity and hyperreflexia in all limbs, with extensor plantar responses.  26 days postpartum (day 7 Neuro ICU ): o pupils were dilated and did not react to light. Rx given after admission to Mass Gen Neuro ICU :  Subsequent days postpartum (day 2-7 Neuro ICU ): o IV fosphenytoin, labetalol, and magnesium sulfate given via continuous infusion. o Nicardipine was injected into the left vertebral and right and left internal carotid arteries, resulting in nearly complete resolution of the arterial narrowing. o Nimodipine was administered. Repeated cerebral angiography with the administration of intraarterial and intravenous nicardipine again resulted in improvement of the arterial narrowing. Treatment with intrathecal nicardipine, insulin on a sliding scale, cefazolin, nafcillin, propofol (titrated to intracranial pressure) and milrinone was begun. o intravenous phenylephrine, fludrocortisone, and intravenous norepinephrine were administered in an effort to raise systemic blood pressure and improve cerebral perfusion. o Hypertonic therapy, mannitol, pentobarbital, acetylcysteine, and hypothermia were administered, but the patient's condition did not improve. Laboratory Testing :  19 days postpartum (day 1 Neuro ICU ): o D-dimer level = 1975 ng/mL (normal level <500) o CBC = normal o serum electrolytes, calcium, phosphorus, and magnesium = normal. o RFT and LFT = normal.  20 days postpartum (day 2 Neuro ICU ): o plasma triglyceride level = 168 mg/dL (reference range 40-150 mg/dL) o anticardiolipin IgM antibody level = 17.9 IgM phospholipid units (reference range 0-15) o erythrocyte sed rate = 51 mm/hr (reference value <25) o lipids, creatine kinase, troponin T, thyrotropin, & complement (C3 and C4) = normal o negative test results for antibodies to proteinase 3, antibodies to myeloperoxidase, antineutrophil cytoplasmic antibodies, anticardiolipin IgG antibodies, antinuclear antibodies, and rheumatoid factor. Radiological Report :  19 days postpartum (day 1 Neuro ICU ): o follow-up MRI showed the expansion of the previously abnormal hypertense regions with new restricted diffusion, indicating cytotoxic edema secondary to ischemia. o MRA showed worsening of the parenchymal lesions and worsening of the multifocal anterior, middle, and posterior cerebral-artery stenoses.  20 days postpartum (day 2 Neuro ICU ): o CT angiographic showed presence of multifocal severe proximal stenoses of the anterior, middle, and posterior cerebral arteries. Page 2 of 5

Case Study #2 SOAP Note Lisa A : The patient's condition is consistent with delayed postpartum eclampsia with postpartum angiopathy (reversible cerebral vasoconstriction syndrome) complicated by brain edema and ischemic and hemorrhagic strokes. The clinical presentation and imaging findings suggest a dynamic process of arterial vasoconstriction. Initial Diagnosis : Recurrent headaches with hypertension developed in this 36-year-old woman 10 days after an unremarkable cesarean delivery of twins, which followed an uncomplicated pregnancy. Diagnosis : Delayed postpartum eclampsia with postpartum angiopathy (reversible cerebral vasoconstriction syndrome) complicated by brain edema, ischemic, and hemorrhagic strokes. Differential Diagnosis : 1. Primary Headache Disorders : Migraine and tension-type headaches are common postpartum, but the patient's severe and rapid-onset headaches are atypical for these types. 2. Subarachnoid Hemorrhage : Thunderclap headache can be a symptom, but the patient's normal brain imaging, clear CSF, and recurrent nature make this less likely. 3. Cerebral-Artery Dissections and Venous Sinus Thrombosis : Thunderclap headache can occur with these conditions, but imaging did not show evidence of cerebral venous sinus thrombosis, and the neck arteries were not initially imaged. 4. Postdural Puncture Headache : Possible, but the absence of information on CSF opening pressure makes it challenging to diagnose. 5. Delayed Postpartum Eclampsia : The patient's symptoms and imaging findings are consistent with delayed postpartum eclampsia, especially given the occurrence of seizures and hypertension. 6. Pregnancy-Related Stroke : Risk factors and the patient's symptoms suggest pregnancy-related stroke, but progressive multifocal vasoconstriction on MRA raises specific diagnostic considerations. 7. Primary Angiitis of the Central Nervous System : Unlikely due to the absence of CSF pleocytosis and initially normal MRI and MRA. 8. Reversible Cerebral Vasoconstriction Syndrome (Postpartum Angiopathy ): Highly suggestive due to recurrent thunderclap headaches, benign CSF results, rapidly progressive brain edema, strokes, and dynamic arterial changes. Treatment with calcium-channel antagonists, corticosteroids, and blood- pressure-modulating agents is initiated. 9. Hypertensive Small-Vessel Changes: Autopsy findings indicated mild hypertensive small-vessel changes, which could have been a contributing factor to the patient's cerebral ischemia. P : Treatment Plan : 1. Supportive Care : The patient's condition rapidly deteriorated, leading to extensive cerebral infarctions and brain edema. Supportive care, including placing an external ventricular drain was placed to monitor intracranial pressure; the trachea was intubated, and cerebral angiography was performed while the patient was under general anesthesia was provided in the Neuro ICU. 2. Pharmacological Management : The patient received various medications, including magnesium sulfate, hydralazine, nimodipine, phenylephrine, fludrocortisone, and norepinephrine, to manage blood pressure, cerebral perfusion, and seizures. During admission to Neuro ICU, intrathecal nicardipine, insulin on a sliding scale, cefazolin, nafcillin, propofol (titrated to intracranial pressure) and milrinone was started as well as intravenous phenylephrine, fludrocortisone, and intravenous norepinephrine were administered in an effort to raise systemic blood pressure and improve cerebral perfusion. 3. Autopsy : An autopsy was performed to further understand the pathological changes associated with the patient's condition. 4. Investigation of PlGF and sFlt-1 Levels : Blood levels of placental growth factor (PlGF) and soluble Flt-1 (sFlt-1) were analyzed to assess their role in the pathophysiology of the patient's condition, as they are associated with antepartum eclampsia. 5. Alternative Treatment Options : Pharmacologic blood-pressure modulation, calcium-channel antagonists, and direct interventions such as balloon angioplasty or injection of vasodilators may not be effective in preventing disease progression. Opening the artery may expose the brain to the risks of reperfusion injury. Nevertheless, the prompt but transient relief of vasoconstriction with the use of a vasodilator supports vasospasm as the underlying mechanism. 6. Further Research : Research should focus on uncovering precise mechanisms for the various conditions included in the reversible cerebral vasoconstriction syndrome in order to develop specific therapies. Page 4 of 5

Case Study #2 SOAP Note Lisa Follow-up : Unfortunately, despite intensive medical management, the patient's condition deteriorated rapidly, leading to her passing away 27 days postpartum (day 8 Neuro ICU). Autopsy findings confirmed the presence of extensive cerebral infarctions and edema. This case emphasizes the complexity and challenges in managing severe postpartum neurological complications, particularly in the context of reversible cerebral vasoconstriction syndrome. Final Diagnosis : Reversible Cerebral Vasoconstriction Syndrome (Postpartum Angiopathy). Page 5 of 5