3. In the case of suspected compartment syndrome, the urgent invasive measure to perform would be to measure the intracompartmental pressure and, depending on the result, proceed with treatment.

A 35-year-old man suffers a high-voltage electrical burn (3000 volts) from direct contact with wire with his left hand. On admission he presents flexion contracture of the hand, pallor of the fingers and absence of radial and ulnar pulse on palpation What is the emergency invasive measure to be performed?

14,000 volt electrical injury to bilateral upper extremities: a case report.

Electrical burns are among the most devastating of burn injuries. High voltage electrical injuries result in extensive deep tissue damage and are associated with multiple complications, long term morbidity, and a high mortality rate. We describe the case of a 47 year-old electric company linesman who suffered a high voltage electrical injury (HVEI) of 14,000 volts to bilateral hands and wrists managed by the Division of Plastic and Reconstructive Surgery at the McGill University Health Center in Montreal, Quebec, Canada. His management included multiple operative procedures, including escharotomies, fasciotomies, serial debridements, and bilateral pedicle groin flaps, and amputation of his left hand.

[Effects of flow-through descending branch of lateral circumflex femoral artery flap on repairing high-voltage electrical burn wounds of wrist of patients].

<bObjective:</b To investigate the effects of flow-through descending branch of lateral circumflex femoral artery flap on repairing high-voltage electrical burn wounds of wrist of patients. <bMethods:</b From January 2014 to June 2016, 5 patients with high-voltage electrical burn of unilateral wrist were hospitalized in our burn ward, with extensive necrosis of skin soft tissue of burn wrist. Five patients were transferred to our burn ward 6 to 12 days post injury after undergoing emergency dermotomy of wrist to reduce tension in other hospitals. In 2 to 3 days after admission, operation was performed by two surgeon group at the same time, when patients' general condition were stable. One group underwent debridement and the other group designed and dissected flap according to the range of skin soft tissue defect of wrist. Wrist wounds after debridement ranged from 15 cm×10 cm to 24 cm×15 cm. Three patients were treated with flow-through descending branch of lateral circumflex femoral artery flap and great saphenous vein for repairing wounds of wrist and reconstruction of ulnar and radial artery. Two patients were treated with flow-through descending branch of lateral circumflex femoral artery flap for repairing wounds of wrist and reconstruction of ulnar artery. The dissected flaps ranged from 16 cm×12 cm to 26 cm×16 cm and the length of bridging vessel ranged from 15 to 21 cm. <bResults:</b The flow-through descending branch of lateral circumflex femoral artery flaps of five patients survived well. Wounds of 4 patients healed and wounds of 1 patient with infection under the flap on 3 days after operation healed after changing wound dressing and undergoing debridement for 2 weeks. After the operation, wrists and hands of 5 patients had adequate blood supply and ulnar and radial artery recovered patency. Follow-up of patients for 6 months to 1 year showed good flap appearance and adequate blood supply of burn hands. <bConclusions:</b The flow-through descending branch of lateral circumflex femoral artery flap can repair wrist wounds and recover blood supply of hands and it is a good method for repairing high-voltage electrical burns of wrist.

Pressure guided surgery of compartment syndrome of the limbs in burn patients.

Compartment syndrome is a serious complication of high voltage electrical burns, limb carbonization and deep circular burns with delayed escharotomy. Without treatment, ischemic tissue damage leads to irreversible necrosis. Treatment is emergency surgical decompression. The burned patient is usually not searchable and cannot always be readily examined because of bulky dressings; diagnosis of compartment syndrome is always hard to make. The pressure transducer used in central arterial catheters is easy available. We used it to measure pressure in muscular compartments. We measured compartment pressure three times at different depths in all cases of electrical burn, carbonization and deep circumferential burns with delayed escharotomy. We also took the pressure in the uninjured limb. The pressure assessment device was composed of a blood pressure transducer commonly used in arterial catheters for arterial pressure monitoring with three connecting branches. The first branch was connected to the 'arterial pressure exit' in the monitoring device. The second, an IV tube, was connected to one litre of physiological serum in a pressure bag inflated to 200 mmHg. The third, also an IV tube with a sterile extension cable, was directly connected to an 18G standard straight needle to be inserted in the tissues for which interstitial pressure had to be measured. In patients with thermal burns, we measured pressure before and after escharotomy. Threshold intracompartmental pressure was 35 mmHg. We carried out pressure assessment of all muscular compartments during and at the end of surgery. The pressure transducer provides a pressure value in all muscular compartments with a time of installation and measuring of less than 5 minutes. Sensitivity is measured at +/- 1 mmHg. Operation is simple, non-operator dependent, and accessible to medical and paramedic teams. The pressure transducer allows accurate diagnosis of early or established compartment syndrome. It requires no additional equipment and its application does not delay therapeutic management. Its use helps with fasciotomy decision, especially after escharotomy, guides the surgeon in the exploration of different compartments and verifies the effectiveness of surgery.

[A black wound on the lower arm].

A 19-year-old man presented on the Emergency Room on New Year's Eve with a 2 cm-wide black burn located on his lower arm. Earlier that evening he was hit by a piece of firework. Even though he immediately felt a sharp burning pain, he did not realize the severity of the injury. He presented with numbness in the digiti 4 and 5 and the Wartenberg sign, which are signs of an ulnar nerve injury. An exploration of the ulnar nerve was performed. Extensive burns and gunpowder were seen on the flexor carpi radialis and ulnaris muscle, the fascia and the epineurium of the ulnar nerve. However, the ulnar nerve was intact. A week later a babysitting procedure was performed because of absent intrinsic muscle activity, with an end-to-side anastomosis of the anterior interosseous nerve to the motor branch of the ulnar nerve. Hand physiotherapy was started after the operation.

Surgery_Schwartz

Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar digital pad. A sensorimotor exam should be per-formed. Objective evidence of inadequate perfusion (i.e., deteri-orating clinical exam with changes in or loss of pulse or Doppler signal) indicates the need for escharotomy, especially in the set-ting of circumferential burns. Escharotomy may be performed at bedside with scalpel or electrocautery under local anesthesia or intravenous sedation. In the forearm, axially oriented midra-dial and midulnar incisions are made for the entire extent of the burn. Escharotomy should proceed as distally as necessary into the wrist and hand to restore perfusion. Digital escharotomies are made via a midaxial (the middle of the longitudinal axis on sagittal view) incision over the radial aspects of the thumb and small finger and the ulnar aspects of the index,

Anterolateral Thigh Flap for Low-Voltage Fourth-Degree Electrical Burn Injury With Immediate Radial Nerve Palsy at the Elbow: A Case Report.

While high-voltage electrical injuries usually cause severe burn wounds and axonal polyneuropathy, low-voltage electrical injuries cause limited cutaneous wounds and demyelinating mononeuropathy, of which the median and ulnar nerves are the most commonly involved. We present the case of a 42-year-old man who suffered a 480-voltage electrical injury at his right elbow, resulting in a 24 × 10 cm fourth-degree burn wound and immediate radial nerve palsy. The burn wound was debrided with confirmation and preservation of radial nerve continuity. The wound was covered with a free anterolateral thigh flap and it healed uneventfully. The Tinel's sign continued to advance at follow-up, and electrodiagnostic studies showed progressive reinnervation. His radial nerve function recovered completely in 9 months. This is a rare case of low-voltage electrical injury with a fourth-degree burn wound and immediate radial nerve palsy. We treated the wound aggressively with early debridement and prompt flap coverage, but conservatively treated the radial nerve injury. The nerve recovery course indicates that it had a "shocked-cooked" injury and served itself as a well-placed nerve graft for the subsequent regeneration. We believe that our successful outcome in this case can provide more insights into the management of such injuries.

Surgery_Schwartz

ery-thema, blistering, and blanching of skin. Topical dressings are the mainstay of treatment. Deep partial-thickness burns involve damage to the reticular dermis with damage to skin appendages, as well as the dermal plexus blood vessels and nerves. These have decreased sensation and no cap refill and appear pale or white. Blistering may be present. Damage to the skin append-ages and blood supply in the dermal plexus precludes spontane-ous healing without scar. Excision with skin grafting is needed. Third-degree burns involve full-thickness damage through the dermis and are insensate with no blistering. They appear dry, leathery, and even charred.Acute ManagementAdvanced trauma life support guidelines should be followed. After primary survey, circulation to the hand should be assessed. Palpation and Doppler ultrasound should be used to evaluate blood flow within the radial and ulnar arteries, the pal-mar arches, and digital blood flow at the radial and ulnar aspect of each volar

Glossary of medicine

Brachial artery – is the major blood vessel of the (upper) arm. It is the continuation of the axillary artery beyond the lower margin of teres major muscle. It continues down the ventral surface of the arm until it reaches the cubital fossa at the elbow. It then divides into the radial and ulnar arteries which run down the forearm. In some individuals, the bifurcation occurs much earlier and the ulnar and radial arteries extend through the upper arm. The pulse of the brachial artery is palpable on the anterior aspect of the elbow, medial to the tendon of the biceps, and, with the use of a stethoscope and sphygmomanometer (blood pressure cuff) often used to measure the blood pressure.

Peripheral sympathetic block with therapeutic local anesthesia for the manage-ment of upper limb digital ischemia.

Thromboangiitis obliterans (TAO) is a non-arteriosclerotic segmental inflammatory occlusive vasculitis typically in the upper and lower extremities affecting small- and medium-sized arteries and veins. We present the treatment protocol for TAO involving the use of peripheral sympathetic block through an axillary catheter. An unconscious 56-year-old female patient was transferred to the emergency service, intubated, and mechanically ventilated. The patient was provisionally diagnosed with hypertensive intracranial hematoma and admitted to the intensive care unit. Invasive arterial pressure monitoring was performed through the left radial artery cannula. Four days later, upon the observation of symptoms of a circulatory disorder in the fingers distal of the left and right hands, the cannula was removed from the left radial artery, and another was placed in the left dorsalis pedis artery. At the same time, an 18 Gauge catheter was placed in the axillary perineural sheath bilaterally, and a total of 10 ml lidocaine 0.5 % (5 ml for each side) was injected six times a day. During each injection, the temperature was measured using a surface probe on the distal of the fingers with poor perfusion and another area of the same hand with good perfusion. Lidocaine treatment protocol through the axillary perineural catheter was applied for 15 days for the right hand and 18 days for the left hand. As the treatment proceeded, a significant increase was observed in the results of the temperature measurements on the fingers with poor perfusion.  Conclusion: We believe that a peripheral sympathetic block as we report herein could be considered as an alternative in the treatment of TAO. HIPPOKRATIA 2018, 22(3): 141-144.

Escharotomy and fasciotomy of the burned upper extremity.

Escharotomy and fasciotomy are performed in the burned upper extremity to prevent and treat the sequelae of circumferential full-thickness burns and high-voltage electrical burns. Indications to perform these procedures are determined primarily by clinical examination but can be supplemented by measurements of subfascial pressures. The techniques are designed to avoid further complications. Options for wound closure are discussed. The use of allograft as temporary coverage of fasciotomy incisions may allow delayed primary closure.

PFO closure in high-risk patient with paradoxical arterial embolism, deep vein thrombosis, pulmonary embolism and factor V Leiden genetic mutation.

Occurrence of paradoxical arterial embolism may cause the first symptoms in patients with a coexisting hypercoagulable state and patent foramen ovale (PFO). This can result in significant morbidity and mortality depending on the location of the embolism. The risks and benefits of closure of small PFOs have not been well elucidated in prior studies. We describe a patient with a history of Factor V Leiden heterozygosity who presented with left arm pain secondary to arterial embolism. The patient was a 51-year-old male who initially presented to the emergency department after awaking from sleep with progressive, severe, burning left arm pain. He had also noted intermittent shortness of breath over the 2 weeks prior to admission. Temperature was 97.4 F, pulse 86, respiratory rate 20 and blood pressure 121/87. Oxygen saturation was 94% on supplemental oxygen. He had a cool left upper extremity and the patient described subjective paresthesias in this extremity. Left radial pulse was difficult to palpate. Physical exam was otherwise unremarkable. Troponin I was mildly elevated at 0.217 ng/l. White blood cell count was 11.8 and INR 1.1. EKG showed sinus tachycardia with non-specific T abnormalities in the anterior leads. His past medical history was notable for only hypertension and hyperlipidemia. Current recommendation is for antiplatelet or anticoagulation for those with hypercoaguable states who suffer a stroke; there is currently no absolute indication for closure device. We describe the case of a 51-year-old male who had presented with left arm pain and shortness of breath. The computed tomography (CT) angiography of chest showed pulmonary emboli with heavy clot burden bilaterally. Heparin was started, but patient was found to have occlusion along large arteries of the left arm. Emergent left axillary, brachial, radial and ulnar embolectomy for acute critical arm ischemia were performed. The transthoracic echocardiogram done the next day with bubble study was positive for patent foramen ovale. Hypercoaguability showed factor V Leiden heterozygosity. Decision was made for the patient to initiate long-term anticoagulation with rivaroxaban and closure was performed. Patient was advised that closure is off label but opted to proceed with closure in light of hypercoaguable state.

Simultaneous bilateral ulnar neuropathy: an unusual complication caused by neuroleptic treatment-induced tardive dyskinesia: A Case Report.

In the past decade, only a few studies have focused on simultaneous bilateral ulnar neuropathy. A 54-year-old Asian male who has suffered from paranoid schizophrenia for 2 years. He reported that flexion contracture occurring over his fourth and fifth fingers on both hands appeared since six months after he started taking the antipsychotic drug. The electromyogram revealed bilateral ulnar neuropathy with chronic axonal degeneration at the elbow level. McGowan classification was performed to evaluate the severity of the ulnar nerve injury, and the patient was diagnosed with a grade 3 injury on his left hand and a grade 2 injury on his right hand. Simultaneous bilateral ulnar neuropathy at the elbow, a complication caused by tardive dyskinesia in a patient under the high-dose, first-generation, antipsychotic drug. We consulted a psychiatrist to assist in adjusting the patient's kind of the antipsychotic drug and performed the anterior transposition of ulnar nerve to avoid nerve entrapment caused by tardive dyskinesia. Numbness of the palms continued to regress over the following 6 months after the anterior transposition of the ulnar nerve. Regression of the involuntary movements, including repeated bending of the elbows, and shaking of both feet, was noted from the patient but was incomplete. Two literatures concluded that parkinsonian rigidity is the main cause of simultaneous bilateral ulnar neuropathy by Sampath et al and Kurlan et al. Unlike the cases of stereotyped posture-caused neural compression reported previously, we inferred that repeated involuntary motion caused by first-generation antipsychotic drug might have been one of the causes of the patient's nerve compression.

Role of escharotomy and fasciotomy as a first aid measure in the early treatment of an electrically burned arm and wrist.

The saving of the hand and forearm of a patient with a deep circumferential electrical burn of the wrist and forearm following contact with 10 000 V AC demonstrates the important role played by escharotomy and fasciotomy in the early treatment of electrically injured extremities.

[Axillary plexus catheter block in accidental intra-arterial levomethadone HCl injection in an HIV-positive, hepatitis B and C active drug dependent patient].

We report the case of a 36-year-old male patient who inadvertently injected intraarterially (radial artery) levomethadon-HCl-solution (15 ml corresponding to 37.5 mg) which was intended for substitutional use only. He subsequently developed all clinical signs of malperfusion of his left lower arm and entire hand. Reaching the clinic only two hours after the injection, he received a continuous axillary plexus block which led to the nearly complete restoration of the perfusion of his left lower arm and hand. Thus, we were able to avoid further surgical interventions. We were using the new local anesthetic substance Ropivacain (Naropin), which offers the advantage of 12-hour-injection intervals. Already 36 hours after the "trauma", colour-coded Doppler sonography demonstrated normal flow-rates of the radial, ulnar, and common digital arteries. Only the arterial flow of the index and middle fingers was not detectable at that time--corresponding to partial hypaesthesia of the tip of the second and radial side of the third digits. Even if there are no studies concerning the continuous axillary plexus block in HIV, hepatitis B- and C-positive patients, this anaesthesiological technique should not be withheld from this group of immunocompromised patients.

Escharotomies, fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of an algorithm for surgical decision making.

Escharotomies are usually performed in patients with circumferential third degree burns of the extremities or anterior trunk. Fasciotomies are recommended for patients who sustained high voltage (or associated crush) injuries, with entrance or exit wounds in one or more extremities. Carpal tunnel release is practiced routinely in some services for cases of electrical injury. We have reviewed the literature which provides relatively little information as to when should these procedures actually be performed and what would happen if they were not done. We present a series of patients treated at our institution when an algorithm was used for surgical decision making as to when (or not) to operate (perform an escharotomy, a fasciotomy or a carpal tunnel release), based on clinical signs and monitoring alternatives, using the oximeter and the Doppler flowmeter. 13 938 burn patients were treated at our institution during the year of 2005. Of these, 571, with an average of 22.3 % TBSA, were treated as inpatients. Of these, 58 (10.3 %) had circumferential or electrical burns of one or more extremities. Patients were monitored hourly from admission and decision to operate was based on clinical signs and in absent or below 90 % oximetry, regardless of Doppler flow signs. 68 % were males, 6 (11.3 %) patients had immediate escharotomies, while 4 (7.5 %) had immediate fasciotomies. 2 of these patients were operated regardless of positive Doppler sign but no oximetry. All patients recovered oximetry over 90 % immediately after the operations. 3 patients had negative Doppler sign but oximetry > 90 % and were not operated. 3 patients had carpal tunnel releases based on oximetry < 90 % and symptoms of compression of the median nerve. Patients who were not operated fared well with no signs or symptoms of impairment of circulation or nerve damage up to their 3 and 6 months reevaluations.

Conservative Management of Median Nerve Brachial Plexopathy after Microwave-based MiraDry Treatment for Axillary Hyperhidrosis.

Axillary hyperhidrosis is characterized by excessive sweating of the armpits, which can significantly affect quality of life. A new microwave-based therapy, MiraDry (Miramar labs, Sunnyvale, Calif.), is a promising minimally-invasive treatment option. We report a case of unilateral brachial plexus thermal injury in a thin 19-year-old man treated for axillary hyperhidrosis with the MiraDry system. He initially experienced swelling and pain in the left hand and was prescribed 1 week of methylprednisolone. He then presented 1 week later with induration and swelling of bilateral axillae with swelling of left thumb, left index, and left long fingers, decreased sensation in median nerve distribution of the left hand, and the inability to flex the left index finger DIP joint. EMG showed absent median nerve motor and sensory function, consistent with median nerve plexopathy. He was conservatively managed with close observation and regular occupational hand therapy appointments. At his 12-month follow-up, there was complete return of left pronator teres strength, thumb flexion, and index finger flexion. Decreased sensation remained at the tip of the left index finger. We report the case of median nerve palsy after MiraDry therapy for axillary hyperhidrosis in a thin young man. We recommend using low-energy settings and pre-procedural ultrasound for young, thin patients because of the more superficial course of the brachial plexus within the axilla.

[Value of early decompression in compartment syndrome of the burnt hand].

Our experience with over one hundred burned hands has shown that the compartment syndrome is a frequent occurrence in the hand and fingers. It is often underestimated because clinical diagnosis is difficult and an infra-clinical ischaemia may exist although the pulse is present. We believe it is important to carry out systematically Whiteside's method of investigating pressure in the compartments of the hand. When pressure exceeds 40 mm Hg the interosseous compartments and sometimes the digital canals or even the antebrachial compartment should be opened. This simple technique followed by early excision and graft and intensive rehabilitation has in our experience transformed the prognosis of burned hands.

[Clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound on the wrist].

<bObjective:</b To explore the clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound of type Ⅱ and Ⅲ on the wrist. <bMethods:</b From May 2016 to February 2019, 25 patients with deep high-voltage electrical burn wounds on the wrist were admitted to Zhengzhou First People's Hospital, including 23 males and 2 females, aged 11-63 years. Among them, 4 cases had bilateral electrical burns on the wrist, and 21 cases had unilateral electrical burns on the wrist. There were 29 wounds in 29 affected limbs with depth of full-thickness to full-thickness with tendon and bone exposure, and 17 wounds were type Ⅱ and 12 wounds were type Ⅲ. Twenty-four patients underwent CT angiography of the upper extremities before surgery, while the other one patient did not undergo the examination due to seafood allergy. There were no obvious injury to the ulnar and radial arteries in 7 affected limbs, simple ulnar artery injury in 6 affected limbs, simple radial artery injury in 7 affected limbs, and both ulnar and radial arteries injury in 9 affected limbs. The wound areas after debridement were 10 cm×7 cm-36 cm×17 cm, and the free anterolateral thigh flaps were obtained with area of 11 cm×8 cm-37 cm×18 cm for repairing the wounds. For patients with no damage of ulnar artery and radial artery, the trunk of descending branch of lateral circumflex femoral artery of the flap or combined with the thick muscle perforating branch or lateral branch was anastomosed with the ulnar or radial artery of the wound. For patients with simple ulnar artery or radial artery injury, the trunk, lateral branch, or medial branch was anastomosed with the ulnar artery or radial artery of the wound. For patients with long injury of ulnar artery and radial artery, the ulnar artery or radial artery of the wound was reconstructed with one of the above-mentioned methods, the injured artery that was not anastomosed was reconstructed with great saphenous vein, and the transplanted blood vessel was embedded in the lateral femoral muscle. The accompanying vein of the descending branch of the lateral circumflex femoral artery of the flap was anastomosed with the accompanying vein of the ulnar artery or radial artery of the wound and/or the cephalic vein. The donor sites of flaps were sutured directly or repaired with split-thickness skin graft from the thigh. The survival condition of flap and affected limb after operation and during follow-up was observed, and hand function of the affected limb during follow-up was evaluated according to the evaluation standard after repair of peripheral nerve injury in upper limbs. <bResults:</b Fifteen affected limb wounds had tissue liquefaction but healed after second debridement on 14-28 days after flap repair operation. All 29 flaps survived in the end. One patient had long ulnar artery and radial artery injuries in affected limbs and the hand was necrotic due to second embolism of the blood vessel in 1 week post operation, and the remaining affected limbs survived. During the follow-up of 6 to 30 months after operation, the flaps were slightly bloated, the affected limbs were warm with normal blood flow, and finger flexion, wrist flexion, and sensory function of hand recovered to varying degrees. The functions of the survived affected limbs were evaluated as excellent in 8 affected limbs, good in 9 affected limbs, medium in 5 affected limbs, and poor in 6 affected limbs, with an excellent and good rate of 60.71%. <bConclusions:</b The clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction is good for repairing high-voltage electrical burn wound on the wrist, and the patency restoration of the ulnar artery and/or radial artery of the upper limb in stage Ⅰ is helpful for improving the success rate of limb salvage.

[Methods of determining clinically sufficient decurarization and its evaluation].

Mechanomyoscopy as an objective method for determining the degree of decurarisation is particularly useful in the case of uncooperative patients and those who are incapable of adequate neck flexion mostly for spinal column diseases. The authors use for that purpose a Czechoslovak-made neuromuscular stimulator (LSN 110), with constant 50 Hz frequency of stimulation, 0.3 ms impulse duration, max. 50 mA and, depending on skin impedance, 5-140 V. The stimulator switch is manually controlled. The absence of muscular fatigue (fade) on single as well repeated stimulation lasting only a fraction of a second necessary to elicit muscular response does not rule out residual curarisation despite the fact that less than 70% of the cholinergic receptors are blocked. The only reliable sign of clinically sufficient decurarisation is the ability of the muscles of the hand to maintain contraction on tetanic stimulation of the motor point of the ulnar nerve in the wrist for at least 5 seconds without fatigue, and that even on a repeated exercise. This corresponds to a block of less than 60% of the cholinergic receptors. The patient's ability to raise his or her head and to keep it raised at 4 fingerbreaths for a period of 4 seconds is also a manifestation of clinically sufficient decurarisation. The value of forced expiratory volume is not conclusive evidence of sufficient decurarisation, it only gives a rough idea of its degree. The final decision is up to the an anaesthesiologist, his knowledge and experience based on objective data.

Carotid rupture following electrical injury:  a report of two cases.

Electrical injuries often result in extensive tissue damage where vascular damage may occur and result in thrombosis and spontaneous rupture of blood vessels. Rupture of the brachial, radial, ulnar, internal mammary, and obturator arteries has been reported in the literature. The authors present two cases of carotid artery rupture following high-voltage electrical injuries. The first case is a 21-year-old man who was climbing a fence near a high-voltage power line when a gold chain he was wearing around his neck caught on the power line, resulting in a 10% circumferential electrical injury to his neck. He presented with visible arterial bleeding from the large neck wound and was taken to the operating room, where a 1-cm laceration to the carotid artery was repaired with a vein patch. On the second postoperative day, the patch dislodged, and a spontaneous rupture of the common carotid artery occurred. The damaged artery was subsequently ligated. The patient recovered with no neurological sequelae. The second case is a 43-year-old man who suffered a high-voltage injury while working on an electrical panel, resulting in a 50% TBSA full-thickness burn to the face, scalp, trunk, and extremities. Four weeks after admission, a latissimus dorsi myocutaneous free flap was used for coverage of exposed outer table of the skull. Intraoperatively, the carotid artery spontaneously ruptured proximal to where the dissection was being carried out. The patient recovered with no neurological sequelae. High-voltage electrical injury results in significant damage to blood vessels via a number of mechanisms. Rupture of a major vessel is a rare, life-threatening sequelae of electrical injury.

Diagnostics and Treatment of Volkmann Ischemic Contracture in a Seven-Year-Old Child.

A 7-year-old boy presented 6 weeks after open reduction and crossed Kirschner wire (K-wire) fixation of a supracondylar humerus fracture. Previous treatments had restored skeletal anatomy without documented complications. However, the patient would not move the entire arm, including his forearm and hand. Any passive movement led to anxious adverse reactions, and there was partial numbness of all fingers. After intensive physio- and occupational therapy supported by nerve stimulation and psychological counseling, anxiety-related functional deficits of the shoulder and elbow resolved to reveal the severe Volkmann contracture of the right hand developed fully. Electroneurography, X-ray, magnetic resonance imaging of the forearm, and ultrasonography showed nonfunctional ulnar and a partially disturbed radial motor nerve distal to the elbow along with damaged flexor muscles of the forearm after compartment syndrome. In addition, damage to the median nerve at the elbow level was diagnosed. After intense conservative therapy, we partially resected fibrotic fascia of the superficial flexor compartment, freed ulnar and median nerves, and performed staircase-like releases of tendons and tenotomies. We achieved a full range of motion of all fingers and markedly improved the range of motion of the wrist. The Disabilities of the Arm, Shoulder and Hand scores for function improved from 80 to 16 at the 2-year follow-up postoperatively, but some impairments of fine motor function persisted. Subtle symptoms of a developing compartment syndrome need to be recognized. Overlooked and untreated, a consecutive Volkmann contracture can turn the extremity nonfunctional. Intensive physical, psychological, and surgical therapy in a specialized center can restore function but requires endurance and perseverance throughout the lengthy recovery.

[One case of patient with bilateral ectopic subclavian vein catheterization].

One female patient aged 18 years, with severe burns and inhalation injury was admitted to our unit on June 5th, 2013. After admission, the right subclavian vein catheterization was performed for rapid fluid infusion against shock. Escharectomy on both upper extremities was planned to carry out and repaired with medium-thickness skin on right thigh 52 hours after injury. However, after general anesthesia, the right subclavian vein catheter was with poor fluid infusion, and the left subclavian vein catheterization was performed. Supraventricular tachycardia and decreased blood pressure occurred followed by fluid replacement and dilatation, cardiotonics, and diuretics. Postanesthetic 1.3 hours, the patient's vital signs were stable, and the operation began. Postoperative chest X-ray film showed that distal ends of the left and right subclavian vein catheters were respectively located in the right atrium and the right internal carotid vein, and the catheters were removed immediately. This case suggests that clinical physician should be careful to prevent catheter heterotopia in subclavian vein catheterization, and postoperative routine chest X-ray examination is necessary to identify position of the catheter.

Cardiac Catheterization Risks and Complications -- Technique or Treatment

When using the hand/wrist, the common site of access is the radial artery, even though the ulnar artery and brachial artery are also used in some situations. [3] The ideal place to access the radial artery is 2 cm proximal to the radial styloid. Before accessing the radial artery, an Allen test or Barbeau test is performed to confirm adequate collateral circulation to the palm. Allen test is performed by compressing both the radial and ulnar arteries until the palm blanches, and then the ulnar artery is released. The blush response in the hand is noted, and if the color in the palm returns before 10 seconds, the blood supply to the hand via the ulnar artery and palmar arch is considered satisfactory. Barbeau test removes the subjectivity of the Allen test, and a pulse oximeter is placed on the ipsilateral thumb. Similar to the Allen test, compression of both the arteries is performed until the pulse oximetry trace is blunted. The test is considered normal if the pulse oximetry tracing returns to normal within 10 seconds of releasing the pressure on the ulnar artery.

[Total-endoscopic Thyroid Resection in ABBA-Technique: Comments on the Integration of Intraoperative Neuromonitoring].

<bBackground:</b Total endoscopic thyroid resections without any scars on the neck are a special challenge for the surgeon. Clinical results of intraoperative neuromonitoring (IONM) in the axillo-bilateral-breast-approach (ABBA) have not been described so far. <bMethods:</b 29 female patients (~ 40 years) were operated for one-sided thyroid pathology using the ABBA technique (20 subtotal resections, 9 hemithyroidectomies). Suspected malignoma, size > 35 mL, known thyroiditis and recurrencies were excluded. For stimulation a 30-cm handprobe and for signal deviation a tube adhesive electrode (ISIS; Fa. Inomed, Emmendingen, Germany) were used. <bResults:</b The average operation time was 132 minutes. Intraoperative blood loss necessitated conversion to the open procedure in 1 case. A single tube electrode dislocation occurred. In the alternative a bipolar needle electrode was inserted percutaneously through the cricothyroid ligament. One intraoperative signal loss was confirmed by the laryngoscopic finding of vocal cord paresis, which recovered within 6 months. An additional case of incomplete brachial plexus paralysis was observed with a 2-day recovery time. <bConclusion:</b Direct neuromonitoring of the recurrent laryngeal nerve can be easily applied in the total endoscopic ABBA technique for thyroid resection. Vagal stimulation, which is obligatory in open thyroid surgery, cannot consequently be included in this endoscopic operation method. Unexpected tube electrode dislocation may cause IONM misinterpretation. A risk of double-sided vocal cord palsy is theoretically present.

[Wound repair and functional reconstruction of high-voltage electrical burns in wrists].

<bObjective:</b To explore the methods and effects of wound repair and functional reconstruction of high-voltage electrical burns in wrists. <bMethods:</b From January 2009 to June 2016, 71 patients with high-voltage electrical burns in wrists were hospitalized, with 118 wrist wounds including 21 of type Ⅰ, 69 of type Ⅱ, 9 of type Ⅲ, and 19 of type Ⅳ. According to the wrist injuries, different surgical operations were performed. Forearm amputation was conducted in 20 wrists with necrosis in the distal end. On the basis of fasciotomy for decompression, early debridement was performed on the other 98 wrist wounds. After debridement, wounds with area ranging from 10 cm×7 cm to 30 cm×18 cm were repaired with tissue flaps with abundant blood supply. Thirty-two wounds were repaired with pedicled groin flaps, 11 wounds with pedicled paraumbilical flaps, 3 wounds with pedicled anterolateral thigh island flaps, 9 wounds with combined abdominal axial pattern flaps, 37 wounds with free skin flaps or myocutaneous flaps, and 6 wounds with flow-through descending branch of lateral femoral circumflex artery flaps, with tissue flap area ranging from 12 cm×8 cm to 34 cm×20 cm. Ulnar artery or radial artery vascular reconstruction was performed in 20 wrist wounds. Forty-one donor sites were sutured directly, while 14 were closed by thin split-thickness skin grafts from same-side thighs, and 43 were closed by thin split-thickness skin grafts from opposite-side thighs. Fifty-three wrist wounds were performed with tendon and nerve repair surgery, of which 20 were performed with simple tendon and nerve release surgery. Flexor digitorum profundus tendons and (or) flexor pollicis longus tendons were reconstructed with autologous or allogeneic tendon transplantation in 33 wrist wounds, and the median nerve was repaired with sural nerve graft in 21 wrist wounds. In 6 to 24 months after the last operation, tendon function of 53 wrist wounds which had tendon repair was evaluated with finger total active motion (TAM) method, while median nerve function of 21 wrist wounds which had median nerve repair was evaluated with integrate estimation method. <bResults:</b (1) After forearm amputation, the incisions of 20 wrists with necrosis in the distal end were healed. (2) Among the 98 tissue flaps, 90 had good blood flow, while 8 had distal necrosis, of which 6 were healed after necrotic tissue removal and skin grafting, and two were sutured directly after debridement. Infection occurred under 7 flaps, of which 3 were healed by dressing change, and 4 were healed after second debridement. Twenty wrist wounds which had radial artery or ulnar artery repair had good blood supply of hand and amputation was avoided. During follow-up of 1 to 3 years, the incisions and flaps of patients who had tissue flap repair surgery healed well. (3) The excellent and good rate of TAM in each finger of the corresponding affected limbs of 53 wrist wounds which had tendon and nerve repair surgery was 51%. (4) Twenty wrists which had simple tendon and nerve release surgery were followed up for 1 to 2 years. The strength of muscle dominated by the median nerve was restored to grade Ⅴ in 1 wrist, grade Ⅳ in 3 wrists, and grade Ⅲ in 2 wrists. The strength of muscle dominated by the ulnar nerve was restored to grade Ⅳ in 3 wrists, with no recovery in other wrists. Sensory function examination showed grade S0 in 4 wrists, grade S1 in 2 wrists, grade S2 in 3 wrists, grade S3 in 8 wrists, and grade S4 in 3 wrists. Twenty-one wrists which had median nerve repair were followed up for 1 to 2 years. There was no recovery in muscle strength dominated by the median nerve. Sensory function examination showed grade S0 in 3 wrists, grade S1 in 5 wrists, grade S2 in 8 wrists, and grade S3 in 5 wrists. <bConclusions:</b It is a good method to sequentially conduct early fasciotomy for decompression, early debridement, vascular reconstruction, transplant of tissue flap with abundant blood supply, tendon and nerve repair in repairing electrical burn wounds of wrists, avoiding amputation, and reconstructing hand function according to the condition of electrical burns of wrists.

Medial Lemniscus Tract Lesion After High Voltage Electrical Injury: A Case Report.

We present the case of a 33-year-old man who experienced a 10,000-V electrical shock when working with electrical wiring. He suffered third-degree burns on his scalp at the right occiput (entry wound) and on his left arm (exit would), and a second-degree burn on his left foot (exit wound). He presented with severe spasticity of both lower extremities, motor weakness with a Medical Research Council grade of 3, and sensory impairments below thoracic level 11 that included an inability to sense light touch and defects in proprioception. Initial magnetic resonance imaging (MRI) scans of his spine and brain showed no definite abnormalities. However, tractography obtained by diffusion tensor imaging of the brain showed absence of the right medial lemniscus tract. A cervical MRI scan 1 month later showed spinal cord swelling from cervical 1-5 levels, and signal changes in the lateral and posterior white matter in the axial view. After 6 months of rehabilitation, he recovered almost normal degree of motor function in his lower extremities and disappearance of spasticity. However, since the sensory impairments persisted, especially defects in proprioception, he was unable to walk independently.

Intramuscular pressure in the burned arm: measurement and response to escharotomy.

Using a wick catheter technique, sequential measurements of intramuscular pressure were obtained in 31 burned arms in 18 patients. Abnormally high pressures were recorded in 90 percent of extremities and exceeded the potentially harmful level of 30 mm Hg in 42 percent. Correlation of intramuscular pressure with signs and symptoms of extremity compression, including Doppler pulses, was poor. Intramuscular pressure elevation appeared to parallel edema formation beneath the burn wound. A high incidence of pressure measurements in excess of 30 mm Hg was found in patients who had 30 percent or greater total body surface area injury (67 percent), 10 percent or greater full-thickness burns (75 percent), and extremities with circumferential involvement (57 percent). In every case echarotomy produced a dramatic decrease in intramuscular pressure, while a randomized group of extremities that were not decompressed developed sustained pressures as high as 64 mm Hg despite the presence of intact Doppler pulses. Extremities treated in this manner appeared slower in resolving edema and regaining motion and strength. Measurement of intramuscular pressure beneath the burn eschar is recommended in evaluating all patients at risk from extremity burns.

[Risk of arrhythmia and domestic low-voltage electrical injury].

Analysis of domestic low-voltage (220-240 V) electrical injury in children admitted to a pediatric emergency department to illustrate the low risk of initial or delayed risk of arrhythmia. Retrospective study between 2001 and 2008 analyzing all children aged less than 15 years admitted for a low-voltage electrical injury. The data collected were age, sex, time and circumstances of the accident, time and day of admission, transport modalities, presence of risk factors for arrhythmia (transthoracic current, wet skin, tetany, loss of consciousness or neurological symptoms, and initial EKG abnormalities), injuries, EKG, muscular and/or cardiac enzyme values, progression and complications. For statistical analysis, data were entered in Microsoft Excel tables. Analysis was done with StatView5.1 (SAS Institute) and Epi Info 6.04fr (VF, ENSP epiconcept). In the descriptive analysis, the data are presented as mean values with SD, median and range. Forty-eight children were included. The mean annual number of admissions was equal to 6 (range, 3-12). The mean age was 6.2 + or - 4.3 years (median, 4.6 years). There was a male predominance: the overall sex ratio was 1.5, i.e., 3 before the age of 2 and 2.6 before the age of 10. The electrical injury occurred after contact with a wire or a connected cord or after the introduction of a metallic object in a wall socket. Ten children had risk factors of arrhythmia (mainly wet skin or thoracic pain). Twenty-nine children suffered from burns to the extremities (digits and hands, 70 %). At admission, 45 children had an EKG performed. The initial EKG was considered abnormal in 8 cases showing: sinusal tachycardia (n=4), incomplete right bundle branch block (n=4), and V(1) negative T waves (n=1). The EKG normalized within the first 12h. Hospitalization for cardiac monitoring was required for 18 children. No delayed arrhythmia occurred. In a mean time of 3.5h after the accident, a troponin dosage was given to 15 children and was normal in all cases. One child developed rhabdomyolysis and evolved without needing dialysis. After a low-voltage electrical injury, initial arrhythmia is not frequent, with often a nonspecific and transitory EKG expression; delayed arrhythmia is very rare. Children presenting to the emergency department after such an electrical accident, who are asymptomatic, without any risk factors for arrhythmia (wet skin, tetany, vertical pathway of the current, preexistent cardiological conditions, loss of consciousness) and with a normal initial EKG do not require cardiac monitoring.

A comparison of coracoid and axillary approaches to the brachial plexus.

Brachial plexus block by the coracoid approach does not require arm abduction and may be more effective than the axillary approach because of a more proximal injection of local anaesthetic. However, the clinical usefulness of the coracoid approach has not been tested in prospective controlled trials. The present randomized, observer-blinded study compared success rates, time to obtain a complete block, frequency of adverse effects and block discomfort in two groups of 30 patients, anaesthetized for hand surgery using either the coracoid or the axillary approach to the brachial plexus. After subcutaneous infiltration with 5 ml of 1% mepivacaine/adrenaline the brachial plexus was located using a nerve stimulator and an insulated pencil-point needle. Ropivacaine 0.75%, 20-40 ml, depending on body weight, was used for the initial block. In the coracoid (C) group two plexus cords, and in the axillary (A) group four terminal nerves were electrolocated and the volume of ropivacaine was divided equally between them. Spread of analgesia to the arm was assessed every 5 min, by an anaesthetist unaware of the block technique. The block was defined as effective (complete) when analgesia was present in all five sensory nerve areas distal to the elbow. Incomplete blocks were supplemented 30 min after the initial block. In the C group a median 11 min was required for block performance as compared to 12 min in the A group (NS). Onset of block was shorter and the frequency of incomplete blocks lower in the A group (median 17 min and 17%) than in the C group (30 min and 47%, respectively). Lack of analgesia of the ulnar nerve was the main cause of incomplete initial blocks in the C group. All incomplete blocks were successfully supplemented. However, total time to obtain complete block was shorter in the A group than in the C group (29 min vs. 41 min, P<0.05). Accidental arterial puncture occurred in seven patients (five in C and two in A group), which resulted in two haematomas, both in the C group (NS). No permanent sequelae were observed. The axillary approach to the brachial plexus using four injections of ropivacaine results in a faster onset of block and a better spread of analgesia than the coracoid approach using two injections.

Blood pressure cuff compression injury of the radial nerve.

We describe a 19-year-old man who underwent emergency laparotomy for perforated peptic ulcer. He was otherwise healthy before this admission with no history of diabetes mellitus or neuropathy. A standard-size adult blood pressure cuff connected to a Dinamap monitor, set to cycle automatically every 3 minutes was affixed to his left upper extremity during surgery. One day after the operation he complained of numbness over the dorsum of the left hand and wrist drop. Physical examination revealed 0/5 muscle power of the left wrist and finger extensor muscles with reduced sensation on the radial aspect of the dorsum of the same hand. A diagnosis of acute radial nerve injury was made and rehabilitation was started. The wrist numbness and sensation improved with physical therapy, and he was discharged 9 days after the operation with an active wrist splint. He continued with rehabilitation on an out-patient basis. The muscle power of the wrist extensors gradually improved after three months of physical therapy and reverted to completely normal one month later. Locating the cuff higher on the arm, away from the elbow joint, to avoid the most superficial portion of radial nerve, may prevent this type of compression injury especially in asthenic patients.

Surgery_Schwartz

terrible aesthetic sequelae. When indicated, they are usu-ally performed at the bedside, preferably with electrocautery to minimize blood loss. Extremity incisions are made on the lateral and medial aspects of the limbs in an anatomic position and may extend onto thenar and hypothenar eminences of the hand. Digital escharotomies do not usually result in any meaningful salvage of functional tissue and are not recommended. Inad-equate perfusion despite proper escharotomies may indicate the need for fasciotomy, but this procedure should not be routinely performed as part of the eschar release. Thoracic escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions. Extension of the ante-rior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar.The strategy of early excision and grafting in burned patients revolutionized survival outcomes in burn care. Not only did it improve

Axillary compression syndrome with neurapraxia due to operative positioning.

A 20-year-old man underwent a 9-hour operation in a left lateral position for the removal of an osteoblastoma involving the pedicles of thoracic vertebrae T-11 and T-12 and for fixation with bond grafting. Immediately after the operation, extensive swelling of the left shoulder area was noted. The radial pulse on the left was intact, and there was movement of the fingers of the left hand, which ceased completely by the following morning. A computerized axial tomographic scan showed extensive swelling of the pectoral, deltoid, and other muscles around the shoulder. An emergency decompression procedure was carried out by dividing the pectoral and anterior scalene muscles; prompt return of some motor activity in the left hand followed, and this gradually returned to normal. This case of what may be termed "axillary" compression syndrome suggests that extra care should be taken to use an adequate axillary roll and to avoid lengthy operations in a lateral position, and indicates a method for decompression.


Chronic hypertension is defined as hypertension that is present before pregnancy or that is diagnosed before the 20th week of gestation. In this case, the patient is 10 weeks pregnant, so the correct answer is 3.

Chronic hypertension is defined as hypertension that is present before pregnancy or that is diagnosed before the 20th week of gestation. In this case, the patient is 10 weeks pregnant, so [HIDDEN].

A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg. She was in good general condition, with only mild headache, which was the reason for taking her blood pressure. After 4 hours of rest she presented with a blood pressure of 150/95mmHg. A complete blood count is normal and proteinuria is negative. What type of hypertension is present?

Hypertensive disease of pregnancy

Preeclampsia superimposed on chronic hypertension occurs when a pregnant woman with chronic hypertension develops signs of pre-eclampsia, typically defined as new onset of proteinuria ≥30 mg/dL (1+ in the dipstick) in at least 2 random urine specimens that were collected ≥4 h apart (but within a 7-day interval) or 0.3 g in a 24-h period. Like ordinary pre-eclampsia, superimposed pre-eclampsia can also occur with severe features, which are defined as: systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg despite escalation of antihypertensive therapy; thrombocytopenia (platelet count <100,000/microL); impaired liver function; new-onset or worsening renal insufficiency; pulmonary edema; or persistent cerebral or visual disturbances. As a result, superimposed pre-eclampsia can be diagnosed without proteinuria when a sudden increase in previously well-controlled blood pressure is accompanied by severe features of pre-eclampsia.

Eclampsia

Vital signs One of the core features of pre-eclampsia is high blood pressure. Blood pressure is a measurement of two numbers. If either the top number (systolic blood pressure) is greater than 140 mmHg or the bottom number (diastolic blood pressure) is greater than 90 mmHg, then the blood pressure is higher than the normal range and the person has high blood pressure. If the systolic blood pressure is greater than 160 or the diastolic pressure is greater than 110, the hypertension is considered to be severe. Laboratory testing Another core feature of pre-eclampsia is proteinuria, which is the presence of excess protein in the urine. To determine if proteinuria is present, the urine can be collected and tested for protein; if there is 0.3 grams of protein or more in the urine of a pregnant woman collected over 24 hours, this is one of the diagnostic criteria for pre-eclampsia and raises the suspicion that a seizure is due to eclampsia.

Gestational hypertension

Diagnosis Conditions There exist several hypertensive states of pregnancy: Gestational hypertension Gestational hypertension is usually defined as having a blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart, without the presence of protein in the urine and diagnosed after 20 weeks of gestation. Pre-eclampsia Pre-eclampsia is gestational hypertension plus proteinuria (>300 mg of protein in a 24-hour urine sample). Severe pre-eclampsia involves a blood pressure greater than 160/110, with additional medical signs and symptoms. HELLP syndrome is a type of pre-eclampsia. It is a combination of three medical conditions: hemolytic anemia, elevated liver enzymes and low platelet count. Eclampsia This is when tonic-clonic seizures appear in a pregnant woman with high blood pressure and proteinuria. Pre-eclampsia and eclampsia are sometimes treated as components of a common syndrome. Treatment

Home blood-pressure monitoring in a hypertensive pregnant population.

The majority of patients with chronic or gestational hypertension do not develop pre-eclampsia. Home blood-pressure monitoring (HBPM) has the potential to offer a more accurate and acceptable means of monitoring hypertensive patients during pregnancy compared with traditional pathways of frequent outpatient monitoring. The aim of this study was to determine whether HBPM reduces visits to antenatal services and is safe in pregnancy. This was a case-control study of 166 hypertensive pregnant women, which took place at St George's Hospital, University of London. Inclusion criteria were: chronic hypertension, gestational hypertension or high risk of developing pre-eclampsia, no significant proteinuria (≤ 1+ proteinuria on dipstick testing) and normal biochemical and hematological markers. Exclusion criteria were maternal age < 16 years, systolic blood pressure > 155 mmHg or diastolic blood pressure > 100 mmHg, significant proteinuria (≥ 2+ proteinuria on dipstick testing or protein/creatinine ratio > 30 mg/mmol), evidence of small-for-gestational age (estimated fetal weight < 10<supth</sup centile), signs of severe pre-eclampsia, significant mental health concerns or insufficient understanding of the English language. Pregnant women in the HBPM group were taught how to measure and record their blood pressure using a validated machine at home and attended every 1-2 weeks for assessment depending on clinical need. The control group was managed as per the local protocol prior to the implementation of HBPM. The two groups were compared with respect to number of visits to antenatal services and outcome. There were 108 women in the HBPM group and 58 in the control group. There was no difference in maternal age, parity, body mass index, ethnicity or smoking status between the groups, but there were more women with chronic hypertension in the HBPM group compared with the control group (49.1% vs 25.9%, P = 0.004). The HBPM group had significantly fewer outpatient attendances per patient (6.5 vs 8.0, P = 0.003) and this difference persisted when taking into account differences in duration of monitoring (0.8 vs 1.6 attendances per week, P < 0.001). There was no difference in the incidence of adverse maternal, fetal or neonatal outcome between the two groups. HBPM in hypertensive pregnancies has the potential to reduce the number of hospital visits required by patients without compromising maternal and pregnancy outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

[Atypical preeclampsia and perinatal success: a case report].

Preeclampsia is a multi systemic syndrome of variable severity, pregnancy specific, consequence of an abnormal vascular response to placentation, with increase in peripheral vascular resistance, stimulation of platelet aggregation, activation of the coagulation cascade, and endothelial dysfunction. In the majority of cases, it will present with gestational hypertension and proteinuria, after 20 weeks, nevertheless, in other cases, it has presented as an atypical form (with absence of hypertension and/or proteinuria) behaving like severe preeclampsia. We report the case of a patient, 32 year old primigravida, with a 26.6 weeks gestation, that comes to the office with postprandial projectile vomiting. At the time of admission, she presents with sudden headache, phosphenes, and tinnitus, associated to epigastric pain, with a blood pressure of 110/70 mmHg; fetal heart rate of 146 bpm, normal lower limbs and reflexes. The Complete Blood Count and liver function tests are within normal values, urinalysis with proteinuria. Normal hepatic ultrasound. Obstetric ultrasound; with fetal measurements of 2.6 weeks below, with flattening of the growth curve, Doppler flowmetry with an increase in placental resistance and oligohydramnios. Given the clinical manifestations compatible with severe preeclampsia, magnesium sulfate, and antenatal corticosteroid therapy are initiated, and abdominal termination of pregnancy is decided. A female newborn is obtained, of 595 g, Apgar 4/7. On immediate puerperium, she presents with an increase in blood pressure of 150/90 mmHg, discharged with normal blood pressure 96 hours later. The newborn girl was discharged when she reached a weight of 2000 g. Today, she is neurologically unimpaired.

Hypertensive disease of pregnancy

Preeclampsia can also be diagnosed if a woman has both increased blood pressure and 1 or more signs of significant organ damage. Signs of significant organ damage include: Severely elevated blood pressure (blood pressure > 160/110) Thrombocytopenia Increased or rapidly elevating levels of creatinine in the blood Increased liver enzymes Pulmonary edema New or persistent headaches that do not respond to pain medication Blurred or altered vision If a woman with preeclampsia has any of these signs of significant organ damage, then her condition is classified as preeclampsia with severe features. This diagnosis can be made even if the patient does not have proteinuria. Women with preeclampsia with severe features are encouraged to deliver the child after 34 weeks of gestation to minimize the risks of the severe complications. Preeclampsia can also present with seizures in the pregnant mother. In this case, the patient would be diagnosed with eclampsia.

Pre-eclampsia

Immune factors may also play a role. Diagnosis Testing for pre-eclampsia is recommended throughout pregnancy via measuring a woman's blood pressure. Diagnostic criteria Pre-eclampsia is diagnosed when a pregnant woman develops: Blood pressure ≥140 mmHg systolic or ≥90 mmHg diastolic on two separate readings taken at least four to six hours apart after 20 weeks' gestation in an individual with previously normal blood pressure. In a woman with essential hypertension beginning before 20 weeks' gestational age, the diagnostic criteria are an increase in systolic blood pressure (SBP) of ≥30 mmHg or an increase in diastolic blood pressure (DBP) of ≥15 mmHg. Proteinuria ≥ or more of protein in a 24-hour urine sample or a SPOT urinary protein to creatinine ratio ≥0.3 or a urine dipstick reading of 1+ or greater (dipstick reading should only be used if other quantitative methods are not available).

Gestational hypertension

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks' gestation without the presence of protein in the urine or other signs of pre-eclampsia. Gestational hypertension is defined as having a blood pressure greater than 140/90 on two occasions at least 6 hours apart. Signs and symptoms No single diagnostic test currently exists to predict the likelihood of developing gestational hypertension. High blood pressure is the major sign in diagnosing gestational hypertension. Some women with gestational hypertension may present asymptomatic, but a number of symptoms are associated with the condition. Symptoms Edema Sudden weight gain Blurred vision or sensitivity to light Nausea and vomiting Persistent headaches Increased blood pressure

Blood pressure, edema and proteinuria in pregnancy. 9. Proposal for classification.

The frequency distributions of blood pressures in large populations fail to show two groups, one normotensive and the other hypertensive. In the spectrum of pressures, some people merely have higher levels than others and division of abnormal from normal is artificial and arbitrary, although it is useful for prognosis. The blood pressure of 140/90 as the conventional dividing line does not seem to be appropriate in pregnant women. From the standpoint of fetal prognosis, a level of 125/75 before the thirty-second week and 125/85 thereafter seems more reasonable. Moreover, those levels are close to the 120/80 that Robinson and Brucer specified as the upper limit of normal for all adults and are close to the 130/70 and 120/80 that the eminent British authority, F.J. Browne, used successively in the diagnosis of hypertensive disorders in pregnancy. If the standard of 125/75 were adopted, however, a quarter of all pregnant women would be hypertensive in the second trimester and half in the last month, which are disturbingly high proportions. For the diagnosis of preeclampsia, a rise in blood pressure probably is more significant than an arbitrary level. The usual blood pressure in midpregnancy merely defines the patient's place in the spectrum. Figure 9-1 indicates that in white nulliparas the diastolic pressure rises an average of 10 mm. Hg in the middle of the third trimester. If the mean and median are close together, greater increases would occur in half of the women. The classification of the American Committee on Maternal Welfare and of the Committee on Terminology of the American College of Obstetricians and Gynecologists specify increases of 30 mm. Hg or more in the systolic or 15 mm. Hg or more in the diastolic pressures as criteria of preeclamptic hypertension. pperhaps the rise in diastolic pressure should be set at some greater value. Our analysis of data made thus far cannot decide that issue. The next phase of the study will include analyses in individual women of the times, magnitudes, persistence or transience, and the like of changes in blood pressure, edema, and proteinuria. Such data will afford much more information than can be derived from the preliminary studies reported here. Although edema of the hands and face may be more common in preeclamptic than in normal women, such edema is so common in normal pregnancy as to suggest that it usually is normal. In our data, edema seems to bear no relation to hypertension or proteinuria. The triad of signs -- hypertension, proteinuria, and edema -- is generally accepted as characteristic, though far from specific for preeclampsia. Our data support Hytten's conclusion that edema should by dropped from the triad. There is some indication, however, that some edema is abnormal and that it is associated with an adverse effect when it coincides with proteinuria late in pregnancy.

Hypertensive disease of pregnancy

Because chronic hypertension can progress to more severe forms of disease, it is important to accurately diagnose the condition early, ideally prior to pregnancy, and initiate management to control parental blood pressure. This is often difficult, as many reproductive individuals may not regularly visit the doctor and, when pregnant, may initially present for prenatal care in the second trimester. Pre-eclampsia and eclampsia Preeclampsia is a medical condition which usually develops after 20 weeks of gestation and traditionally involves both newly increased blood pressure (blood pressure > 140/90 mmHg) and proteinuria. Preeclampsia is a leading cause of fetal complications, which include low birth weight, preterm birth, and stillbirth. Women with preeclampsia are encouraged to deliver the child after 37 weeks of gestation to minimize the risks of the severe complications.

Hypertensive disease of pregnancy

Risks Some women have a greater risk of developing hypertension during pregnancy. These are: Women with chronic hypertension (high blood pressure before becoming pregnant). Women who developed high blood pressure or preeclampsia during a previous pregnancy, especially if these conditions occurred early in the pregnancy. Women who are obese prior to pregnancy. Pregnant women under the age of 20 or over the age of 40. Women who are pregnant with more than one baby. Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma. Diagnosis There is no single test to predict or diagnose preeclampsia. Key signs are increased blood pressure and protein in the urine (proteinuria). Other symptoms that seem to occur with preeclampsia include persistent headaches, blurred vision or sensitivity to light, and abdominal pain.

Prognostic value of office and ambulatory blood pressure measurements in pregnancy.

With the objective to assess the prognostic value of office values as compared with ambulatory monitoring in pregnancy, we analyzed 2430 blood pressure series systematically sampled from 403 untreated pregnant women for 48 consecutive hours every 4 weeks from the first visit to the hospital until delivery. Women were divided into 5 groups: "detected" gestational hypertension, women with office blood pressures >140/90 mm Hg after 20 weeks of gestation and hyperbaric index (area of blood pressure excess above the upper limit of a time-specified tolerance interval) consistently above the threshold for diagnosing hypertension in pregnancy; "undetected" gestational hypertension, office values <140/90 mm Hg but hyperbaric index above the threshold for diagnosis; normotension, both office values and hyperbaric index below the thresholds for diagnosis; white coat hypertension, women with recorded diagnosis of gestational hypertension but hyperbaric index consistently below the threshold for diagnosis; and preeclampsia, defined as gestational hypertension and proteinuria. Results indicate small and nonsignificant differences in 24-hour mean of ambulatory pressures between "detected" and "undetected" gestational hypertension at all stages of pregnancy, in contrast with highly significant differences between these two groups and normotensive pregnancies. Average office blood pressure values were similar for preeclampsia, "detected," and "undetected" gestational hypertension. The hyperbaric index was, however, significantly higher for women with preeclampsia after 20 weeks of gestation as compared with all other groups and higher for women with either "detected" or "undetected" gestational hypertension as compared with normotensive pregnant women. The incidence of preterm delivery and intrauterine growth retardation were similar for "detected" and "undetected" gestational hypertension but significantly lower for normotensive women. In pregnancy, the hyperbaric index derived from ambulatory monitoring is markedly superior to office measurements for diagnosis of what should be truly considered gestational hypertension, as well as for prediction of the outcome of pregnancy.

Hypertensive disease of pregnancy

All of these sensations can be caused by other disorders; they can also occur in healthy pregnancies. Regular visits are scheduled to track blood pressure and level of protein in urine, to order and analyze blood tests that detect signs of preeclampsia, and to monitor fetal development more closely. Classification A classification of hypertensive disorders of pregnancy uses 4 categories as recommended by the U.S. National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy: Chronic hypertension; Preeclampsia-eclampsia; Preeclampsia superimposed on chronic hypertension; Gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy).

Preeclampsia: an update.

Preeclampsia was formerly defined as a multisystemic disorder characterized by new onset of hypertension (i.e. systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg) and proteinuria (> 300 mg/24 h) arising after 20 weeks of gestation in a previously normotensive woman. Recently, the American College of Obstetricians and Gynecologists has stated that proteinuria is no longer required for the diagnosis of preeclampsia. This complication of pregnancy remains a leading cause of maternal morbidity and mortality. Clinical signs appear in the second half of pregnancy, but initial pathogenic mechanisms arise much earlier. The cytotrophoblast fails to remodel spiral arteries, leading to hypoperfusion and ischemia of the placenta. The fetal consequence is growth restriction. On the maternal side, the ischemic placenta releases factors that provoke a generalized maternal endothelial dysfunction. The endothelial dysfunction is in turn responsible for the symptoms and complications of preeclampsia. These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures. Despite a better understanding of preeclampsia pathophysiology and maternal hemodynamic alterations during preeclampsia, the only curative treatment remains placenta and fetus delivery. At the time of diagnosis, the initial objective is the assessment of disease severity. Severe hypertension (SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg), thrombocytopenia < 100.000/μL, liver transaminases above twice the normal values, HELLP syndrome, renal failure, persistent epigastric or right upper quadrant pain, visual or neurologic symptoms, and acute pulmonary edema are all severity criteria. Medical treatment depends on the severity of preeclampsia, and relies on antihypertensive medications and magnesium sulfate. Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures. The decision of terminating pregnancy and perform delivery is based on gestational age, maternal and fetal conditions, and severity of preeclampsia. Delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation. Between 24 and 34 weeks of gestation, conservative management of severe preeclampsia may be considered in selected patients. Antenatal corticosteroids should be administered to less than 34 gestation week preeclamptic women to promote fetal lung maturity. Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks of gestation. Maternal end organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age. Neuraxial analgesia and anesthesia are, in the absence of thrombocytopenia, strongly considered as first line anesthetic techniques in preeclamptic patients. Airway edema and tracheal intubation-induced elevation in blood pressure are important issues of general anesthesia in those patients. The major adverse outcomes associated with preeclampsia are related to maternal central nervous system hemorrhage, hepatic rupture, and renal failure. Preeclampsia is also a risk factor for developing cardiovascular disease later in life, and therefore mandates long-term follow-up.

Hypertensive disease of pregnancy

Gestational hypertension Gestational hypertension is a provisional diagnosis that involves newly increased blood pressure in a pregnant woman that usually develops after 20 weeks of gestation, but does not currently show any signs of proteinuria or other features associated with preeclampsia. Up to 50% of gestational hypertension patients go on to develop some form of preeclampsia. Gestational hypertension will normally resolve by 12 weeks postpartum. In this case, the diagnosis of gestational hypertension will be updated to be transient hypertension of pregnancy. If the increased blood pressure does not resolve by 12 weeks postpartum, then the diagnosis of gestational hypertension will be updated to be chronic hypertension.

Hypertensive disease of pregnancy

The diagnostic criteria for chronic hypertension are typically considered to be at least two separate blood pressure readings taken at least four hours apart with systolic blood pressure ≥ 140mmHg, diastolic blood pressure ≥90 mmHg, or both, identified before pregnancy, before 20 weeks gestation, or persisting at least 12 weeks after giving birth. However, there is some controversy over the utility of adopting lower thresholds for diagnosis of chronic hypertension, which is more consistent with recent recommendations from the American College of Cardiology and the American Heart Association for the diagnosis of hypertension in adults. Chronic hypertension in pregnancy is now considered mild if blood pressures do not exceed 159 mmHg systolic and 109 mmHg diastolic and severe if pressures are ≥ 160 mmHg systolic or 110 mmHg diastolic, although controversy also exists as to the most appropriate cutoffs for this definition.

Obstentrics_Williams

C, FIGURE 40-1 Schematic shows normal reference ranges for mean arterial blood pressure changes across pregnancy. Patient A (blue) has mean blood pressures near the 20th percentile throughout pregnancy. Patient B (red) has a similar pattern with mean pressures at the 25th percentile until approximately 36 weeks when her blood pressure begins to rise. By term, it is substantively higher and in the 75th percentile, but she is still considered "normotensive." 25th percentile until 32 weeks. These begin to rise in patient B, who by term has substantively higher blood pressures. However, her pressures are still < 140/90 mm Hg, and thus she is considered to be "normotensive." We use the term delta hypertension to describe this rather acute rise in blood pressure. Some of these women will go on to have obvious preeclampsia, and some even develop eclamptic seizures or HELLP (hemolysis, devatedliver enzyme levels, low 2latelet count) syndrome while still normotensive.

[Hypertensive disorders in pregnancy].

Hypertension in pregnancy is defined by a systolic blood pressure > or = 140 mm Hg and a diastolic blood pressure of > or = 90 mm Hg or by a rise in blood pressure of systolic > or = 30 mm Hg and diastolic > or = 15 mm Hg. High blood pressures are found in 5-10% of all pregnancies. The outcome of pregnancy is influenced by the fact whether there occurs a proteinuria in addition to hypertension. While the prognosis of an isolated hypotension is good, the combination of hypertension and proteinuria leading to preeclampsia is the primary cause of maternal death in many countries and is responsible for 20-25% of perinatal mortality. A simple classification divides between chronic hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension and transient hypertension. With chronic hypertension pregnancy outcome is determined by a preexisting nephropathy and the occurrence of a superimposed preeclampsia. Preeclampsia and superimposed preeclampsia are pregnancy induced multiorganic diseases, endangering both the mother and the fetus. Transient hypertension is a benign pathology, which occurs toward the end of pregnancy usually on the basis of a latent essential hypertension, which is laid open through pregnancy. While a severe chronic hypertension in pregnancy must be treated to prevent a hypertensive maternal encephalopathy, a less severe chronic hypertension should not be treated as the risk of a superimposed preeclampsia and the maternal and fetal outcome cannot be influenced by antihypertensive therapy. The incidence of preeclampsia is 3-5% in nulliparae and 0.5% in multiparae. Preeclampsia is a severe and dangerous pathology with an unknown etiology. Pregnancy termination is the only causal therapy. At present it is still recommended to terminate a severe preeclampsia after stabilizing the mother, irrespective of gestational age. In less severe preeclampsia occurring before 32 weeks of gestation, termination of pregnancy can be postponed under intensive monitoring and a prophylaxis with magnesium sulfate in order to accelerate the fetal lung maturation with glucocorticoids. A conservative management in the case of a HELLP-syndrome (Haemolyis, Elevated Liver enzymes, Low Platelets), which is a very severe form of preeclampsia, is not recommended because it hasn't been validated in prospective controlled studies. The most dangerous complication of preeclampsia is eclampsia, which is defined by general tonic-clonic convulsions before or after birth. The most effective prophylaxis of eclamptic attacks is the intravenous therapy with magnesium sulfate. A primary prohylaxis for preeclampsia doesn't exist. Treatment with low-dose aspirin in high-risk patients, i.e. after a severe preeclampsia, in cases of chronic hypertension, in cases of nephropathy and in cases with antiphospholipid-syndrome++ can be recommended. The prophylactic use of low-dose heparin, which has lead to a significant decreased incidence of preeclampsia in retrospective analysis, is now the object of a randomized, controlled trial in our hospital. All women who suffered from a preeclampsia should have a check-up after 3-6 months. Preexisting pathologies are found in up to 40% of patients, mostly in multiparae, i.e. chronic hypertension, nephropathy, endocrine pathologies, anomalies of blood coagulation and antiphospolipid-syndrome.

Hypertensive disease of pregnancy

Preeclampsia can also present with seizures in the pregnant mother. In this case, the patient would be diagnosed with eclampsia. There is no proven way to prevent preeclampsia/eclampsia. Most women who develop signs of preeclampsia, however, are closely monitored to lessen or avoid related problems. The only way to "cure" preeclampsia/eclampsia is to deliver or abort the baby. Eclampsia Eclampsia is one particularly concerning form of preeclampsia in which a pregnant woman who previously presented with signs of newly increased blood pressure begins to experience new generalized seizures or coma. Up to 70% of patients with eclampsia experience complications associated with pregnancy. These complications can include HELLP syndrome, acute kidney injury, and disseminated intravascular coagulation among others.

Hypertensive emergency

Diagnosis The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120 mmHg or systolic blood pressure greater than or equal to 180 mmHg. Hypertensive emergency differs from hypertensive urgency in that, in the former, there is evidence of acute organ damage. Both of these definitions had collectively been known as malignant hypertension, although this medical term is replaced. In the pregnant patient, the definition of hypertensive emergency (likely secondary to pre-eclampsia or eclampsia) is only a blood pressure exceeding 160 mmHg systolic blood pressure or 110 mmHg diastolic blood pressure.

Hypertension In Pregnancy -- Evaluation

The criteria for pre-eclampsia can also be met in the absence of proteinuria if one has new-onset hypertension with thrombocytopenia(platelets less than 100,000 x10(9)/L, renal insufficiency(double of baseline serum creatine or serum creatine >1.1mg/dL), pulmonary edema, impaired liver function (AST/ALT greater than twice upper limit of normal), or new-onset headache unresponsive to medications with no alternative cause.Pre-eclampsia can be superimposed with chronic hypertension, or as advancement along the spectrum of gestational hypertensive disease. Per ACOG guidelines, systolic blood pressure of greater than 160mmHg or diastolic blood pressure greater than 110mmHg on two separate readings 4 hours apart or any severe range pressure that requires antihypertensive medication which by treatment guidelines is severe pressures seperated by minutes(10-30 minutes). [15]

Transient gestational hypertension and pre-eclampsia: Two case reports and literature review on the need for stringent monitoring.

Transient gestation hypertension is a contributor to adverse pregnancy outcomes particularly when it progresses to pre-eclampsia (PE). This requires frequent monitoring. We illustrate the need for stringent monitoring of gestational hypertension, transient gestational hypertension (TGH) and PE without severe features and conducted a brief rapid review of the literature. Two cases are presented: Firstly, a 25-year-old primigravida at 30 gestational weeks who had an isolated TGH with high blood pressure (BP) of 141/87 mmHg, which was not investigated. Four weeks later, she presented with a BP of 202/128 mmHg, imminent eclampsia and intrauterine foetal death and had an uncomplicated induction of labour and delivered a 1400 g macerated male stillborn. Secondly, a 30-year-old primigravida at 30 gestational weeks who developed PE but her monitoring was compromised initially by inadequate healthcare capacity including unavailability of hospital bed-space for inpatient care and later by poor clinic attendance as a result of poor finances. At 32 gestational weeks, she presented with decreased foetal movement and was diagnosed as haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome and intrauterine foetal death. She was stabilised, had induction of labour and delivered a 1400 g male macerated stillborn. Thereafter, the need for her to go home to complete the cultural burial rites of her baby and the pressure from her workplace resulted in an inadequate postpartum follow-up care. In conclusion, transient gestational hypertension is associated with adverse maternal and foetal outcomes, including foetal demise. Unavailability of hospital bed-space and poor personal finances interfere with stringent monitoring of hypertensive disorders and can be associated with adverse pregnancy outcomes. Stringent laboratory monitoring in these cases is defined by the authors as testing at least blood levels of serum Creatinine, Haemoglobin concentration, Alanine transaminase and Platelet count (abbreviated as 'CHAP') weekly.

Hypertensive disease of pregnancy

There is limited evidence to suggest that calcium supplementation may reduce the risk of pre-eclampsia or stillbirth but it is unclear if it has other benefits. Prognosis The effects of high blood pressure during pregnancy vary depending on the disorder and other factors. Preeclampsia does not in general increase a woman's risk for developing chronic hypertension or other heart-related problems. Women with normal blood pressure who develop preeclampsia after the 20th week of their first pregnancy, short-term complications, including increased blood pressure, usually go away within about six weeks after delivery. Some women, however, may be more likely to develop high blood pressure or other heart disease later in life. More research is needed to determine the long-term health effects of hypertensive disorders in pregnancy and to develop better methods for identifying, diagnosing, and treating women at risk for these conditions.

Pre-eclampsia

Suspicion for pre-eclampsia should be maintained in any pregnancy complicated by elevated blood pressure, even in the absence of proteinuria. Ten percent of individuals with other signs and symptoms of pre-eclampsia and 20% of individuals diagnosed with eclampsia show no evidence of proteinuria. In the absence of proteinuria, the presence of new-onset hypertension (elevated blood pressure) and the new onset of one or more of the following is suggestive of the diagnosis of pre-eclampsia: Evidence of kidney dysfunction (oliguria, elevated creatinine levels) Impaired liver function (noted by liver function tests) Thrombocytopenia (platelet count <100,000/microliter) Pulmonary edema Ankle edema (pitting type) Cerebral or visual disturbances

Complications of pregnancy

High blood pressure Potential severe hypertensive states of pregnancy are mainly: Preeclampsia – gestational hypertension, proteinuria (>300 mg), and edema. Severe preeclampsia involves a BP over 160/110 (with additional signs). It affects 5–8% of pregnancies. Eclampsia – seizures in a pre-eclamptic patient, affect around 1.4% of pregnancies. Gestational hypertension HELLP syndrome – Hemolytic anemia, elevated liver enzymes and a low platelet count. Incidence is reported as 0.5–0.9% of all pregnancies. Acute fatty liver of pregnancy is sometimes included in the preeclamptic spectrum. It occurs in approximately one in 7,000 to one in 15,000 pregnancies. Venous thromboembolism Deep vein thrombosis (DVT), a form of venous thromboembolism (VTE), has an incidence of 0.5 to 7 per 1,000 pregnancies, and is the second most common cause of maternal death in developed countries after bleeding.

Hypertensive disease of pregnancy

Signs and symptoms Although many pregnant women with high blood pressure have healthy babies without serious problems, high blood pressure can be dangerous for both the mother and baby. Women with pre-existing, or chronic, high blood pressure are more likely to have certain complications during pregnancy than those with normal blood pressure. However, some women develop high blood pressure while they are pregnant (often called gestational hypertension). Chronic poorly-controlled high blood pressure before and during pregnancy puts a pregnant woman and her baby at risk for problems. It is associated with an increased risk for maternal complications such as preeclampsia, placental abruption (when the placenta separates from the wall of the uterus), and gestational diabetes. These women also face a higher risk for poor birth outcomes such as preterm delivery, having an infant small for his/her gestational age, and infant death.

[Atypical preeclampsia: case report].

Preeclampsia that occurs at < 20 weeks of gestation is rare and has been usually reported with molar or hydropic degeneration of the placenta and antiphospholipid syndrome. To describe the clinical presentation of atypical preeclampsia of a patient of 37 years old at her first gestation who developed this entity at 18.5 weeks of gestation. She had history of pre-existing hypertension and infertility. This pregnancy was obtained through in vitro fertility. She reported a severe headache and was admitted to our hospital secondary to elevated blood pressure of 160/110 mm Hg. The laboratory evaluation revealed platelet count 51,000, alanine aminotransferase of 331 UI/L, aspartate aminotransferase of 285 UI/L, lactate dehydrogenase 421 UI/L and urinalysis with +2 proteinuria, soluble fms-like tyrosine kinase-1/placental growth factor ratio 895.5. The diagnosis of chronic hypertension and superimposed preeclampsia and incomplete HELLP syndrome was supported. After termination of pregnancy, the patient improved rapidly. She was discharged home on postoperative day 7 with a blood pressure of 120/70 mm Hg with normal laboratory. Clinicians should consider the diagnosis of preeclampsia and HELLP syndrome before 20 weeks of gestation in women presenting with clinical or laboratory abnormalities consistent with this disease.

Obstentrics_Williams

TABLE 40-1. Classification and Diagnosis of Pregnancy-Associated Hypertension Gestational hypertension Preeclampsia: Hypertension plus • 2300 mg/24 h, or Urine protein: creatinine ratio 20.3, or Platelet count < 1 OO,OOO/.LL 1.1 mg/dL or doubling of baselineb Headache, visual disturbances, convulsions aRecommended only if sole available test. bNo prior renal disease. CAST (aspartate transaminase) or ALT (alanine transaminase). BP = blood pressure. Modified with permission from American College ofObstetricians and Gynecologists; Task Force on Hypertension in Pregnancy: Hypertension in pregnancy. Report ofthe American College ofObstetricians and Gynecologists'Task Force on

Pre-eclampsia

Differential diagnosis Pre-eclampsia can mimic and be confused with many other diseases, including chronic hypertension, chronic renal disease, primary seizure disorders, gallbladder and pancreatic disease, immune or thrombotic thrombocytopenic purpura, antiphospholipid syndrome and hemolytic-uremic syndrome. It must be considered a possibility in any pregnant woman beyond 20 weeks of gestation. It is particularly difficult to diagnose when pre-existing conditions such as hypertension are present. Women with acute fatty liver of pregnancy may also present with elevated blood pressure and protein in the urine, but differ by the extent of liver damage. Other disorders that can cause high blood pressure include thyrotoxicosis, pheochromocytoma, and drug misuse.

Hypertensive disease of pregnancy

For all hypertensive disorders of pregnancy, a major component of care is management of the associated hypertension. This involves use of antihypertensive medication as well as restricting activity to lower blood pressure to reduce the risk of stroke. In women with preeclampsia or eclampsia, magnesium sulfate is often prescribed to prevent the occurrence of seizures in the gestational parent. Treatment should be continued from the time of diagnosis to several weeks postpartum given the increased risk of medical complications immediately following delivery of the fetus. Prevention Blood pressure control can be accomplished before pregnancy. Medications can control blood pressure. Certain medications may not be ideal for blood pressure control during pregnancy such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II (AII) receptor antagonists. Controlling weight gain during pregnancy can help reduce the risk of hypertension during pregnancy.

Pre-eclampsia

Risk factors for pre-eclampsia include obesity, prior hypertension, older age, and diabetes mellitus. It is also more frequent in a woman's first pregnancy and if she is carrying twins. The underlying mechanism involves abnormal formation of blood vessels in the placenta amongst other factors. Most cases are diagnosed before delivery. Commonly, pre-eclampsia continues into the period after delivery, then known as postpartum pre-eclampsia. Rarely, pre-eclampsia may begin in the period after delivery. While historically both high blood pressure and protein in the urine were required to make the diagnosis, some definitions also include those with hypertension and any associated organ dysfunction. Blood pressure is defined as high when it is greater than 140 mmHg systolic or 90 mmHg diastolic at two separate times, more than four hours apart in a woman after twenty weeks of pregnancy. Pre-eclampsia is routinely screened for during prenatal care.

Hypertensive encephalopathy

Hypertensive encephalopathy (HE) is general brain dysfunction due to significantly high blood pressure. Symptoms may include headache, vomiting, trouble with balance, and confusion. Onset is generally sudden. Complications can include seizures, posterior reversible encephalopathy syndrome, and bleeding in the back of the eye. In hypertensive encephalopathy, generally the blood pressure is greater than 200/130 mmHg. Occasionally it can occur at a BP as low as 160/100 mmHg. This can occur in kidney failure, those who rapidly stop blood pressure medication, pheochromocytoma, and people on a monoamine oxidase inhibitor (MAOI) who eat foods with tyramine. When it occurs in pregnancy it is known as eclampsia. The diagnosis requires ruling out other possible causes.