The patient with a neurologic emergency does not present with a diagnosis but rather with one or several clinical manifestations. The nature of the presentation, sequence of events, and constellation of signs and symptoms suggest a differential diagnosis. Starting from the presentation, the physician must select diagnostic tests and procedures, and then, once a diagnosis is made initiate treatment. The differential diagnosis may be altered by pregnancy and diagnostic procedures employed may be different from those one would use in nonpregnant patients. We will consider the following presentations: headache, seizures, altered state of consciousness, and motor or sensory changes. This signs and symptoms approach was chosen because patients do not usually come to the physician with a diagnosis but with a change in their condition, appearance of symptoms, and the need for care. An exception to the signs and symptoms’ approach will be the discussion of autonomic dysreflexia at the end of the chapter.
Common Complaint in Pregnancy
Headache is a common complaint in pregnancy.1 Patients who report having had the same problem for some time prior to pregnancy do not usually have a neurologic emergency. Chronic and recurrent headaches may be due to tension, migraine, sinusitis, pseudotumor cerebri, or in many cases be unexplained.
Migraine headaches are relatively common in reproductive age of women and often become less frequent and severe in pregnancy (75% of women). In a minority (5%) of migraine sufferers, however, they may present for the first time or become more severe in pregnancy and must be distinguished from other more immediately dangerous conditions. Many patients who think they have migraines do not have the classical pattern of aura, headache, and nausea. Headaches which, aside from frequency, are similar to those the patient has experienced in the past can generally be considered to not represent a neurologic emergency and can be managed symptomatically. Medications used for the treatment of migraine headache are listed in Table 16-1. If headaches appear to be becoming more frequent and severe or have accompanying neurologic manifestations, then they require further evaluation.
TABLE 16-1.Medications for Migraine ||Download (.pdf) TABLE 16-1. Medications for Migraine
|Medication ||Class ||Dosage ||Rout of administration ||Safety in pregnancy |
|Acetaminophen ||Pain reliever ||4 g/d max ||po or pr ||Yes |
|Codeine ||Narcotic ||30-90 mg q3-4h ||po ||Yes |
|Meperidine (Demerol) ||Narcotic ||25-100 mg q3-6h ||po, IM, or IV ||Yes |
|Ibuprofen ||Nonsteroidal ||3200 mg/d (divided doses) ||po ||Avoid in late pregnancy |
|Fioriceta ||Sedative, pain reliever, vasoconstrictor ||2 tabs q4h, 6/d max ||po ||Yes |
|Midrinb ||Vasoconstrictor, sedative, pain reliever ||2 caps, then 1 qh, no more than 5 in 12 h ||po ||Yes |
|Caffeine ||Vasoconstrictor ||500 mg in 50 mL IV, may repeat ||po or IV ||Yes |
|Imitrexc ||Vasoconstrictor ||po 300 mg/d SC 6 ...|