What is the management for a 13-week pregnant patient presenting with headache, blurry vision, and lightheadedness?

Management of a 13-Week Pregnant Patient with Headache, Blurry Vision, and Lightheadedness

For a 13-week pregnant patient presenting with headache, blurry vision, and lightheadedness, immediate comprehensive evaluation for preeclampsia and other serious neurological conditions is essential, even though preeclampsia typically develops after 20 weeks gestation. 1, 2

Initial Assessment

• Measure blood pressure immediately - hypertension (≥140/90 mmHg) is a key diagnostic finding 1
• Assess for proteinuria with urinalysis and protein:creatinine ratio or 24-hour urine collection 1
• Perform complete neurological examination, including assessment for hyperreflexia and clonus 1
• Evaluate for other signs/symptoms of severe preeclampsia:
  • Epigastric/right upper quadrant pain 1
  • Visual changes beyond blurry vision (scotomata, photopsia) 3
  • Altered mental status 1

Laboratory Workup

• Complete blood count with focus on platelet count 1
• Comprehensive metabolic panel including:
  • Liver function tests (AST, ALT) 1
  • Renal function (creatinine, BUN) 1
  • Electrolytes 1
  • Uric acid (elevated levels associated with worse outcomes) 1
• Coagulation studies (PT, PTT, fibrinogen) 1

Imaging Considerations

• If neurological symptoms persist or are severe, MRI of the brain is preferred over CT to avoid radiation exposure 4
• Avoid contrast agents unless absolutely necessary 4
• Consider ultrasound assessment of fetal growth and amniotic fluid if preeclampsia is suspected 1

Differential Diagnosis

• Preeclampsia (though typically presents after 20 weeks) 1, 2
• Cerebral venous thrombosis 5
• Posterior reversible encephalopathy syndrome (PRES) 5
• Migraine with aura 5
• Pituitary disorders (tumor, apoplexy) 5
• Intracranial hemorrhage 2
• Carbon monoxide poisoning 4

Management Algorithm

1. If BP ≥140/90 mmHg:

   • Initiate antihypertensive therapy aiming for diastolic BP of 85 mmHg and systolic BP <160 mmHg 1
   • First-line agents: oral methyldopa, labetalol, or nifedipine 1
   • Reduce or discontinue if diastolic BP falls below 80 mmHg 1

2. If severe features present (BP ≥160/110 mmHg, neurological symptoms, thrombocytopenia, elevated liver enzymes):

   • Admit to hospital for close monitoring 1
   • Consider magnesium sulfate for seizure prophylaxis if preeclampsia is strongly suspected, even at this early gestational age 6

3. If normal BP but persistent neurological symptoms:

   • Admit for observation and serial neurological assessments 4
   • Proceed with MRI brain if symptoms persist 4, 5

4. For all patients:

   • Monitor maternal vital signs closely 1
   • Arrange follow-up within 1 week for repeat BP check and symptom assessment 1
   • Schedule detailed fetal ultrasound to assess growth and placental function 1

Important Considerations and Pitfalls

• Although preeclampsia typically develops after 20 weeks, atypical presentations can occur earlier, especially in patients with underlying conditions 1, 2
• Visual disturbances in pregnancy should never be dismissed as normal pregnancy symptoms - they can be the first sign of serious pathology 3
• Headache in pregnancy, especially when accompanied by visual changes, should be considered a potential warning sign for preeclampsia or other serious neurological conditions until proven otherwise 6
• Even if initial evaluation is reassuring, close follow-up is essential as symptoms may progress rapidly 1, 6
• Patients should be educated about warning signs requiring immediate medical attention (worsening headache, visual changes, right upper quadrant pain) 1