From the Guidelines
The best next step in evaluation for this patient is an MRI of the brain with and without contrast. This 17-year-old pregnant woman presents with symptoms and findings consistent with idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri. Her clinical picture includes morning headaches, pulsatile tinnitus, bilateral papilledema (optic disc edema), and risk factors such as obesity and significant weight gain during pregnancy. While her blood pressure is slightly elevated, the minimal proteinuria and absence of right upper quadrant pain make preeclampsia less likely at this stage, as suggested by the guidelines for hypertensive disorders of pregnancy 1.
Key Considerations
- The patient's symptoms and findings are more indicative of IIH than preeclampsia, given the presence of bilateral optic disc edema and the absence of severe hypertension or significant proteinuria.
- An MRI is necessary to rule out other potential causes of increased intracranial pressure such as mass lesions, venous sinus thrombosis, or structural abnormalities before confirming the diagnosis of IIH.
- After the MRI, if no structural cause is identified, a lumbar puncture would likely follow to measure opening pressure and further confirm the diagnosis, as part of the diagnostic criteria for IIH.
- The management would then focus on reducing intracranial pressure, potentially through weight management, acetazolamide (though used cautiously in pregnancy), or in severe cases, therapeutic lumbar punctures or surgical interventions to preserve vision and reduce symptoms.
Rationale for MRI
- The guidelines for managing hypertensive disorders of pregnancy emphasize the importance of identifying and managing potential complications, including those related to increased intracranial pressure 1.
- Given the patient's clinical presentation, an MRI is the most appropriate next step to rule out other causes of her symptoms and to guide further management.
- The use of MRI in pregnancy is considered safe, especially when necessary for diagnostic purposes, and it provides valuable information for managing conditions like IIH.
Prioritizing Morbidity, Mortality, and Quality of Life
- The primary concern in this case is the patient's neurological symptoms and the potential for long-term vision loss or other complications if IIH is not properly diagnosed and managed.
- By prioritizing an MRI and potential subsequent lumbar puncture, the focus is on reducing the risk of morbidity and preserving the patient's quality of life, in line with the principles of managing hypertensive disorders of pregnancy and other conditions that may affect pregnant women 1.
From the Research
Evaluation of the Patient
The patient is a 17-year-old primigravida at 29 weeks gestation presenting with headaches and intermittent throbbing pain in the left frontal region. The patient's symptoms, combined with the presence of bilateral optic disc edema and trace protein in the urinalysis, suggest a possible diagnosis of preeclampsia 2, 3.
Key Findings
- Bilateral optic disc edema, which is a sign of increased intracranial pressure 4
- Trace protein in the urinalysis, which is a common finding in preeclampsia 2, 3
- The patient's age, gestational age, and pre-pregnancy BMI are all relevant factors to consider in the evaluation of preeclampsia 2, 3
Next Steps in Evaluation
- Measure the patient's blood pressure to assess for hypertension, a key component of preeclampsia 2, 3
- Perform a complete urinalysis to assess for proteinuria, which is a common finding in preeclampsia 2, 3
- Consider ordering liver function tests, as preeclampsia can cause liver damage 5, 6
- Assess the patient's visual symptoms and perform a thorough neurologic examination to evaluate for any signs of cerebral edema or other complications of preeclampsia 2, 3, 4