What is the appropriate workup for a 20-year-old female with a history of preeclampsia, presenting with near syncope, visual disturbances, shortness of breath, intermittent dizziness, and general malaise?

Workup for Postpartum Patient with Near Syncope and History of Preeclampsia

This patient requires immediate hospitalization with urgent evaluation for postpartum preeclampsia/eclampsia, peripartum cardiomyopathy, and other life-threatening cardiovascular complications, as 10% of maternal deaths from hypertensive disorders occur postpartum and symptoms can progress rapidly even 4 months after delivery. 1

Immediate Assessment Upon Admission

Vital Signs and Cardiovascular Monitoring

• Blood pressure measurement immediately - severe hypertension (≥160/110 mmHg) persisting >15 minutes requires emergency treatment, though eclampsia can occur even with diastolic BP ≤100 mmHg 1
• Continuous cardiac monitoring with pulse oximetry - maternal early warning if oxygen saturation <95% 2
• Orthostatic vital signs to evaluate syncope etiology 2

Neurological Assessment

• Visual disturbances with headache are independent risk factors for eclampsia and require immediate blood pressure and proteinuria assessment 1
• Assess for severe headache, altered mental status, confusion, or agitation 2
• Deep tendon reflexes evaluation (hyperreflexia suggests preeclampsia) 2

Essential Laboratory Workup

Immediate Blood Tests

• Complete blood count - assess for thrombocytopenia (platelets <100,000/μL suggests HELLP syndrome), hemolysis, and anemia 2
• Comprehensive metabolic panel including:
  • Creatinine (renal dysfunction is a criterion for severe preeclampsia) 2
  • Liver transaminases (AST/ALT elevation indicates HELLP syndrome) 2
  • Electrolytes and glucose 2
• Peripheral blood smear if hemolysis suspected 2
• Lactate dehydrogenase (LDH) - elevated in HELLP syndrome 2
• Coagulation studies (PT/PTT) if thrombocytopenia present 2

Urine Studies

• 24-hour urine collection for protein quantification - most reliable method, with protein creatinine ratio ≥30 mg/mmol confirming significant proteinuria 1, 2
• Urinalysis with dipstick - proteinuria ≥+ with symptoms requires same-day assessment 1
• Urine output monitoring via Foley catheter - target ≥100 mL/4 hours or >35 mL/hour 2

Cardiovascular Evaluation

Cardiac Assessment

• 12-lead electrocardiogram - evaluate for ischemia, arrhythmias, or peripartum cardiomyopathy 1
• Echocardiogram - essential to rule out peripartum cardiomyopathy (can present months postpartum with dyspnea, near syncope) and assess for pulmonary edema 1, 2
• Brain natriuretic peptide (BNP) or NT-proBNP if heart failure suspected 1
• Troponin if cardiac ischemia suspected 1

Pulmonary Evaluation

• Chest X-ray - assess for pulmonary edema (absolute indication for delivery during pregnancy; evaluate for postpartum complications) 2
• Arterial blood gas if respiratory distress present 1

Neurological Imaging

Brain Imaging

• CT head or MRI brain - evaluate for:
  • Posterior reversible encephalopathy syndrome (PRES) - associated with preeclampsia 1
  • Cerebral hemorrhage - risk increased with systolic BP >160 mmHg 1, 2
  • Cerebral venous thrombosis - can present with headache and visual changes postpartum 1
  • Stroke - women with preeclampsia have increased lifetime risk 3

Additional Considerations

Risk Stratification

• History of preeclampsia 4 months ago places her at high risk for recurrent hypertensive complications and future cardiovascular disease 3, 4
• Quantified protein excretion is independently associated with undiagnosed underlying medical conditions 1

Common Pitfalls to Avoid

• Do not dismiss symptoms because delivery occurred 4 months ago - postpartum preeclampsia can occur weeks to months after delivery, and 10% of maternal deaths from hypertensive disorders occur postpartum 1
• Do not assume normal blood pressure rules out serious pathology - 34% of eclamptic women had maximum diastolic BP ≤100 mmHg 1
• Visual disturbances and headache without hypertension or proteinuria still warrant investigation per local protocols 1

Monitoring Frequency

• Blood pressure every 15 minutes until stable, then hourly 1, 2
• Laboratory monitoring at least twice weekly or more frequently with clinical deterioration 2
• Continuous pulse oximetry and cardiac monitoring 2

Immediate Treatment Considerations While Completing Workup

• If BP ≥160/110 mmHg persisting >15 minutes: initiate IV labetalol (20mg bolus, then 40mg after 10 minutes, then 80mg every 10 minutes to maximum 220mg) with target BP 110-140/85 mmHg 1, 2
• If seizure activity or severe neurological symptoms: magnesium sulfate 4-5g IV loading dose over 5 minutes, followed by 1-2g/hour maintenance 2
• Avoid ACE inhibitors and ARBs even postpartum if breastfeeding 1, 2