Why a severe headache in late pregnancy matters
A severe headache late in pregnancy, especially with changes in vision or new swelling, needs her blood pressure and urine checked at once, because both mother and baby can deteriorate quickly.
What to ask in the history
- The headache: when it started, what it is like, what she has taken
- Vision
- Pain in the upper abdomen, nausea, vomiting
- Swelling of face and hands
- The baby's movements
- Blood pressure readings at antenatal visits
- Fits, fever, neck stiffness
- Medicines
Red flags
- Severe headache or changes in vision
- Very high blood pressure
- Pain in the upper abdomen
- Little urine
- A fit
- Fewer movements from the baby
- Breathlessness
What to examine
- Blood pressure, repeated
- Urine for protein
- Reflexes and clonus
- Fundi
- Swelling
- Abdomen: tenderness, fundal height
- The baby's heart rate
- Neurological examination, chest
First investigations
- Urine protein, including a protein-to-creatinine ratio
- Full blood count with platelets
- Liver and kidney function, LDH, clotting
- Continuous fetal heart monitoring (CTG)
- Ultrasound for fetal growth and blood flow
- Brain imaging if the picture is unusual
Differential diagnosis of a severe headache in late pregnancy
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Brain
- Migraine
- Tension headache
- Cerebral venous thrombosis
- Stroke
- Posterior reversible encephalopathy syndrome
Pregnancy-related
- Pre-eclampsia
- HELLP syndrome
- Impending eclampsia
Other
- Meningitis
- Sinusitis
- High blood pressure from another cause
Common mistakes
- Giving painkillers without checking her blood pressure.
- Acting on a single blood pressure reading either way.
- Forgetting to monitor the baby.