# A bad headache at 37 weeks of pregnancy, a 22-year-old: a case to work up

> An obstetrics case for medical students: a first-time mother at 37 weeks with a headache since morning, blurred vision and swelling. What to ask, red flags, examination, first tests and the differential.

- Obstetrics & Gynecology · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/22-year-old-woman-37-weeks-pregnant-with-a-bad-headache
- Work up this patient: https://www.medikarya.in/case-studies/22-year-old-woman-37-weeks-pregnant-with-a-bad-headache

## How the patient presents

A first-time mother at 37 weeks is brought to the labour room by her mother-in-law. Her head has hurt since morning and paracetamol has not touched it, her vision is blurred, and her face and hands have been swelling for five days.

## 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.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.