A 28-year-old G1P0 woman at 32 weeks’ gestation presents to urgent care with a severe, throbbing headache that started 6 hours ago. She describes the pain as 9/10 in intensity, located primarily in the frontal and occipital regions, not relieved by oral acetaminophen. She also reports photophobia, nausea, and 1 episode of vomiting. She denies visual aura, trauma, or recent illness. She has a history of migraines, but notes that this headache feels “different and worse than usual.” She reports decreased fetal movement over the past few hours. On physical examination, her vitals are blood pressure 172/110 mmHg; heart rate 92 bpm; respiratory rate 18 breaths per min; temperature 98.7˚ F; and SpO2 98% on room air. Fetal heart rate is around 110 beats per min, audible but sluggish, and the rest of her physical examination is normal.
Which of the following findings most strongly indicates the need for emergent ED referral?
- History of migraines
- Nausea and photophobia
- Elevated blood pressure with brisk reflexes and decreased fetal movement
- Use of acetaminophen without relief
Click to see the answer
Answer: c. Elevated blood pressure with brisk reflexes and decreased fetal movement
This presentation suggests pre-eclampsia with severe features, which requires urgent maternal-fetal evaluation and possible delivery. You urgently referred the patient to the ED, and while waiting on the EMS transport, you made the patient more comfortable by giving her 750 mg IV acetaminophen, 10 mL/kg IV normal saline bolus, and 5 g IV magnesium sulfate. You later learned she delivered a healthy, but premature, 3 lb, 12 oz baby boy later that day.
For an in-depth review of this topic, access the full course.
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
