Obstetrics [ECLAMPSIA]

Introduction Criteria to consider

High blood pressure in a pregnant woman is neither good for baby 1. Blood Pressure: > 140 / > 90
or mom. Women of child bearing age should not be hypertensive. 2. Timing: whether before or after 20 weeks
It can be simply the changes of pregnancy or it could be an 3. Urine: >300mg/24hrs vs >5g/24hrs
ominous forst for the dreaded Eclampsia. 4. Alarm symptoms: any, either yes or no
5. Seizures: if yes, ignore all others
1) Transient Hypertension (tHTN)
Just like normal patients, pregnant females can have a high blood
pressure because they get nervous (anxiety or white coat
hypertension) or due to exercise (running to the office because Any nonsustained hypertension for any reason after 20
she was late). So, if a hypertensive patient is discovered ( > 140/ weeks, resolves after delivery
> 90) the first thing to do is just let her relax and recheck it (same
visit). In a medicine patient we wait two weeks and recheck.
However, hypertension in a pregnant female can be more than just
hypertension, so we SHOULD get a urinalysis (rule out
proteinuria) and have her keep a log (i.e ambulatory blood
pressure monitoring). If it goes back to normal, great - don't worry
about it.

2) Chronic Hypertension (cHTN)

Hypertension before pregnancy is defined as a chronic (not
transient) blood pressure of > 140 / > 90 before 20 weeks. IE this
is someone who had hypertension prior to the pregnancy. It can
complicate things. Absolute pressures can no longer be used as
markers for eclampsia. But the goal remains in the same: prevent Any sustained hypertension for any reason before 20 weeks
organ damage. Control the blood pressure with α-methyldopa,
the only anti-hypertensive safe in pregnancy (hydralazine and
labetalol might also be on the test). Because blood pressure can
no longer be used, a close follow-up (urinalysis for protein and
ultrasound for intrauterine growth restriction) must be
maintained.

3) Mild Preeclampsia
When fetal proteins are released, they can cause a diffuse
vasospasm (increase risk of thrombosis). If there’s sustained
hypertension with an onset after 20 weeks, it’s within the realm
of preeclampsia. MILD PreE is defined as a mildly high blood Mildly elevated, Sustained BP, after 20 weeks, mild
pressure (> 140 / > 90) and mild proteinuria (5g/24 hrs). If an proteinuria
elevated BP is found it’s time to actively look for alarm
symptoms. There may be edema of the hands - the earliest sign
of PreE turning bad. Do a CBC to look for hemoconcentration
secondary to 3rd spacing of fluid. If there’s hypertension after 20
weeks, reflex to Urinalysis and CBC, ask about edema and
abdominal pain.

© OnlineMedEd. http://www.onlinemeded.org
 Obstetrics [ECLAMPSIA]

Severely elevated, Sustained BP, after 20 weeks, severe

4) Severe Preeclampsia proteinuria, no seizures
When PrE gets bad, there’s going to be a high blood pressure (>
160 / > 110) and a major proteinuria (5g/24 hours) OR any
alarm symptom (scotomata, headaches, blurry vision, epigastric
pain). If these are found cover yourself by making sure it isn't
going to full eclampsia. Get a CBC, a DIC panel, and LFTs. The
goal is to stabilize and deliver regardless of gestational age.
Eclampsia is around the corner. The answer is magnesium. It’s
prophylaxis for seizures. Then, control blood pressure with
metoprolol or hydralazine. At the point of severe PreE, we need
the baby out. Baby comes out with induced labor (pitocin).

5) Eclampsia
When that vasospasm affects the brain ischemia results, followed Severely elevated, sustained BP, after 20 weeks, severe
by reperfusion edema, resulting in a new onset seizure - typically proteinuria,
tonic-clonic. Make sure there is no HELPP syndrome with LFTs,
DIC, U/A, etc. But the most important thing is to stop the WITH SEIZURES
seizures with magnesium and get the baby out. Either induce if
she is already in active labor or C-section. The point is get the
baby out or mom will die so c-section happens now, unless
already in advanced labor. The test loves to give abdominal pain
as a sign of impending eclampsia, caused by capsular stretch.

6) HELLP Syndrome
Defined as Hemolysis Elevated Liver Enzymes and Low
Platelets. Treat it like Eclampsia.

Blood Pressure Timing Urine Symptoms Treatment

Transient >140 / >90 Unsustained ø ø Conservative
HTN after 20 weeks Keep a Log
Chronic >140 / >90 Sustained, Starting ø ø α-methyldopa
HTN before 20 weeks close follow-up
Mild PreE >140 / >90 Sustained, Starting >300mg ø > 36 weeks mag + deliver urgently (induced)
after 20 weeks proteinuria <36 weeks bed rest
Severe > 160 / > 110 Sustained, Starting >5 g Positive* Mag + BP + deliver urgently (Induced)
PreE after 20 weeks proteinuria
Eclampsia Any Any Any Seizures Mag + Deliver emergently (Section)
HELLP Hemolysis Elevated LFTs Low Platelets Mag + Deliver emergently (Section)

*Positive = Abdominal Pain, Swelling, Blurry vision, scotomata, headaches, blurry vision, epigastric pain

© OnlineMedEd. http://www.onlinemeded.org