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8/24/17 2
Outpatient Management:
SBP 150mmHg / DBP 100mmHg
Urine protein 100 mg/24 hours
Asymptomatic
Normal LFT's
Platelets 1000/mm3
Daily BP and urinalysis
Twice weekly evaluation
Growth and fluid assessment q 3 weeks
Hospitalize with disease progression
8/24/17 3
Severe Gestational Hypertension
Increased maternal and perinatal morbidity
Outcomes similar in both conditions.
Abruptio-placentae
Preterm delivery
SGA [Small for Gestational Age] infants
Manage like severe preeclampsia
8/24/17 4
Mild Preeclampsia - Management
Management < 37 weeks remains controversial
Antihypertensive medications?
Bed rest?
8/24/17 5
Weekly antepartum fetal evaluation
Twice weekly testing with IUGR or oligohydramnios
Orient on fetal movement counting (kick chart) daily, to be reported
at ANC visits Frequent evaluation for progression of disease
Monitor blood pressure, urine protein, reflexes (DTR) & fetal
condition, twice weekly.
Encourage the woman to eat a normal diet (salt restriction should be
discouraged)
No medications (do not give anticonvulsants, anti hypertensives,
sedatives or tranquillizers) & Encourage additional periods of bed
rest
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if the signs remain unchanged, keep the woman in the hospital
Continue the same management & monitor fetal growth &
well-being (by symphysis fundal height kick chart & other
methods if available).
If there are signs of growth restriction consider early delivery
If not, continue hospitalization until term ( & consider
termination if cervix is favorable)
If signs worsen (urinary protein level increased etc) manage as
severe pre-eclampsia
8/24/17 7
Mild Preeclampsia - Management
Mild preeclampsia at term with favorable cervix
Delivery
Unfavorable cervix 37 weeks - ? Cervical ripening
Delivery 34 weeks if there is
Progressive labor
ROM
Abnormal testing
IUGR
Deliver by 40 weeks even with unfavorable conditions
8/24/17 8
Severe Preeclampsia < 34 Weeks
Timing of delivery: Severe pre-eclampsia is usually treated conservatively till
the end of the 36th week to ensure reasonable maturation of the foetus.
Indications of termination before 36th week include:
Delivery is definitive therapy
Delivery may not be optimal for the premature fetus
34 weeks deliver
< 23 weeks offer termination
33 - 34 weeks steroids with delivery after 48-hrs
23 - 32 weeks gestation
Individualized treatment based on clinical response during the
initial 24 hours observation
8/24/17 9
Severe Preeclampsia
Hospitalization _ stabilize the patient
MgSO4 prophylaxis
Antihypertensive medication
Maintain SBP 140 -155mm and DBP 90 -105mm
24 - 34 weeks
Steroids for lung maturity
Maternal assessment :-BP, UOP, Cerebral status, Epigastric pain,
tenderness, Labor, Vaginal bleeding ,Plts, LFT, serum Cr
Fetal assessment:- Continuous monitoring, BPP,USG for growth and
amniotic fluid,FLMT or L/S ratio.
8/24/17 10
Antihypertensive Medication
5 mg IV or 10 mg IM. Repeat at 20 min intervals
pending response. Repeat prn when controlled (usually
Hydralazine 3 hrs). Max dose 20 mg IV or 30 mg IM.
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Antihypertensive Therapy
8/24/17 12
Severe Preeclampsia
Progressive deterioration in both maternal and fetal conditions
Deliver with onset after 34 weeks
Increased rate of maternal morbidity/mortality
Significant fetal risk
Delivery prior to 34 weeks:
Imminent eclampsia
Multiorgan dysfunction
Severe IUGR
Suspected abruption
Non-reassuring fetal testing
8/24/17 13
Timing of delivery: Severe pre-eclampsia is usually treated conservatively till the
end of the 36th week to ensure reasonable maturation of the foetus. Indications
of termination before 36th week include:
Maternal: deteriorating
: deteriorating placental function
maternal condition as judged
as judged by:
by:
intrauterine growth
blood pressure is sustained or
retardation,
exceeds 180/110 mmHg,
oligohydramnios,
urine proteinuria > 5 gm/24
reduced foetal movements,
hours,
abnormal foetal heart patterns, oliguria,
or
evidence of DIC, or
failing biochemical results.
imminent or already developed
8/24/17
eclampsia. 14
Severe Preeclampsia < 34 Weeks
Considerable disagreement
Delivery is definitive therapy
Delivery may not be optimal for the premature fetus
34 weeks deliver
< 23 weeks offer termination
33 - 34 weeks steroids with delivery after 48-hrs
23 - 32 weeks gestation, _steroids
Individualized treatment based on clinical response during the initial 24
hours observation
8/24/17 15
Low Risk Chronic HTN
Usually good perinatal outcome irrespective of antihypertensive
drugs
Most poor outcomes were related to superimposed preeclampsia
Discontinue antihypertensive meds
Treat BP > 160 / 110 mmHg to keep DBP 105 mmHg
In absence of superimposed preeclampsia, pregnancy may
continue
~ if @ Favorable cervix
@ Labor _can able to Completion of 40 weeks
8/24/17 16
High Risk Chronic HTN
Antihypertensive medication
Absent target organ damage
Maintain BP 140 -150 / 90 -100 (140 -160 / 90 -105)
Target organ damage
BP < 140 / 90
Close monitoring
Fetal evaluation at 28 (as early as 26) weeks
Superimposed preeclampsia
Hospitalization
Delivery with GA 34 weeks
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Medication for BP 180/110
Drug Starting dose Max dose
Acute treatment
Hydrazaline 5-10 mg IV q 20 min 30 mg
Labetalol 20-40 mg IV q 5-10 min 220 mg
Nifedipine 10-20 mg po q 30 min 50 mg
Long-term treatment
Methyldopa 250 mg bid 4 g/d
Labetalol 100 mg bid 2400 mg/d
Nifedipine 10 mg bid 120 mg/d
Thiazide diuretic 12.5 mg bid 50 mg/d
8/24/17 18
HELLP Syndrome
with a suspected dx. of HELLP syndrome should be hospitalized
immediately and observed in a labor and delivery unit.
managed as if they have PE with severe features and should
initially receive IV Mgso4 and antihypertensive medications to
maintain SBP <160 mm Hg or DBP <105 mm Hg.
This can be achieved with a 5-mg bolus dose of hydralazine
repeated as needed every 20 min. for a max. dose of 25
mg/hour.
BP is recorded every 20 min. during therapy and every hour
once the desired values are achieved.
8/24/17 19
THERAPEUTIC MODALITIES USED TO TREAT
OR REVERSE HELLP SYNDROME
Plasma volume expansion Immunosuppressive agents
Bed rest Steroids
Crystalloids Miscellaneous
Albumin 5% to 25% Fresh-frozen plasma infusions
Antithrombotic agents Exchange plasmapheresis
Low-dose aspirin Dialysis
Dipyridamole
Heparin
Antithrombin III
8/24/17 20
Eclampsia
Management: Prevention
Women with headache, epigastric pain and vomiting in
pregnancy (and puerperium ) should be considered to have
fulminating preeclampsia until proven otherwise !
Management
It is hazardous to proceed directly to cesarean section after
a seizure
Stabilization of the mother is the number one priority !
8/24/17 22
Eclampsia
Management: 3 chronological steps
1- avoid injury (padded bedside rails, physical restraints,
padded tongue blade)
- maintain oxygenation (8 - 10 L/min by face mask, pulse oximetry or arterial
blood gas measurements)
- minimize aspiration (lateral position, suctioning of vomitus and oral secretions)
- anticonvulsant therapy with diazepam:
5 - 20 mg over 1 - 2 minutes i.v.
Control of convulsions using an intravenously administered loading dose of
magnesium sulfate that is followed by a maintenance dose, usually
intravenous, of magnesium sulfate
8/24/17 23
Conclusion
- magnesium sulfate recommended for:
- preeclampsia with severe features
- eclampsia
- delivery:
- CHTN:> 38w0d
- GHTN: > 37w0d
- Preeclampsia, w/o severe > 37w0d
- Preeclampsia, w/ severe varies; 34w0d latest
Eclampsia
Management: 4 chronological steps
8/24/17 30
General considerations
Hypertension in pregnancy is
a major cause of maternal death
and a major source of
- maternal and perinatal morbidity
- perinatal mortality.
Many of the problems relating to maternal mortality in
preeclampsia arise from a failure by clinicians to appreciate
the varied presentations ,its severity and or from
inappropriate or inadequate treatment
8/24/17 31
Intrapartum Management of Preeclampsia
vaginal delivery is the preferred approach.
Cervical ripening agents and oxytocin are used as needed.
During labor, Mgso4 is administered for seizure prophylaxis.
UOP and Scr level are monitored, and the magnesium dose is adjusted accordingly.
Pain control is achieved with regional anesthesia or with IM or IV narcotic
analgesics.
Close monitoring of the foetus is indicated.
Proper analgesia to the mother.
Anti-Hypertensives may be given if needed.
2nd stage of labour may be shortened by forceps.
8/24/17 32
Postpartum care
8/24/17 34
Postpartum care
Any patient diagnosed with preeclampsia is at significantly greater risk
of having an underlying medical condition.
around 6 weeks after delivery:
- medical examination focussing on kidney and
vascular diseases unassociated with pregnancy
- counselling about future pregnancies and contraception
close follow up in the subsequent years:
- 20 - 40 % of patients with a history of preeclampsia develop
chronic hypertension
8/24/17 35
0
References:
Current OBGYN 2007
Gabbe OBSTETRICS NORMAL AND PROBLEM
PREGNANCIES 6th Edition
Obstetrics Normal and Problem
Pregnancies_nodrm
DC Dutta s Textbook of Obstetrics_7E.pdf
filename=UTF-8 DC 20Dutta 27s 20Textbook 20of
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