 List criteria for the diagnosis of preeclampsia

 List criteria for the diagnosis of severe

preeclampsia/HELLP syndrome
 Discuss current management considerations
 Sustained BP elevation of 140/90 or greater
 Proper cuff size
 Measurement taken while seated
 Use 5th Korotkoff sound
 Gestational Hypertension
 Formerly called Pregnancy-Induced Hypertension
 No proteinuria
 Gestational Hypertension
 Preeclampsia
 Hypertension with proteinuria
 May have other evidence of end-organ disease
 Edema
 Visual changes
 Headache
 Epigastric pain
 Laboratory changes
 30/15 increase in BP over baseline levels
 No longer appropriate
 73% of patients will exceed 30 mm systolic and
57% will exceed 20 mm diastolic
 P a tie nt w ith H y pe rte nsion

E lev ate d B P a bo v e G estatio na l h ype rte ns ion P ree clam psia

first trim es ter N o p ro teinu ria H ype rte nsion
le v e ls 25% P ro te in uria
5 5 -7 5% 5 -8% of p ro g na nc ies
 Gestational Hypertension
 Preeclampsia
 Chronic Hypertension
 As a group these occur in 12 to 22% of
pregnant patients and are directly responsible
for approximately 18% of maternal mortality
nationally.
 Pre-existing hypertension
 Hypertension before 20 weeks in the absence of
gestation
 If hypertension persists beyond 6 weeks
postpartum
 Hypertension after 20
weeks of gestation
 Proteinuria- 300mg
 Edema
 Hypertension after 20  BP > 160 systolic or >110
diastolic
weeks of gestation  5grams of protein in 24 hour
 Proteinuria- 300mg urine
 Edema  Oliguria
 Cerebral of visual
distrubances
 Pulmonary edema or
cyanosis
 Epigastric or RUQ pain
 Impaired liver function
 Thrombocytopenia
 IUGR
FACTOR RISK RATIO
Nulliparity 3:1
Age > 40 3:1
African American 1.5:1
Chronic hypertension 10:1
Renal disease 20:1
Antiphospholipid 10:1
syndrome
FACTOR RISK RATIO

Family history of PIH 5:1

Diabetes mellitus 2:1

Twin gestation 4:1

 Low dose ASA ineffective in patients at low
risk
 Calcium supplementation is ineffective (1.0 g of
calcium gluconate per day)
 No compelling evidence that either are harmful
 Recent study done with antioxidant (1,000mg
VitC and 400mg VitE).
 Small study that needs to be confirmed.
 Hypertension
 Increased cardiac output
 Increased systemic vascular resistance
 Hypovolemia
 Seizures-eclampsia
 Headache
 Cerebral edema
 Hyper-reflexia
 Capillary leak
 Reduced colloid osmotic pressure
 Pulmonary edema
 Volume contraction
 Elevated hematocrit
 Low platelets
 Anemia due to hemolysis
 Decreased glomerular filtration rate
 Increased BUN/creatinine
 Proteinuria
 Oliguria
 Acute tubular necrosis
 Increased perinatal morbidity
 Placental abruption
 Fetal growth restriction
 Oligohydramnios
 Fetal distress
 BP > 160-180 systolic  Low platelets
or 110 diastolic  Growth restriction
 Proteinuria > 5 g per  Decreased AFV
day  Headache
 Pulmonary edema
 Epigastric pain
 Oliguria
 Elevated liver
enzymes
 The ultimate cure is delivery
 Assess gestational age
 Assess cervix
 Fetal well-being
 Laboratory assessment
 Rule out severe disease!!
 Delivery is always a reasonable option if term
 If cervix is unfavorable and maternal disease is
mild, expectant management with close
observation is possible
 Rule out severe disease
 Conservative management
 Serial labs
 Twice weekly visits
 Antenatal fetal surveillance
 Outpatient versus inpatient
 Worsening BP
 Nonreassuring fetal condition
 Development of severe PIH
 Fetal lung maturity
 Favorable cervix
 No contraindication to prostaglandin agents
 If < 32 weeks, consider cesarean
 When favorable, oxytocin
 Fetal monitoring
 IV access
 IV hydration
 The reason to treat is maternal, not fetal
 May require ICU
 Diastolic BP > 105-110
 Systolic BP > 200
 Avoid rapid reduction in BP
 Do not attempt to normalize BP
 Goal is DBP < 105 not < 90
 May precipitate fetal distress
 Crises are associated with hypovolemia
 Clinical assessment of hydration is inaccurate
 Unprotected vascular beds are at risk, eg,
uterine
 250-500 cc of fluid, IV
 Avoid multiple doses in rapid succession
 Allow time for drug to work
 Avoid over treatment
 Hydralazine
 Labetalol
 Nifedipine
 Nitroprusside
 Diazoxide
 Clonidine
 Dose: 5-10 mg every 20 minutes
 Onset: 10-20 minutes
 Duration: 3-8 hours
 Side effects: headache, flushing, tachycardia,
lupus like symptoms
 Mechanism: peripheral vasodilator
 Dose: 20mg, then 40, then 80 every 20 minutes,
for a total of 220mg
 Onset: 1-2 minutes
 Duration: 6-16 hours
 Side effects: hypotension
 Mechanism: Alpha and Beta block
 Dose: 10 mg po, not sublingual
 Onset: 5-10 minutes
 Duration: 4-8 hours
 Side effects: chest pain, headache,
tachycardia
 Mechanism: CA channel block
 Dose: 1 mg po
 Onset: 10-20 minutes
 Duration: 4-6 hours
 Side effects: unpredictable, avoid rapid
withdrawal
 Mechanism: Alpha agonist, works centrally
 Dose: 0.2 – 0.8 mg/min IV
 Onset: 1-2 minutes
 Duration: 3-5 minutes
 Side effects: cyanide accumulation,
hypotension
 Mechanism: direct vasodilator
 Magnesium sulfate
 4-6 g bolus
 1-2 g/hour
 Monitor urine output
 With renal dysfunction, may require a lower
dose
 Is not a hypotensive agent
 Works as a centrally acting anticonvulsant
 Also blocks neuromuscular conduction
 Serum levels: 6-8 mg/dL
 Respiratory rate < 12
 DTR’s not detectable
 Altered sensorium
 Urine output < 25-30 cc/hour
 Antidote: 10 ml of 10% solution of calcium
gluconate 1 v over 3 minutes
 Few people die of seizures
 Protect patient
 Avoid insertion of airways and padded tongue
blades
 IV access
 MGSO4 4-6 bolus, if not effective, give another
2g
 Diazepam 5-10 mg IV
 Sodium Amytal 100 mg IV
 Pentobarbital 125 mg IV
 Dilantin 500-1000 mg IV infusion
 Assess maternal labs
 Fetal well-being
 Effect delivery
 Transport when indicated
 No need for immediate cesarean delivery
 Pulmonary edema
 Oliguria
 Persistent hypertension
 DIC
 Fluid overload
 Reduced colloid osmotic pressure
 Occurs more commonly following delivery as
colloid oncotic pressure drops further and fluid
is mobilized
 Avoid over-hydration
 Restrict fluids
 Lasix 10-20 mg IV
 Usually no need for albumin or Hetastarch
(Hespan)
 25-30 cc per hour is acceptable
 If less, small fluid boluses of 250-500 cc as
needed
 Lasix is not necessary
 Postpartum diuresis is common
 BP may remain elevated for several days
 Diastolic BP less than 100 do not require
treatment
 By definition, preeclampsia resolves by 6
weeks
 Rarely occurs without abruption
 Low platelets is not DIC
 Requires replacement blood products and
delivery
 Continuous lumbar epidural is preferred if
platelets normal
 Need adequate pre-hydration of 1000 cc
 Level should always be advanced slowly to
avoid low BP
 Avoid spinal with severe disease
 He-hemolysis
 EL-elevated liver enzymes
 LP-low platelets
 Is a variant of severe preeclampsia
 Platelets < 100,000
 LFT’s - 2 x normal
 May occur against a background of what
appears to be mild disease
 Controversial
 Steroids
 Requires tertiary care
 Must have stable labs and reassuring fetal
status
 May use antihypertensives
 Criteria for diagnosis
 Laboratory and fetal assessment
 Magnesium sulfate seizure prophylaxis
 Timing and place of delivery