Ominous symptoms: RUQ pain, H/A, Visual disturbances
Dx
1) Pre-existing (chronic) hypertension: HTN (>140/90) that develops either pre-pregnancy or at < 20+0 weeks’ gestation
- Essential HTN ↑ risk of gestational HTN, placenta abruption, IUGR, IUFD
- Performed during early pregnancy: (if not previously documented): serum creatinine, fasting blood glucose, serum potassium, and U/A, and EKG.
- With comorbid condition(s): pre-gestational type I or II diabetes mellitus or kidney disease (↑ CV risk)
- With evidence of preeclampsia = 2) superimposed preeclampsia
- is defined by the development of one or more of the following at ≥ 20 weeks:
● resistant hypertension, or
● new or worsening proteinuria, or
● one or more adverse conditions,* or
● one or more severe complications.*
- is defined by the development of one or more of the following at ≥ 20 weeks:
3) Gestational hypertension
- hypertension that develops for the first time at ≥ 20+0 weeks’ gestation.
4) Preeclampsia
- Gestational hypertension with one or more of the following: May arise de novo
● new proteinuria, or
● one or more adverse conditions,* or
● one or more severe complications.*
5) Severe preeclampsia: preeclampsia with >1 complications.
Transient hypertensive effect: Elevated BP may be due to environmental stimuli, e.g., the pain of labour. HTN not confirmed at subsequent measurement
White-coat hypertensive effect: This is defined as BP >140/90 in the office, but consistently normal outside of the office (< 135/85 mmHg)
Masked hypertensive effect: This is defined as BP that is consistently <140/90 in the office, but≥ 135/85 outside of the office
Adverse conditions (↑ severe c/i) and severe complications (warrant delivery) of preeclampsia
CNS:
- Headache/visual symptoms
- Eclampsia, PRES ( posterior reversible leukoencephalopathy syndrome), Cortical blindness or retinal detachment, Glasgow coma scale < 13, hemorhagic Stroke (50% of deaths), TIA, or RIND (reversible ischemic neurological deficit (< 48 hr))
CV:
- Chest pain/dyspnea, Oxygen saturation < 97%
- Uncontrolled severe hypertension (over a period of 12 h despite use of three antihypertensive agents), Oxygen saturation < 90%, need for ≥ 50% oxygen for > 1 h, intubation (other than for Caesarean section), pulmonary edema, Positive inotropic support, Myocardial ischemia or infarction
Haematological:
- Elevated WBC / INR / aPTT / ; low platelet
- Platelet count < 50 × 109, Transfusion of any blood product
Renal:
- Elevated serum creatinine / uric acid
- AKI (creatinine > 150 µM with no prior renal disease), New indication for dialysis
Hepatic
- N/V, RUQ or epigastric pain, Elevated serum AST, ALT, LDH, or bilirubin, Low plasma albumin
- Hepatic dysfunction (INR > 2 in absence of DIC or warfarin), DIC, Hepatic haematoma or rupture, HELLP syndrome (Tx with FFP infusion / plasma exchange)
Feto-placental:
- Abnormal FHR, IUGR, Oligohydramnios, Absent or reversed end-diastolic flow by Doppler velocimetry
- Abruption with evidence of maternal or fetal compromise, Reverse ductus venous A wave, Stillbirth (IUFD)
Risk factors Gestation HTN
- Maternal:
- primigravida, 1st conception with a new partner, PMHx/FHx of gestational HTN, extremes of maternal age <18 or >35
- DM, chronic HTN, renal insufficiency, antiphospholipid syndrom
- Fetal:
- IUGR or oligohydramnios, GTN, multiple gestation, fetal hydrops
- Previous stillbirth or IUFD
Risk factors Preeclampsia
- Maternal:
- Nulliparity, PMHx / FHx of preeclampsia, age >40 or <18, high BMI
- chronic HTN/renal dz, DM (pregestational or gestational), antiphospholipid syndrome / inherited thrombophilia, vascular / connective tissue dz
- Fetal:
- Hydrops fetalis, unexplained fetal growth restriction, placenta abruption,
Hx:
- Hepatic: Epigastric or RUQ pain, severe N/V,
- CNS: visual disturbances – blurring / scotoma, presence / severity of H/A, tremulousness, irritability, somnolence
- Hematologic: bleeding
- Renal: u/o & color
- Non-dependent edema – hands & face
- Fetal movement
O/E:
- Body weight & non-dependent edema
- CNA: hyperreflexia, visual field
- Hematology: petechiae
- Fetal heart tracing – NST
Ix:
- U/S for growth & biophysical profile, umbilical artery doppler flow studies (part of antenatal fetal surveillance)
- Hb, plt, blood film, PTT, INR, fibrinogen, d-dimer
- ALT, AST, LDH, bilirubin, uric acid, creatinine
- U/A – (proteinuria) 24 hr urine for total protein and creatine clearance
- Definitive testing for proteinuria (by urinary protein:creatinine ratio or 24-hour urine collection) if suspicious of preeclampsia, including:
- ≥ 1+ dipstick proteinuria
- in women with hypertension and rising BP
- in women with normal BP, but S/Sx suggestive of preeclampsia.
Tx HTN:
Low Risk Pt (based on risk factors):
- Dietary salt restriction during pregnancy (I-D), calorie restriction during pregnancy for overweight women (I-D), low-dose acetylsalicylic acid (I-E), vitamins C and E (based on current evidence) (I-E), and thiazide diuretics (I-E) are not recommended.
- For preeclampsia prevention among low-risk women with low dietary calcium intake (<600 mg/d), oral calcium supplementation of at least 1g/d is recommended
- smoking cessation for prevention of low birthweight and preterm birth.
- periconceptual use of a folate-containing multivitamin for prevention of neural tube defects(I-A), and
- exercise for maintenance of fitness(I-A), abstention from alcohol for prevention of fetal alcohol effects (II-2E),
Increased Risk pt:
- For preeclampsia prevention, low-dose Aspirin® (75-100 mg/d) is recommended until delivery (starts before GA 16wk)
- Initial antihypertensive therapy for severe hypertension >160/110 or non-severe HTN (140-159/90-109):
- Labetalol 100-300mg po bid/tid
- Nifedipine 30-50mg po daily
- a-methyldopa 250-500mg po tid/qid (no ACEi, propanolol, diuretics – teratogens)
- If no deterioration, can be followed till 37wk then decide to induce shortly after
- Consider corticosteroids for all women with precelampsia before 34 wk GA
- MgSO4 – 1st line for eclampsia & eclampsia prophylaxis in severe preeclampsia
Tx Preeclampsia:
- If severe, stabilize and deliver, increase maternal monitoring, hourly in/out, urine dip Q12h, hourly neurological vitals, increase fetal monitoring (FHR)
- Lower BP – decrease stroke risk
- Hydralazine 5-10mg IV bolus over 5min Q15-30min prn
- Labetalol 20-50mg IV q10min
- Sz prevention
- MgSO4, PP Rx – risk of seizure highest in first 24hr pp – continue MgSO4 for 12-24 hr after delivery
- Vitals Q1h, consider HELLP (Hemolysis, Elevated Liver enz, Low Platelets) in toxic pt
- Most return to a normal BP in 2 wk
MgSO4 toxicity
- Flushing, hyporeflexia, somnolence, respiratory and cardiac depression, weakness
- increase risk with CCB use or renal dz
- Tx: stop MgSO4, Calcium gluconate 10% in 10ml IV
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