preg htn

• Mild preeclampsia


  Observe inpatient for evaluation/possible early delivery; if 37 weeks, assess cervical status and induce; if under 37 weeks, patient is on bedrest, 2x weekly antenatal testing, corticosteroids in under 34 weeks and decide inpatient or outpatient
• Severe preeclampsia

  Hospitalization, delivery if over 34 weeks, acute blood pressure control with hydralazine, labetalol or procardia; maybe long-term blood pressure medications, magnesium sulfate for seizure prophylaxis
• Management of hypertension in pregnancy without end organ dysfunction/fetal distress

  Mild - no treatment; severe - do a medication and monitor the fetus closely
• Low dose aspirin is a good preeclampsia prevention after 12 weeks gestation in high risk patients
• Understand the diagnostic criteria, features and possible symptoms for preeclampsia, eclampsia and HELLP syndrome
• Chronic hypertension

  Hypertension onset before pregnancy or before 20th week gestation; persistent beyond 12 weeks postpartum; blood pressure greater than or equal to 140/90
• Diagnosis of chronic hypertension

  Check for end-organ damage; labs of CBC, glucose screen, electrolyte panel, creatinine, urinalysis, urine culture and 24hr urine collection; EKG shows LVH in patient with longstanding hypertension; maybe cardiomegaly on echo
• Complications of chronic hypertension

  Superimposed pre-eclampsia, fetal growth restriction, preterm baby; placental abruption
• Medications for chronic hypertension

  Methyldopa, labetalol, nifedipine
• Antepartum fetal surveillance at 32-34 weeks
• Gestational hypertension

  Blood pressure greater than or equal to 140/90 on 2 occasions, 6 hours apart in a normotensive patient at least 20 weeks gestation; NO proteinuria; severe if blood pressure persistently over 160 and/or 110
• Complications of severe gestational hypertension

  Increased risk of IUGR, preterm, abruption or stillbirth
• Workup for gestational hypertension

  Monitor closely for preeclampsia, 24hr urine to confirm no proteinuria, liver enzymes, kidney function test, hematocrit, platelet; surveillance of fetus with monthly ultrasound and weekly biophysical profiles and weekly NSTs
• Treatment of severe gestational hypertension

  Same as preeclampsia
• Preeclampsia

  Maternal blood pressure greater than or equal to 140/90 on 2 occasions 6 hours apart; proteinuria greater than or equal to 300mg in 24hr urine specimen; can start in pregnancy or up to 6 weeks postpartum; seen in patients under 20 or over 35
• Symptoms of preeclampsia include headache, scotomate, blurry vision, pain in epigastrium/RUQ, brisk reflexes</b>
• Complications of preeclampsia

  Cerebral injury in cortex; abnormal cardiac output/vascular resistance; noncardiogenic pulmonary edema; RUQ pain/epigastric pain from Glisson's capsule stretch; glomeruloendotheliosis; retinal vasospasm, retinal edema, serous retinal detachment, and cortical blindness; preterm birth, IUGR, placental abruption, maternal pulmonary edema, eclampsia
• Eclampsia

  Complication of severe preeclampsia, 1+ generalized convulsion in setting of preeclampsia
• HELLP syndrome

  Complication of severe preeclampsia; patient has preeclampsia/eclampsia but there is hemolysis with a microangiopathic blood smear, elevated liver enzymes and low platelets
• Patient with HELLP syndrome can be normotensive and not have proteinuria
• Symptoms of HELLP syndrome include abdominal/epigastric pain, nausea/vomiting, malaise, maybe increased blood pressure/proteinuria; jaundice, oliguria, ascites
• Diagnostic criteria for HELLP syndrome

  Evidence of hemolysis with schistocytes on peripheral smear, bilirubin 1.2 or serum lactate dehydrogenase greater than or equal to 600; platelets less than 100,000; AST greater than or equal to 70
• Treatment of HELLP syndrome

  Stabilize, replace blood/coagulation factors, monitor urine output/renal function, treat hypertension; best treatment is delivery
• Preeclampsia with severe features requires hospitalization, delivery if over 34 weeks, acute blood pressure control with hydralazine, labetalol or procardia; maybe long-term blood pressure medications, magnesium sulfate for seizure prophylaxis
• Magnesium toxicity

  Low blood pressure, hyporeflexia, nausea/vomiting, facial flushing, urine retention, ileus, depression, lethargy, arrhythmias, muscle weakness
• Treatment of magnesium toxicity

  Stop infusion or decrease dose