HTN in pregnancy


Hypertension
High BP on 2 separate occasions at least 4 hrs apart
> 140/90
(x2 4hr apart)
>160/100
(x2 within minutes apart)
Gest./Chronic HTN Mild PreEclamp Severe PreEclampia Eclampsia
< 20 Wk pregnant
(-) protein
New HTN at > 20 Wk gestation

Proteinuria
+1 random (30mg/dl)

0.3g/24hr

 

Proteinuria
>3+ x2 rad
5g/24hr

Ogliuria: <500ml/24hr

CNS findings
LIVER problems
plt <100K
elevated LDH
Severe PreEclamp
PLUS
Seizure

NOTE:
Eclampsia can occur up to 2 weeks postpartum.
Management Management Management Management
• Get baseline 24hr urine protein.

• Blood pressures persistently above 160/105 should be treated to goals between 120/80 and 160/105.
– Labetalol
– Nifedipine
– Methyldopa

US screening for fetal growth restriction is appropriate.

• Antenatal fetal surveillance* should be performed in women who:
– Require antihypertensive therapy
– Have superimposed preeclampsia
– Have fetal growth restriction
Deliver @ 36wk

WORKUP

- 2 BP 4 hr apart,
- Urine dipstick or a 24-hr urine.

LAB:
- High-risk patients:
baseline assessment of renal function (24-hr urine protein & Cr clearance).
- CBC, CMP, UA, UDS, +/- IV Fluids,
- PT/PTT, Fibrinogen, LDH.
- GBS: Test if pre-trerm. Tx pt. has no harm.
- Uric acid.
- HELLP syndrome:
LDH > 600 U/L
Thrombocytopenia < 100,000/mm3
AST >70 U/L
- Immediate Delivery @ any age, consider a 48-hr delay only to give steroids for fetal lung maturity.
- Restrict fluids & monitor urine output; control BP with hydralazine or labetalol;
- Magnesium sulfate 4-6 g IV is given over 15 min followed by 2 g/hr drip for seizure prophylaxis; monitor Mg q 4-6 h.

Signs of Mg toxicity:
Hyporeflexia,
Loss of DTR,
Respiratory depression
Bradydysrhythmias.

- Repeat LFTs and creatinine.
-Aggressive furosemide treatment is appropriate in the presence of pulmonary edema.

Antidote for toxicity: Calcium gluconate 1 g IV over 3 minutes
1. Airway, O2
2. Roll on LEFT side w/bedside raised

3. Magnesium sulfate 4-6 g IV is given over 15 min followed by 2 g/hr drip for seizure prophylaxis; monitor Mg q 4-6 h, +/- ativan

4. Deliver @ any age
Bed-rest is NOT recommended for prevention OR treatment of preeclampsia


 
Antihypertensive Therapy:
(
Antihypertensive medications should not be administered unless BPs are persistently > 160/110.)
Hydralazine  5-10mg IV q20min (max: 20mg)
Methyldopa 250mg PO bid, max: 4g/day
Labetalol  20mg, 40mg, 80mg IV q10min (220mg)
                or
                100mg PO bid, max: 2400 mg/day
                or
                1 mg/kg infusion (maximum 220 mg)
Nifedipine 10 mg po and repeat in 30 minutes, if necessary; [oral nifedipine lowers BP more quickly than did IV labetaolol. ]
Sodium nitroprusside 0.25 ug/kg/min to a maximum of 5 ug/kg/min