What am I? (definitions, not an existential question)
New onset elevated blood pressures (BP >140/90) detected after 20 weeks gestation based on two elevated measurements at least 4 hours apart in an otherwise asymptomatic patient, which resolves by 12 weeks postpartum
Why is it recommended to start ASA in certain pregnant patients, and at what gestational age would you start it?
ASA is used to prevent and/or delay progression to pre-eclampsia. Before 16 weeks, ideally at 12 weeks.
What is the definitive treatment of preeclampsia?
Delivery
True or False: Approximately half of women with gestational HTN progress to develop pre-eclampsia.
True
What is the diagnostic criteria of HELLP?
Hemolysis: Increased bilirubin >1.2; Increased LDH >600 IU/L; Abnormal peripheral blood smear (schistocytes, burr cells, echinocytes)
Elevated LFTs: Increased AST and/or ALT >2x ULN
Platelet count < 100,000/mm3
HTN present before pregnancy or dx before 20 wks or HTN that exists more than 12 weeks postpartum
Chronic HTN
How do you treat Chronic HTN in pregnancy?
First line: Labetalol, Nifedipine
Alternatives: Methyldopa, hydrochlorothiazide
What labs would you order if you suspect preeclampsia?
CBC
CMP
Uric Acid
LDH
Urine P:C
True or False: Losartan is an acceptable second-line agent for HTN in pregnancy
False
ACE/ARBs are teratogenic and may cause renal failure, oligohydramnios, hypocalvaria
This is the pathophysiological cause of preeclampsia
Abnormal placental spiral arteries => endothelial dysfunction, vasoconstriction, ischemia
i.e. the placenta ain't working right
New onset HTN with proteinuria (>/= 0.3g over 24 hours, or P:C 0.3, or >/= 2+ on urine dip stick)
Pre-Eclampsia without severe features
How to diagnose and treat magnesium toxicity.
Symptoms: Hypotension, loss of DTRs, respiratory depression or arrest, oliguria, shortness of breath, chest pains, EKG changes.
Diagnosis: Serum magnesium levels, EKG
Treatment: Discontinue magnesium. Calcium gluconate 1g IV over 3 minutes
In a chronic hypertensive patient not previously on medication at what BP threshold would you initiate treatment?
140/90
Based on benefits seen in CHAP trial. This trial showed a reduction in patients who progressed to preeclampsia with severe features and a decrease in medically indicated preterm birth <35 wks gestation, abruption or fetal/neonatal death when initiating treatment when BP >140/90
True or False: HTN is always present in HELLP syndrome.
False. You do not need to have HTN, nervous system dysfunction or renal dysfunction present.
33 y/o G2P1001 at 37w6d w/ no PMHx presents to triage for elevated BP noted at her prenatal visit. At the office her BP was noted to be 163/99. She reports a headache that started this morning, but denies any vision changes, cp, sob, RUQ pain or new swelling. She also denies any LOF, VB, ctx or decreased FM. While in triage she has two severe range BPs, HR 55, RR 18 O2 Sat 98% RA. What initial medication and dose would you order?
Hydralazine 5 mg IV over 2 minutes or Nifedipine 10 mg PO
**if HR>60, Labetalol 20mg over 2 minutes would be acceptable
BP >160/110 with signs of end organ damage
Preeclampsia with severe features
- Elevated BP, CNS dysfunction, elevated LFT >2 upper limit, thrombocytopenia, Renal insufficiency
What is the first line treatment in eclampsia?
Magnesium sulfate
At what GA is delivery indicated in preeclampsia without severe features vs preeclampsia severe features?
Without severe features: 37w0d
With severe features: 34w0d
True or False: Valproic acid is recommended for seizures refractory to magnesium sulfate
False, this is contraindicated in pregnancy due to teratogenicity.
Lorazepam, Diazepam, Midazolam, Thiopental Sodium, phenytoin**
**teratogenic but may be indicated for use of refractory seizures in eclamptic patients
What position should you place patient in if they are having an active seizure, and why?
Left Lateral decubitus. It decreases the risk of aspiration and helps to improve uterine blood flow by relieving obstruction of the vena cava by the gravid uterus.
Convulsions or unexplained coma during pregnancy or postpartum not related to other cerebral conditions in patients with signs and symptoms of preeclampsia.
Eclampsia
Name 3 indications for starting ASA
High Risk
- History of pre-e, multi-gestation, CHTN, T1DM or T2DM, Renal Disease, Autoimmune Disease (SLE, Antiphospholipid syndrome)
Moderate Risk (need more than 1)
- Nulliparity, Obesity, Family Hx of Pre-eclampsia (mother or sister), Sociodemographic characteristics (AA or low socioeconomic status), 35 years or older, Personal Hx factors (low birth weight, SGA, previous adverse preg outcome, more than 10 year preg interval)
When are antenatal corticosteroids indicated and before what gestational age?
In in a pre-eclamptic patient where expectant management is indicated and the clinician believes birth within the next 7 days is likely. Should be administered before 34 weeks.
True or False: Patients with no previous hypertension can present with postpartum eclampsia up to 2 weeks.
False, up to 4-6 weeks.
Magnesium sulfate is contraindicated in what disease?
Myasthenia Gravis
Magnesium has significant inhibitory effect on ACh release. Magnesium can precipitate a severe myasthenic crisis.