Preeclampsia: Difference between revisions
Ostermayer (talk | contribs) |
Ostermayer (talk | contribs) |
||
Line 64: | Line 64: | ||
==Management== | ==Management== | ||
===BP Control=== | ===BP Control=== | ||
* | *For pregnant women with chronic HTN, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg | ||
**[[Labetalol]] | *Either labetol or hydralazine can be used for initial control. Maximize the dose of each drug before adding on additional therapy. | ||
===Urgent BP Control=== | |||
*[[Labetalol]] | |||
**Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg | |||
*** | **Option 2: Constant IV infusion of 1-2mg/min | ||
*[[Hydralazine]] | |||
** | **Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg | ||
*** | **Option 2: Constant infusion 0.5-10mg/hr | ||
*[[Nifedipine]] | |||
**Option 1: 10-20mg PO, repeat in 30 minutes PRN; then 10-20 mg q 2-6 hours | |||
===Common Oral AntiHTN meds used in Chronic HTN of pregnancy=== | |||
*[[Labetalol]] | |||
**Option 1: 200-2400 mg/d in two to three divided doses | |||
*[[Nifedipine|Nifedipine ER]] | |||
**Option 1: 30-120 mg/d | |||
*[[Methydopa]] | |||
**Option 1: 0.5-3 g/d in two to three diveded doses | |||
*Thiazide diuretics - used as second line agent | |||
*ACE Inhibitor/ARB - CONTRAINDICATED IN PREGNANCY DUE TO TERATOGENICITY | |||
===Delivery Timing=== | |||
*Pre Eclampsia without severe features, delivery at 37 weeks | |||
*Pre Eclampsia with severe features | |||
**Before fetal viability, delivery after maternal stabilization, expectant management is not recommended | |||
**Viable fetus at 33 6/7 weeks or less may delay delivery for 48 hours of corticosteroids if maternal and fetal conditions remain stable with any of the following: | |||
***PPROM | |||
***Labor | |||
***Low platelet count <100,000mL | |||
***Persistent abnormal LFT(2x normal concentration) | |||
***IUGR<5% | |||
***Severe oligohydramnios (AFI<5cm) | |||
***Reversed end diastolic flow on umbilical artery Doppler studies | |||
***New onset renal dysfunction or increasing renal dysfunction. | |||
*Do not delay delivery after initial maternal stabilization regardless of gestational age for women with PreE with severe features complicated by any of the following: | |||
**Uncontrollable severe HTN | |||
**Eclampsia | |||
**Pulmonary edema | |||
**Abruption placentae | |||
**Disseminated intravascular coagulation | |||
**Evidence of nonreassuring fetal status | |||
**Intrapartum fetal demise | |||
===Prevention=== | ===Prevention=== | ||
*The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ([[Evidence Based Recommendation Levels| B recommendation]])<ref>http://annals.org/article.aspx?articleid=1902275</ref> | *The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ([[Evidence Based Recommendation Levels| B recommendation]])<ref>http://annals.org/article.aspx?articleid=1902275</ref> | ||
*[[Magnesium]]: For seizure prevention, load | *[[Magnesium]]: For seizure prevention, load 4-6g IV over 20min infusion followed by 1-2g per hr in coordination with admission by OBGYN | ||
**Observe for loss of reflexes, respiratory depression | **Observe for loss of reflexes, respiratory depression | ||
Revision as of 18:01, 19 December 2015
Background
- Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
- May occur sooner with gestational trophoblastic disease
- Defined as SBP>140 or DBP>90 in previously normotensive pt AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
- Only 10% of cases occur prior to 34wk
Risk Factors
- Past history of preeclampsia
- First pregnancy
- Family history of preeclampsia
- Preexisting medical conditions:
- Pregestational diabetes
- Blood pressure ≥130/80 mm Hg at the first prenatal visit
- Antiphospholipid antibodies
- Body mass index ≥26.1
- Chronic kidney disease
- Twin pregnancies
- Advanced maternal age
Clinical Features
- Edema
- Elevated BP
- With increasing severity pulmonary edema, visual changes, and AMS can develop
Differential Diagnosis
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Diagnosis
Work-Up
- CBC
- Thrombocytopenia suggests severe disease
- Chemistry
- Elevated Cr suggests severe disease
- Baseline Mg level
- LFT
- AST/ALT elevation suggests severe disease
- LDH
- Elevation suggests microangiopathic hemolysis
- Uric acid level
- Often elevated in preeclampsia
- UA
- Proteinuria
ACOG Diagnostic Criteria
In 2013, ACOG has decided to remove proteinuria from the definition of severity of preeclampsia[1]
- Blood Pressure
- Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs
- Systolic ≥160 mmHg or diastolic ≥110 mmHg, confirmed within a short interval (minutes) to facilitate timely antiHTN meds
AND
- Proteinuria
- Proteinuria ≥300mg in a 24-hour urine collection
- Spot protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3
- 1+ on urine dipstick (if no quantitative measurement is unavailable)
OR
- In the absence of proteinuria, new onset HTN with any severe features:
- Systolic BP ≥160 or diastolic BP ≥110, 2 occasions, 4 hours apart, while on bed rest (unless antiHTN meds were started before this time)
- Thrombocytopenia platelets <100,000/mL
- Elevated LFTS (2x normal concentration), severe persistent RUQ/epigastric pain unresponsive to medications and no alternative diagnosis
- Progressive renal insufficiency (Cr >1.1mg/dL or doubling of Cr concentration in absence of renal disease)
- Pulmonary edema
- New onset cerebral or visual disturbance
Management
BP Control
- For pregnant women with chronic HTN, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg
- Either labetol or hydralazine can be used for initial control. Maximize the dose of each drug before adding on additional therapy.
Urgent BP Control
- Labetalol
- Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg
- Option 2: Constant IV infusion of 1-2mg/min
- Hydralazine
- Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg
- Option 2: Constant infusion 0.5-10mg/hr
- Nifedipine
- Option 1: 10-20mg PO, repeat in 30 minutes PRN; then 10-20 mg q 2-6 hours
Common Oral AntiHTN meds used in Chronic HTN of pregnancy
- Labetalol
- Option 1: 200-2400 mg/d in two to three divided doses
- Nifedipine ER
- Option 1: 30-120 mg/d
- Methydopa
- Option 1: 0.5-3 g/d in two to three diveded doses
- Thiazide diuretics - used as second line agent
- ACE Inhibitor/ARB - CONTRAINDICATED IN PREGNANCY DUE TO TERATOGENICITY
Delivery Timing
- Pre Eclampsia without severe features, delivery at 37 weeks
- Pre Eclampsia with severe features
- Before fetal viability, delivery after maternal stabilization, expectant management is not recommended
- Viable fetus at 33 6/7 weeks or less may delay delivery for 48 hours of corticosteroids if maternal and fetal conditions remain stable with any of the following:
- PPROM
- Labor
- Low platelet count <100,000mL
- Persistent abnormal LFT(2x normal concentration)
- IUGR<5%
- Severe oligohydramnios (AFI<5cm)
- Reversed end diastolic flow on umbilical artery Doppler studies
- New onset renal dysfunction or increasing renal dysfunction.
- Do not delay delivery after initial maternal stabilization regardless of gestational age for women with PreE with severe features complicated by any of the following:
- Uncontrollable severe HTN
- Eclampsia
- Pulmonary edema
- Abruption placentae
- Disseminated intravascular coagulation
- Evidence of nonreassuring fetal status
- Intrapartum fetal demise
Prevention
- The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ( B recommendation)[2]
- Magnesium: For seizure prevention, load 4-6g IV over 20min infusion followed by 1-2g per hr in coordination with admission by OBGYN
- Observe for loss of reflexes, respiratory depression
Disposition
- Consult with OB/GYN regarding discharge versus admission
- Some cases of mild preeclampsia may be candidates for outpatient therapy
- Close follow up and return precautions is key
- Repeat lab tests 1-2x per week (platelet count, creatinine, AST)
- Some cases of mild preeclampsia may be candidates for outpatient therapy
See Also
External Links
LITFL: Pre-eclampsia and Eclampsia
References
- ↑ Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
- ↑ http://annals.org/article.aspx?articleid=1902275