Preeclampsia: Difference between revisions

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==Management==
==Management==
*Only definitive treatment is delivery
**Mild preeclampsia - induction or C-section if > 37 wks; consider close monitoring if 34-37 wks
**Severe Preeclampsia - induction or C-section independent of gestational age
===BP Control===
===BP Control===
*Lower to Sys 130-150, dia 80-100
*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.
***Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
===Urgent BP Control===
***Option 2: Initial 20mg; then IV infusion of 1-2mg/min
*[[Labetalol]]
**[[Nicardipine]]
**Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg
***Initial rate of 5mg/hr and increase by 2.5mg/hr q5min to effect
**Option 2: Constant IV infusion of 1-2mg/min
**[[Hydralazine]]
*[[Hydralazine]]
***Should not be considered first line therapy<ref>Leone M and Einav S. Severe preeclampsia: What's new in intensive care? Intensive Care Med. 2015; 41:1343-1346.</ref>
**Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg
***5mg IV over 1-2min; repeat bolus of 5-10mg q20min 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 4g IV over 15min followed by 1-2g per hr in coordination with admission by OBGYN
*[[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

Hypertension

Diagnosis

Work-Up

  • CBC
  • 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)

See Also

External Links

LITFL: Pre-eclampsia and Eclampsia

References

  1. Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
  2. http://annals.org/article.aspx?articleid=1902275