HYPERTENSIVE DISORDERS OF PREGNANCY Part 02

Mild Preeclampsia   PET uncomplicated by neurologic symptoms or criteria for a diagnosis of severe PET Management of Mild Preeclamp...

Mild Preeclampsia 

PET uncomplicated by neurologic symptoms or criteria for a diagnosis of severe PET

Management of Mild Preeclampsia

1. maternal evaluation
2. history and physical examination
3. laboratory
   
   
   
   • CBC and electrolytes
   • renal function tests ----> BUN, creatinine, uric acid
   • liver enzymes and coagulation studies ----> PT, PTT, FDP
   • urinalysis for protein and casts
   • 24 hour urine for protein and creatinine clearance 
   
   
4. fetal evaluation of FHR, NST,BPP 
5. management with bed rest in left lateral decubitus position (reduces abdominal vessel compression)  normal dietary salt and protein intake 
6. no use of diuretics/antihypertensives

Severe Preeclampsia

PET complicated by at least two of the following

1. BP > 160/110
2. congestive heart failure
3. pulmonary edema or cyanosis
4. proteinuria > 5 g/24 hours or > 2+ on dipstick
5. elevated serum creatinine
6. oliguria (< 400 mL/24 hours)
7. thrombocytopenia (< 100 000 - 150 000/mL)
8. ascites
9. RUQ or epigastric pain (subcapsular hemorrhage)
10. elevated liver enzymes
11. hyperbilirubinemia
12. headache (cerebral artery vasospasm)
13. visual disturbances (i.e. scotomas, loss of peripheral vision)
14. hyperreflexia, clonus
15. IUGR

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Management of Severe Preeclampsia

1. stabilize and deliver; the only "cure" is delivery
2. admit and complete maternal evaluation (same as for mild) --->keep NPO 
3. start IV, cross and type 
4. Foley catheter to monitor urine output 
   

Maternal monitoring

1. hourly input and output, check urine 12 hours for protein
2. vitals and DTR  1 hour 
   

Fetal evaluation

1. NST followed by continuous electronic fetal monitoring until delivery
   

Anticonvulsant therapy

1. given to increase seizure threshold
2. baseline magnesium blood level
3. magnesium sulphate (4g IV push) followed by maintenance of 2-4 g/hour
4. excretion of magnesium sulfate is via kidney therefore patients with oliguria require a lower infusion rate

Signs of magnesium toxicity (> 13 mg % serum level)

1. depression of DTR (deep tendon reflex)
2. depression of RR < 10/minute
3. decreased muscle tonicity
4. CNS or cardiac depression
5. antagonist to magnesium sulphate is calcium gluconate (10%) 10 mL IV if respiratory arrest occurs

Antihypertensive therapy

1. decreasing the BP decreases the risk of stroke (indicated only if BP > 140-170/90-110)
2. first line: hydralazine 5 - 10 mg IV push over 5 minutes q 15 - 30 minutes until desired effect (an arteriolar vasodilator with minimal venous effect)
3. controls BP for hours not days (deliver as soon as possible)
4. next dose is given ~6 hours later with BP readings 15 minutes duration
5. also used in postpartum state if BP remains elevated and urinary output < 25 mL/hour
6. second line: labetalol 20 - 50 mg IV  q 10 minutes
7. third line: nifedipine 10 -20 mg po q 20 - 60 minutes (puncture capsule and swallow liquid)

Postpartum management

1. all antepartum therapy and monitoring continued until stable
2. risk of seizure highest in first 24 hours postpartum
3. continue magnesium sulfate for 12-24 hours after delivery
4. the patient who continues to remain in serious condition may have HELLP
5. most women return to a normotensive BP within 2 weeks but BP may worsen transiently in that time