Superimposed severe preeclampsia Management of severe hypertension Treatment

Superimposed severe preeclampsia Management of severe hypertension

Treatment of c. HTN � For women with persistent chronic hypertension with SBP >160 or DBP >105, start antihypertensive therapy � Maintain blood pressures at 120 -160/80 -105 � Initial therapy (PO): ◦ Labetalol ◦ Nifedipine ◦ Methyldopa

Superimposed preeclampsia � Challenges: ◦ How to distiguish chronic hypertension from preeclampsia ◦ When to treat blood pressures ◦ When to deliver

Preeclampsia: Diagnosis Proteinuria (300 mg/24 hours, PCR >300, +1 on dipstick) Liver transaminases >2 x normal Pulmonary edema SBP >140 or DBP >90 (2 occasions, 4 hours apart, <20 wks) Cerebral or visual disturbances Thrombocytopenia <100 K Creatinine 1. 1 or doubled from baseline

Superimposed preeclampsia New-onset proteinuria or increase in proteinuria from baseline Known chronic hypertension A sudden increase in BP or escalation in need for medications

Severe features SBP >160 or DBP >110 (2 occasions, 4 hours apart) Thrombocytopenia <100 K Creatinine 1. 1 or doubled from baseline Cerebral or visual disturbances Pulmonary edema Liver transaminases >2 x normal

Superimposed preeclampsia with severe features: Treatment � <230 wks gestation: ◦ Deliver after maternal stabilization ◦ Administer magnesuim sulfate intrapartum and postpartum to prevent eclampsia ◦ Treat with antihypertensives for SBP >160 or DBP >110 �≥ 340 wks gestation ◦ Deliver after maternal stabilization ◦ Administer magnesuim sulfate intrapartum and postpartum to prevent eclampsia ◦ Treat with antihypertensives for SBP >160 or DBP >110

Superimposed preeclampsia with severe features: Treatment <340 wks � Transfer to appropriate facility � Administer corticosteroids for fetal lung maturity � Manage expectantly until 34 wks � Deliver after course of corticosteroids (48 hours) if: ◦ PPROM or labor ◦ Thrombocytopen ia <100 K ◦ AST/ALT persistently elevated >2 x normal ◦ IUGR, oligohydramnios, abnormal dop ◦ New-onset or worsening renal dysfunction � Deliver soon after maternal stabilization if: ◦ Uncontrollable severe HTN �Eclampsia �Pulmonary edema �Placental abruption �DIC �Non-reassurring fetal status

For preeclampsia in general… � The ◦ ◦ mode of delivery should depend on: Gestational age Presentation Maternal and fetal status Cervix � Everyone with severe preeclampsia should get intrapartum and postpartum magnesuim sulfate to prevent eclampsia ◦ The continued intraoperative administration is recommended for cesarean delivery � Neuraxial analgesia is recommended � Invasive hemodynamic monitoring does not need to be routinely used

Managing Severe Hypertension In preeclampsia or eclampsia

Severe hypertension � Hypertensive emergency ◦ Severe: SBP >160 or DBP >110 ◦ Persistent: lasting more than 15 minutes ◦ Acute onset

Severe hypertension � “Severe systolic hypertension may be the most important predictor of cerebral hemorrhage and infarction in these patients and, if not treated expeditiously, can result in maternal death. ” � UK report 2003 -2005: 2/3 of maternal deaths resulted from cerebral hemorrhage or infarction � Case series of 28 women with preeclampsia/stroke ◦ All but 1 had severe SBP ◦ 54% died

Severe hypertension � Goal of treatment is to reduce pressures to 140 -160/90 -100 � This should be accomplished before delivery, even if delivery is needed urgently

Severe HTN: labetalol Notify physician (should be an order) Apply EFM Administer labetalol 20 mg IV over 2 minutes If still elevated, labetalol 80 mg IV over 2 minutes Repeat BP in 10 minutes If still elevated, labetalol 40 mg IV over 2 minutes Repeat BP in 10 minutes If still elevated, hydralazine 10 mg IV over 2 minutes Repeat BP in 20 minutes If still elevated, consult MFM, critical care, anesthesia SBP >160 or DBP >110 If BP goal achieved, repeat BP: every 10 minutes for 1 hour, every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 60 minutes for 4 hours

Management of severe HTN: hydralazine SBP >106 or DBP >110 NST Hydralazine 510 mg IV over 2 minutes Repeat BP in 20 minutes If still elevated, hydralazine 10 mg IV over 2 minutes Repeat BP in 20 minutes Repeat BP in 10 minutes If still elevated, consult MFM, critical care, anesthesia If still elevated, labetalol 20 mg IV over 2 minutes If BP goal achieved, repeat BP: every 10 minutes for 1 hour, every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 60 minutes for 4 hours

Considerations � Hydralazine can increase risk of maternal hypotension � Labetalol can cause neonatal bradycardia and should be used with caution in women with asthma, heart failure � Second line intervention: labetalol or nicardipine infusion pump � Sodium nitroprusside only for extreme emergencies ◦ Cyanide toxicity, increased maternal ICP � Once mother is stabilized, discuss plan including delivery