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SUMMARY ACOG HYPERTENSION IN PREGNANCYMAY 2014SPARROW HOSPITAL DEPARTMENT OBGYNGESTATIONAL HYPERTENSION (GHTN)Diagnosis: ≥140 systolic or ≥90 diastolic on two occasions at least 4 hours apart: New onset hypertension after 20 weeks, and returns to normal by 6-12 weeks postpartum24 hr urine protein < 300 mg, no severe features, no FGRManagement:No bed restNo antihypertensive unless persistent severe range blood pressures (≥160 systolic and/or ≥110 diastolic)Daily kick countsOnce weekly AFI and CBC, AST, creatinine ± ALT/LDHOnce weekly NST with BP check and urine dipstick in officeOne additional BP obtained each week in office or at homeDelivery Criteria:37-39 weeks if no evidence of preeclampsia or other indication for deliveryManagement Preeclampsia Without Severe Features (Previously called Mild preeclampsia)No bed rest, regular diet with no salt restrictionNo antihypertensive medication unless persistent severe range blood pressures (≥160 systolic and/or ≥110 diastolic)Daily kick countsGrowth ultrasound every 2-3 weeksIf there is evidence of fetal growth restriction, obtain umbilical artery Doppler velocimetryWeekly or twice weekly AFITwice weekly NST with BP check Once weekly CBC, AST, ALT, creatinine Instruct woman to report symptoms of severe preeclampsia such as severe headache, visual changes, epigastric pain or shortness of breathIf woman reports decreased fetal movement or fundal height is found to be less than 3 cm of expected, prompt evaluation with NST and AFI is indicatedMagnesium Sulfate for seizure prophylaxis is optional and should not be given universallyHospitalization Criteria:Development of features of severe preeclampsia or evidence of fetal growth restriction are indications for immediate hospitalizationDelivery Criteria:>37 weeks>34 weeks plus any of the following:Progressive labor or rupture of membranesUltrasound estimate of fetal weight less than fifth percentileOligohydramnios (persistent AFI less than 5cm or MVP < 2 cm)Persistent BPP 6/10 or lessSuspected abruptionManagement of Severe PreeclampsiaAdmit to L&D If > 34 0/7 weeks, deliver after maternal stabilizationIf diagnosed before fetal viability, deliver after maternal stabilizationIf between viability and 34 weeks, expectant management for 24-48 hours unless contraindicated by one or more of the following (if present, do not delay delivery, deliver after maternal stabilization):EclampsiaPulmonary edemaDICUncontrollable severe hypertensionNon-viable fetusAbnormal fetal test results/evidence of non-reassuring fetal statusPlacental abruptionIntrapartum fetal demiseRenal failureSevere thrombocytopeniaExpectant management for the first 24-48 hours after admission for severe preeclampsia includes: Corticosteroids Magnesium sulfate Daily labs (CBC, AST, ALT, & creatinine)Ultrasound for fetal growth and presentationDelivery may be delayed 48 hours to provide corticosteroid administration for the following complications:> 33 5/7 weeksPersistent symptomsHELLP or partial HELLP syndromeFetal growth restriction (less than 5th percentile)Severe oligohydramnios (persistent AFI < 5cm or MVP < 2 cm)Reverse end-diastolic flow (umbilical artery Doppler studies)Labor or PROMSignificant renal dysfunctionPerinatology consultation recommended if < 34 weeks and/or immediate delivery not planned Amount of proteinuria or change in the amount of proteinuria are NOT correlated with outcome and should not be used as a criteria for delivery in preterm patientsAcute control of severe HTN (≥160 systolic and/or ≥110 diastolic)Option 1:Administer labetalol (20 mg IV over 2 minutes).Repeat BP measurement in 10 minutes and record results.If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.Repeat BP measurement in 10 minutes and record results.If either BP threshold is still exceeded, administer labetalol (80 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.Repeat BP measurement in 10 minutes and record results.If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.Repeat BP measurement in 20 minutes and record results.If either BP threshold is still exceeded, obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists.Option 2:Administer hydralazine (5 mg or 10 mg IV over 2 minutes).Repeat BP measurement in 20 minutes and record results.If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.Repeat BP measurement in 20 minutes and record results.If either BP threshold is still exceeded, administer labetalol (20 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.Repeat BP measurement in 10 minutes and record results.If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists.Option 3: if no IV accessLabetolol 200 mg orally or Nifedipine 10 mg orally (not sublingual)Repeat in 30 minutes if BP >160 systolic or > 110 diastolicOnce BP threshold is achieved check BPsEvery 10 minutes for 1 hourEvery 15 minutes for 1 hourEvery 30 minutes for 1 hourEvery 4 hours until dischargeSeizure ProphylaxisMagnesium Sulfate 4 – 6 gm bolus over 20 minutes, then 1 - 2 gm/hr continuous infusion (may need to reduce to 1 gm/hr if renal impairment and follow serum magnesium levels)Magnesium sulfate 5 mg IM each buttock (10 mg total) if no IV accessAnticonvulsant medications for recurrent seizures or when MGSO4 contraindicated (pulmonary edema, renal failure, myasthenia gravis)Lorazepam 2 – 4 mg IV x 1, may repeat x 1 after 10 minutes)Diazepam 5 – 10 mg IV every 5 – 10 minutes, max dose 30 mgPhenytoin 15 – 20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 minutes. Avoid with hypotension; may cause cardiac arrythmias Keppra 500 mg IV or PO, may repeat in 12 hours, adjust doseECLAMPSIADiagnosisNew-onset grand mal seizures in a woman with preeclampsia.ManagementControl seizures and provide patient safety (Airway-Breathing-Circulation) Correction of hypoxia and acidosis Control severe hypertension Assess neurologic status If antepartum, deliver after maternal stabilization Anticonvulsant Therapy: Initiate and maintain magnesium sulfate infusion for further seizure prevention when eclampsia is suspected. Magnesium sulfate dosage: 4 to 6 grams IV loading dose over 20 minutes, followed by 2gm/hour as a continuous intravenous infusion as per severe preeclampsiaFor women having a convulsion after receiving initial magnesium sulfate, give another IV bolus of 2 g magnesium sulfate. If no IV magnesium sulfate 5 mg IM in each buttock (10 mg total) x 1Continue magnesium sulfate for at least 24 hours after the last convulsionAnticonvulsant medications for recurrent seizures or when MGSO4 contraindicated (pulmonary edema, renal failure, myasthenia gravis)Lorazepam 2 – 4 mg IV x 1, may repeat x 1 after 10 minutes)Diazepam 5 – 10 mg IV every 5 – 10 minutes, max dose 30 mgPhenytoin 15 – 20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 minutes. Avoid with hypotension; may cause cardiac arrythmias SUPERIMPOSED PREECLAMPSIADiagnosis:In a woman with hypertension that had onset < 20 weeks with at least one of the following:New onset proteinuria (≥300 mg/24 hours, or Protein/creatinine ratio >0.3)Increase in baseline proteinuria (double of baseline)Sudden increase in BP that was previously well controlledEscalation in BP medsHeadache, visual changes, epigastric pain – evaluate for preeclampsiaSevere featuresManagement and Delivery Criteria: ? CHTN with Superimposed Preeclampsia without severe features should be delivered ≥ 37 weeksIf severe features develop, deliver as per severe preeclampsia guidelinesPOSTPARTUM MANAGEMENTKeep magnesium sulfate infusing 24 hours postpartum Monitor BP every 4 hours in hospital until dischargeFor women who present postpartum with new-onset hypertension associated with headaches, blurred vision, or preeclampsia with severe hypertension, administer magnesium sulfate, regardless of proteinuria presentAnti-hypertensive therapy is suggested for women with persistent postpartum hypertension, systolic >150 mm Hg, or diastolic > 100 mm Hg, on 2 occasions, 4 hours apart. Persistent systolic > 160 or diastolic > 110 should be treated within 1 hour.Avoid NSAIDs in patients with severe features, HELLP Syndrome, or clinical suspicion of worsening preeclampsia postpartum.Brain imaging studies ifUnremitting headacheFocal signs or symptomsLethargyConfusionSeizuresAbnormal neurologic examCoagulopathy Discharge planning: BP should be checked at 72 hours, in office if patient has been discharged prior to this timeRepeat BP in office 7 – 10 days postpartum or earlier if symptomsProvide patient with specific written discharge orders regarding headache, RUQ or chest pain, visual impairment, and emergency numbersRefer to algorithm below FLP, acute fatty liver of pregnancy; APAS, antiphospholipid antibody syndrome; HELLP, hemolysis, elevated liver enzymes, and low platelet; HUS, hemolytic uremic syndrome; RCVS, reversible cerebral vasoconstriction syndrome; TTP, thrombotic thrombocytopenic purpura. REFERENCESSibai. Postpartum hypertension-preeclampsia. Am J Obstet Gynecol 2012.ACOG Practice bulletin #33, 2012ACOG. (2013). Hypertension in Pregnancy.Summary of the Hypertension in Pregnancy Taskforce, ACOG Annual Meeting 2012Peter von Dadelszen, et al, The Active Implementation of Pregnancy Hypertension Guidelines in British Columbia, OBGYN, VOL. 116, NO. 3, Sept 2010Maternal Safety Bundle for Severe Hypertension in Pregnancy, ACOGDistrict II, January 2014ACOG Committee Opinion #514. Dec 2011. Emergent Therapy for Acute-Onset, Severe Hypertension with Preeclampsia or EclampsiaMagee, L, July 2008, OBGYN, Letters to the Editor pg 563, Re: Avoidance of NSAIDs in postpartum hypertensive patients ................
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