Preeclampsia / Gestational Preeclampsia / Gestational HypertensionHypertension

Diagnosis & ManagementDiagnosis & Management20102010

For Patients at Risk for For Patients at Risk for Developing Preeclampsia Obtain Developing Preeclampsia Obtain Baseline LabsBaseline Labs

• Multifetal gestationMultifetal gestation• History of preeclampsia History of preeclampsia <<34 weeks34 weeks• History of chronic hypertensionHistory of chronic hypertension• 11stst trimester systolic trimester systolic ≥≥130, diastolic 130, diastolic

≥≥8080• BMI BMI > 40> 40• APA SyndromeAPA Syndrome• ThrombophiliaThrombophilia• Collagen vascular diseaseCollagen vascular disease• Renal diseaseRenal disease• Pregestational diabetesPregestational diabetes

BMJ 2005:330:565BMJ 2005:330:565

Chronic Hypertension Patients Chronic Hypertension Patients Increased Risk of Developing Increased Risk of Developing Superimposed Pre-Eclampsia Superimposed Pre-Eclampsia

• Chronic hypertension of 4 years Chronic hypertension of 4 years duration or more (31% get duration or more (31% get Preeclampsia)Preeclampsia)

• Superimposed pre-eclampsia in previous Superimposed pre-eclampsia in previous pregnancy (32% Recur)pregnancy (32% Recur)

SabaiSabai

NEJM 1998:339:667NEJM 1998:339:667

Baseline Labs for Patients at Baseline Labs for Patients at RiskRisk

• CBC with plateletsCBC with platelets

• SGOT/SGPT/total bilirubinSGOT/SGPT/total bilirubin

• BUN/CRBUN/CR

• Evaluation for proteinuriaEvaluation for proteinuria

Consider ASA in High Risk Consider ASA in High Risk PatientsPatients Prevention of Pre-Eclampsia Prevention of Pre-Eclampsia

Meta-Analysis of over 12,000 Meta-Analysis of over 12,000 womenwomen

• ASA 81 mg once daily (at bedtime)ASA 81 mg once daily (at bedtime)– OR perinatal death (.79)OR perinatal death (.79)– OR pre-eclampsia (.86)OR pre-eclampsia (.86)– An increase in birth weight An increase in birth weight 215 G 215 G– No increase of abruptionNo increase of abruption

• ASA causes no harm 96,000 womenASA causes no harm 96,000 women– AbruptionAbruption– Neonatal bleedingNeonatal bleeding– Maternal bleedingMaternal bleeding

Coomarasamy Meta-AnalysisCoomarasamy Meta-AnalysisObstet Gynecol 2003:101:1319Obstet Gynecol 2003:101:1319

KnightKnightCochrane Data Base 2000:2:CD000492Cochrane Data Base 2000:2:CD000492

Consider Ca for All PatientsConsider Ca for All PatientsDecrease Severity of PreeclampsiaDecrease Severity of Preeclampsia

• Calcium 1500 mg dailyCalcium 1500 mg daily

– Reduction in severity of pre-Reduction in severity of pre-eclampsia and incidence of eclampsia and incidence of eclampsiaeclampsia

WHO Randomized Trial over 8000 womenWHO Randomized Trial over 8000 women

AJOG 2006:194:639AJOG 2006:194:639

Diagnosis Diagnosis Gestational HypertensionGestational Hypertension• Hypertension after 20Hypertension after 20thth week of gestation week of gestation

(with no history of CHTN + normal BP (with no history of CHTN + normal BP <<20 20 wk)wk)

• Systolic 140 mm Hg and/or diastolic of 90 Systolic 140 mm Hg and/or diastolic of 90 mm Hg on 2 occasions at least 6 hours mm Hg on 2 occasions at least 6 hours apart and not more than 7 days apartapart and not more than 7 days apart

ANDAND• No proteinuria No proteinuria • 50% progress to preeclampsia if diagnosed 50% progress to preeclampsia if diagnosed

before 32 weeksbefore 32 weeks

Obstet Gynecol 2003:102:181Obstet Gynecol 2003:102:181Am J Obstet Gynecol 2001:184:979Am J Obstet Gynecol 2001:184:979

Diagnosis Diagnosis PreeclampsiaPreeclampsia• Hypertension after 20Hypertension after 20thth week of gestation week of gestation

(with no history of CHTN + normal BP (with no history of CHTN + normal BP <<20 wk)20 wk)

• Systolic 140 mm Hg and/or diastolic of 90 Systolic 140 mm Hg and/or diastolic of 90 mm Hg on 2 occasions at least 6 hours mm Hg on 2 occasions at least 6 hours apart and not more than 7 days apartapart and not more than 7 days apart

ANDAND

• Proteinuria Proteinuria - Dipstick 1+ or 30mg/dl >4 hrs apart - Dipstick 1+ or 30mg/dl >4 hrs apart

- 300 mg/24 hr- 300 mg/24 hr

ObstetGynecol 2003:102:181

Diagnosis of Superimposed Diagnosis of Superimposed Pre-EclampsiaPre-Eclampsia• Development of new onset proteinuria Development of new onset proteinuria

≥300mg/24 hours≥300mg/24 hours• If history of proteinuria before 20 weeks EGA If history of proteinuria before 20 weeks EGA

sudden increase in proteinuria sudden increase in proteinuria• Sudden increase in blood pressure in a Sudden increase in blood pressure in a

woman whose hypertension has previously woman whose hypertension has previously been well controlledbeen well controlled

• Lab changesLab changes– Platelet count Platelet count 100K100K– Increase in SGOT/SGPT/LDHIncrease in SGOT/SGPT/LDH– Increased uric acidIncreased uric acid

• Develop symptomsDevelop symptomsAm J Obstet Gynecol 2000:183:S1Am J Obstet Gynecol 2000:183:S1

““Impending Impending Preeclampsia”Preeclampsia”• ““If blood pressure is rising If blood pressure is rising

(30mm Hg(30mm Hg↑ systolic/15mm Hg ↑ systolic/15mm Hg ↑diastolic) or ↑diastolic) or 130130ss/80/80ss close close observation is warranted”observation is warranted”

• Blood pressure should be re-evaluated Blood pressure should be re-evaluated in 24 – 72 hours or monitored at homein 24 – 72 hours or monitored at home

• Important to discuss signs/symptomsImportant to discuss signs/symptoms• Lab evaluation for at leastLab evaluation for at least

Uric acid (Uric acid (≥≥5.5) and 5.5) and Urine dipstick (1+)Urine dipstick (1+)

AmJ Obstet Gynecol 2000:183:S1AmJ Obstet Gynecol 2000:183:S1Obstet Gynecol 2006:108:826Obstet Gynecol 2006:108:826

Edema and Rapid Weight Edema and Rapid Weight GainGain• Facial and upper extremity edemaFacial and upper extremity edema• Rapid weight gain 5 lbs/one weekRapid weight gain 5 lbs/one week

“May indicate the fluid and sodium “May indicate the fluid and sodium retention of preeclampsia, they retention of preeclampsia, they are neither universally present or are neither universally present or uniquely characteristic of uniquely characteristic of preeclampsia. These signs are at preeclampsia. These signs are at most an indication for close most an indication for close monitoring of blood pressure and monitoring of blood pressure and urinary protein.”urinary protein.”

Am J Obstet Gynecol 2000:183:S1Am J Obstet Gynecol 2000:183:S1

Assessment of SeverityAssessment of Severity Laboratory Evaluation Laboratory Evaluation

H H ●● LDH LDH 600 Iu and/or total bilirubin 600 Iu and/or total bilirubin ≥1.2mg/dl≥1.2mg/dl

ELEL● ● SGOT/SGPT SGOT/SGPT 2x upper limit ( 70 ) 2x upper limit ( 70 )

LPLP● ● Platelets Platelets 100k 100k

-CreatinineCreatinine 1.2 1.2 -Proteinuria 1+ or 30 mg/dl or 300 mg/24 hrProteinuria 1+ or 30 mg/dl or 300 mg/24 hr

-CBC Hemo concentrated 40% -CBC Hemo concentrated 40%

--PT/PTT/FibrinogenPT/PTT/Fibrinogen check especially if liver check especially if liver test are abnormal OR PLATELETS < 100ktest are abnormal OR PLATELETS < 100k

Sibai. Am J Obstet Gynecol 2009

DiagnosisDiagnosis HELLP Syndrome HELLP Syndrome•HHemolysis PBS + 1 criteriaemolysis PBS + 1 criteria

•Elevated LDH Elevated LDH >>600 Iu/l600 Iu/l•Elevated total bilirubin Elevated total bilirubin >>1.2 mg/dl 1.2 mg/dl •Low serum haptoglobin Low serum haptoglobin <<25 mg/dl25 mg/dl•Blood smear with schistocytesBlood smear with schistocytes

– ELEL•Elevated liver function testElevated liver function test•Above upper limit of normal or 2 SD Above upper limit of normal or 2 SD

above the mean AST above the mean AST >>70 u/l70 u/l

– LPLP•Low platelets Low platelets <<100K 100K

Obstet Gynecol 2004:103:981Sibai. Am J Obstet Gynecol 2009

“ “Partial HELLP” Partial HELLP” ≈≈20% of Severe Disease20% of Severe Disease

IsolateIsolated d

%%

Combined Combined

%%

HH 1212 LP 6LP 6

ELEL 3030 LP 24 or H LP 24 or H 77

LPLP 2020Am J Obstet Gynecol 1996:175:460

Sao Paulo Med J 2002:120:180Sibai. Am J Obstet Gynecol 2009

Lab AbnormalitiesLab Abnormalities Uric Acid Uric Acid

• Increase uric acid in the blood Increase uric acid in the blood is is not predictive of the severitynot predictive of the severity of of preeclampsiapreeclampsia

• It is helpful in confirming the It is helpful in confirming the diagnosis. ( 5.5)diagnosis. ( 5.5)

• Uric acid may be most useful in Uric acid may be most useful in diagnosing superimposed diagnosing superimposed preeclampsia 54%S/78%SPpreeclampsia 54%S/78%SP

Meta AnalysisMeta AnalysisBJOG 2006:113:369BJOG 2006:113:369

Am J Obstet Gynecol 1998:17:1067Am J Obstet Gynecol 1998:17:1067

Assessment of SeverityAssessment of Severity Remember the Baby Remember the Baby

• Fetal movementFetal movement

• IUGRIUGR– Fundal heightFundal height– Sono evaluation for EFW/AFISono evaluation for EFW/AFI– <10% vs <5%<10% vs <5%

• AFIAFI

• NSTNST

Epigastric painRight upper quadrant painRetrosternal chest painNausea and vomiting

Shortness of breath/Congestive Heart Failure

Headaches (not responsive to analgesics)Visual changesAltered mental status

Bleeding from mucosal membranesJaundice

Signs and Symptoms Severe preeclampsia

Sibai. Diagnosis and management of a typicalpreeclampsia-eclampsia. Am J Obstet Gynecol 2009

Prodromal Symptoms in Prodromal Symptoms in Patients with EclampsiaPatients with Eclampsia

HeadacheHeadache 50 – 75%50 – 75%

Visual ChangeVisual Change Blurred visionBlurred vision Photophobia Photophobia

20 – 30%20 – 30%

Epigastric painEpigastric pain 10 – 20%10 – 20%

At least one of the At least one of the above symptomsabove symptoms

75%75%

BMJ 1994:309:1395Am J Obstet Gynecol 2000:182:1389Am J Obstet Gynecol 2002:186:1174

Criteria for Severe Preeclampsia*Criteria for Severe Preeclampsia*

SIBAI 2006ACOG 33:2002

• Systolic blood pressure Systolic blood pressure ≥≥160 mm Hg or diastolic 160 mm Hg or diastolic ≥≥110 mm Hg on two occasional at least six hours 110 mm Hg on two occasional at least six hours apart while on bedrestapart while on bedrest

• Symptoms of central nervous system dysfunctionSymptoms of central nervous system dysfunction– Blurred vision, scotomata, altered mental status, severe headacheBlurred vision, scotomata, altered mental status, severe headache

• Symptoms of liver capsule distentionSymptoms of liver capsule distention– Right upper quadrant or epigastric painRight upper quadrant or epigastric pain– Nausea, vomitingNausea, vomiting

• Impaired liver functionImpaired liver function• ThrombocytopeniaThrombocytopenia• ProteinuriaProteinuria

– Over 5 grams in 24 hours or 3+ or more on two random samples four Over 5 grams in 24 hours or 3+ or more on two random samples four hours aparthours apart

• Oliguria 500 ml in 24 hoursOliguria 500 ml in 24 hours• Intrauterine fetal growth restrictionIntrauterine fetal growth restriction• Pulmonary edema or cyanosisPulmonary edema or cyanosis• Cerebrovascular accidentCerebrovascular accident

**One criteria requiredOne criteria required

Criteria for Severe Gestational Criteria for Severe Gestational Hypertension*Hypertension*• Systolic blood pressure Systolic blood pressure ≥≥160 mm Hg or diastolic 160 mm Hg or diastolic

≥≥110 mm Hg on two occasional at least six hours 110 mm Hg on two occasional at least six hours apart while on bedrestapart while on bedrest

• Symptoms of central nervous system dysfunctionSymptoms of central nervous system dysfunction– Blurred vision, scotomata, altered mental status, severe Blurred vision, scotomata, altered mental status, severe

headacheheadache

• Symptoms of liver capsule distentionSymptoms of liver capsule distention– Right upper quadrant or epigastric painRight upper quadrant or epigastric pain– Nausea, vomitingNausea, vomiting

• Impaired liver functionImpaired liver function• ThrombocytopeniaThrombocytopenia• Oliguria 500 ml in 24 hoursOliguria 500 ml in 24 hours• Intrauterine fetal growth restrictionIntrauterine fetal growth restriction• Pulmonary edema or cyanosisPulmonary edema or cyanosis• Cerebrovascular accidentCerebrovascular accident

*One criteria required*One criteria required

Am J Obstet Gynecol 2002:186:66Am J Obstet Gynecol 2002:186:66

Complications of PreeclampsiaComplications of Preeclampsia

ComplicationComplication ControlControl Mild (%)Mild (%) Severe (%)Severe (%)

Liver diseaseLiver disease <<11 33 2020

Kidney Kidney diseasedisease

<<11 55 1313

AbruptionAbruption <<11 <<11 44

Delivery Delivery <<34 34 33 22 1919

IUGRIUGR 44 1010 1919

NICUNICU 1313 2727 4343

Perinatal Perinatal deathdeath

<<22 11 <<22

EclampsiaEclampsia≈No Mg≈No Mg

11//20020022//100100Obstet Gynecol 2000:95:24

Am J Obster Gynecol 2004:190:1520

ComplicationsComplications Severe Gestational HTN & Severe Severe Gestational HTN & Severe PreeclampsiaPreeclampsia

• AbruptionAbruption 7 % 7 % • Pulmonary edema 5 %Pulmonary edema 5 %• DIC 10 %DIC 10 %• Acute Renal Failure 3 %Acute Renal Failure 3 %• IUGR 20 %IUGR 20 %• HELLP 15 %HELLP 15 %

• EclampsiaEclampsia (On Mg 0.5%) vs ( No Mg 2%) (On Mg 0.5%) vs ( No Mg 2%)

AM J Obstet Gynecol AM J Obstet Gynecol 2002:186:662002:186:66Lancet 2005:365:785Lancet 2005:365:785

Obstet Gynecol Obstet Gynecol 2000:95:242000:95:24

ComplicationsComplications HELLP Syndrome HELLP Syndrome

• AbruptionAbruption 10 % 10 %

• Pulmonary edemaPulmonary edema 10 % 10 %

• DICDIC 15 % 15 %

• Acute renal failureAcute renal failure 3 % 3 %

• PTD PTD ≤28≤28 15%15%

• ARDS / CVA / Sepsis ARDS / CVA / Sepsis <1%<1%

• DeathDeath 1% 1%

Obstet Gynecol 2004:103:981

ATYPICAL DISEASE

• Late Eclampsia > 48 hours after Late Eclampsia > 48 hours after deliverydelivery

• Early Preeclampsia prior to 20 weeksEarly Preeclampsia prior to 20 weeks

• Gestational proteinuria Gestational proteinuria

+ 1 or more Sx/Sx or lab criteria+ 1 or more Sx/Sx or lab criteria

• Gestational HTNGestational HTN

+ 1 or more Sx/Sx or lab criteria+ 1 or more Sx/Sx or lab criteriaSibai. Diagnosis and management of atypical preeclampsia-eclampsia.Am J Obstet Gynecol 2009;200:481.e1-481.e7.

ATYPICAL DISEASEOverlapping role of hypertension, capillary leak, maternal symptoms, and fibrinolysis/hemolysis in the spectrum of atypical preeclampsia

Blood Pressure may be normal

Fibrinolysis/Hemolysis 1 or none Low plts/DIC/ LFT’s elevated HELLP or Renal Failure

Capillary Leak Symptoms Proteinuria, Facial edema, Pleural effusions, Pulmonary edema , Ascites

Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009.

Atypical DiseaseAtypical Disease• Not always a progression of Not always a progression of

mildmild severe severe eclampsiaeclampsia• 15% of HELLP no proteinuria 15% of HELLP no proteinuria

AND no hypertensionAND no hypertension• 15% of eclampsia no 15% of eclampsia no

hypertensionhypertension• 15% of eclampsia no proteinuria15% of eclampsia no proteinuria• 30% of eclampsia mild 30% of eclampsia mild

hypertension or no hypertension hypertension or no hypertension and no proteinuriaand no proteinuria

Am J Obstet Gynecol 2000:182:307 & Sibai 2009; Am J Obstet Gynecol 2000:182:307 & Sibai 2009; 200:481.e1-481.e7.BMJ 1994:309:1395BMJ 1994:309:1395Obstet Gynecol 2004:103:981Obstet Gynecol 2004:103:981

ATYPICAL DISEASE

• < 20 week onset r/o Molar pregnancy < 20 week onset r/o Molar pregnancy and and -Lupus nephritis, APA , HUS , TTP-Lupus nephritis, APA , HUS , TTP

• Seizure >48hrs and< 4 weeks PP ~ 15%Seizure >48hrs and< 4 weeks PP ~ 15% - - Start Magnesium (Start Magnesium ( 6 & 2 6 & 2 ) and R/O other causes) and R/O other causes

Sibai. Diagnosis and management of atypical preeclampsia-eclampsia.Am J Obstet Gynecol 2009;200:481.e1-481.e7.

Initial Evaluation for Initial Evaluation for Gestational Hypertension & Gestational Hypertension & PreeclampsiaPreeclampsia

• Consider initial hospitalization for bedrest Consider initial hospitalization for bedrest and serial evaluation of blood pressure/ and serial evaluation of blood pressure/ labslabs

• Rule out other disordersRule out other disorders• Assess the severity of diseaseAssess the severity of disease

– Sx/SxSx/Sx– HELLP LabsHELLP Labs– Total bilirubin/LDH/PBSTotal bilirubin/LDH/PBS– Serum creatinineSerum creatinine– 24 hr urine for total protein24 hr urine for total protein

• Assess the babyAssess the baby– NSTNST– Sono/AFISono/AFI

Management Management

Mild Preeclampsia & Gestational Hypertension Mild Preeclampsia & Gestational Hypertension

• ““Initial inpatient monitoring” is reassuringInitial inpatient monitoring” is reassuring– Sono for : EFW / AFI / BPP Sono for : EFW / AFI / BPP – LabsLabs– Signs/symptomsSigns/symptoms– Blood pressure “stable”Blood pressure “stable”– Serial NST/BPPSerial NST/BPP

• Home managementHome management– Restricted activity, not bedrestRestricted activity, not bedrest– No salt restrictionNo salt restriction– Antihypertensives do not alter the course of disease or Antihypertensives do not alter the course of disease or

alter perinatal morbidityalter perinatal morbidity– Labs once/weekLabs once/week– NST 2x week and daily fetal movementNST 2x week and daily fetal movement– Sono every 2-3 weeksSono every 2-3 weeks– BP and urine dipstick dailyBP and urine dipstick daily

Obstet Gynecol 2003:102:181Obstet Gynecol 2003:102:181

Mild Preeclampsia Home Mild Preeclampsia Home ManagementManagement Progression of DiseaseProgression of Disease Consider Admission to Hospital Consider Admission to Hospital

• Systolic Systolic > >150150

• Diastolic Diastolic >>100100

• Signs/symptoms of severe diseaseSigns/symptoms of severe disease

• Lab abnormalities (HELLP)Lab abnormalities (HELLP)

• Sudden increase to 2+ or more Sudden increase to 2+ or more proteinuriaproteinuria

• Urinary protein Urinary protein >> 1000mg/24 hr 1000mg/24 hr

• Non reassuring/Equivocal fetal testingNon reassuring/Equivocal fetal testing

Obstet Gynecol Obstet Gynecol 2003:102:1812003:102:181

Indications for Delivery in Indications for Delivery in PreeclampsiaPreeclampsia• Maternal indicationsMaternal indications

– Gestational age greater than or equal to Gestational age greater than or equal to 37 37 weeks of weeks of gestationgestation

– Persistent or labile severe hypertensionPersistent or labile severe hypertension– Platelet count less 100,000 cells per cubic millimeterPlatelet count less 100,000 cells per cubic millimeter– Deteriorating liver functionDeteriorating liver function– Progressive deterioration in renal functionProgressive deterioration in renal function– Abruptio placentaeAbruptio placentae– Persistent severe headaches or visual changesPersistent severe headaches or visual changes– Persistent severe epigastric pain, nausea, or vomitingPersistent severe epigastric pain, nausea, or vomiting

• Fetal indicationsFetal indications– Fetal growth restrictionFetal growth restriction– Nonreassuring results from fetal testingNonreassuring results from fetal testing– OligohydramniosOligohydramnios

Am J Obstet Gynecol 2000:183:S1Obstet Gynecol 2003:102:181

Induction of labour versus expectant monitoring forgestational hypertension or mild pre-eclampsia after36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial

Lancet 2009; 374: 979–88

Induction (n=377) Expectant (n=379)

Vaginal Delivery 323 (85%) 307 (84%) NS

Cesarean section 54 (14%) 72 (19%) NS

Poor Maternal Outcome 117 (31%) 166 (44%) p<0·0001

Composite Adverse neonatal outcome 24 (6%) 32 (8%) NS

Indications for Delivery in Indications for Delivery in PreeclampsiaPreeclampsia• Maternal indicationsMaternal indications

– Gestational age greater than or equal to Gestational age greater than or equal to 37 37 weeks of weeks of gestationgestation

– Persistent or labile severe hypertensionPersistent or labile severe hypertension– Platelet count less 100,000 cells per cubic millimeterPlatelet count less 100,000 cells per cubic millimeter– Deteriorating liver functionDeteriorating liver function– Progressive deterioration in renal functionProgressive deterioration in renal function– Abruptio placentaeAbruptio placentae– Persistent severe headaches or visual changesPersistent severe headaches or visual changes– Persistent severe epigastric pain, nausea, or vomitingPersistent severe epigastric pain, nausea, or vomiting

• Fetal indicationsFetal indications– Fetal growth restrictionFetal growth restriction– Nonreassuring results from fetal testingNonreassuring results from fetal testing– OligohydramniosOligohydramnios

Am J Obstet Gynecol 2000:183:S1Obstet Gynecol 2003:102:181

Indications for Delivery Indications for Delivery Preeclampsia Preeclampsia

• 34 weeks AND34 weeks AND– Severe preeclampsiaSevere preeclampsia– IUGRIUGR– OligohydramniosOligohydramnios– Non reassuring fetal testingNon reassuring fetal testing– Labor or SROMLabor or SROM

Expectant Management Expectant Management Severe Disease Severe Disease

• Severe disease @ 33 weeksSevere disease @ 33 weeks– BMS + deliverBMS + deliver

• Severe disease Severe disease <<23 weeks23 weeks– DeliverDeliver

• Severe disease 23 – 32 weeksSevere disease 23 – 32 weeks– Level III Regional HospitalLevel III Regional Hospital– Expert careExpert care

Clinical Obstet Gynecol 2005:48 (2):430Clinical Obstet Gynecol 2005:48 (2):430

Postpartum Postpartum Antihypertensive Antihypertensive TreatmentTreatment• TreatmentTreatment for labile or persistent hypertension for labile or persistent hypertension ≥≥155 or 155 or

≥≥105105– Nifedipine 10 mg q 6 hrNifedipine 10 mg q 6 hr– Procardia 30 XL once or twice / dayProcardia 30 XL once or twice / day– Labetalol 200 mg q 8 hrLabetalol 200 mg q 8 hr

• ““Continue antihypertensive medications until Continue antihypertensive medications until 3-4 weeks3-4 weeks postpartum and observe BP at 1-2 week intervals for one postpartum and observe BP at 1-2 week intervals for one month, then at 3-6 month intervals for one year.” month, then at 3-6 month intervals for one year.” Alternative is to decrease meds if normotensive Alternative is to decrease meds if normotensive >>48 hours48 hours

• Blood pressure returns to normal after deliveryBlood pressure returns to normal after delivery– ~1 week for Gestational Hypertension~1 week for Gestational Hypertension– ~2-3 weeks for Mild PreEclampsia~2-3 weeks for Mild PreEclampsia– ~4-6 weeks for Severe PreEclampsia~4-6 weeks for Severe PreEclampsia

Am J Obstet Gynecol 1994:171:506Am J Obstet Gynecol 1994:171:506Am J Obstet Gynecol 2000: 183:S1Am J Obstet Gynecol 2000: 183:S1

Obstet Gynecol 2003:102:181Obstet Gynecol 2003:102:181

Multiple RCT Conclusively Multiple RCT Conclusively DemonstrateDemonstrate

Mg SoMg So44 No Mg SoNo Mg So44

SeizuresSeizures 4949//63436343

(0.6%)(0.6%)

128128//63306330

(2.0%)(2.0%)

Clinical Obstet Gynecol 2005:48:478

• In patients with SEVERE preeclampsia Mg So4

significantly decreases the risk of eclampsia 4 RCT

Magnesium SulfateMagnesium Sulfate Mild PreeclampsiaMild Preeclampsia 2 Small Randomized Trials2 Small Randomized Trials

Mg SoMg So44PlaceboPlacebo

EclampsiaEclampsia 00//17617600//181181

Progression Progression to severe to severe diseasedisease

12.5%12.5% 13.8%13.8%

Am J Obstet Gynecol 1997:176:623Obstet Gynecol 2003:101:217

Risk of eclampsia with no Mg So4 1/200

Mg SOMg SO44 not Currently Recommended not Currently Recommended for Seizure Prophylaxis with Mild for Seizure Prophylaxis with Mild PreeclampsiaPreeclampsia

• Imminent eclampsia defined as Imminent eclampsia defined as ≥ ≥ 2 2 of : Severe headache, epigastric of : Severe headache, epigastric pain, or hyper-reflexiapain, or hyper-reflexia

11//200200Patients with mild PrE who seizePatients with mild PrE who seize

11//400400To prevent one seizure – mildTo prevent one seizure – mild

11//7171To prevent one seizure – severeTo prevent one seizure – severe

11//3636To prevent one – “imminent” – 4% To prevent one – “imminent” – 4% PPVPPV

SIBAI Am J Obstet Gynecol 2004:190:1520

Obstet Gynecol 2005:105:402Lancet 2002:359:1877

Continued Assessment of Maternal Continued Assessment of Maternal Status for patients who have initial Mild Status for patients who have initial Mild PreEclampsia is Necessary in Labor PreEclampsia is Necessary in Labor

• An induction may last 24 – 48 hoursAn induction may last 24 – 48 hoursAt least At least 10%10% of patients may progress to of patients may progress to severe disease (BP,Sx/Sx/Labs) during this severe disease (BP,Sx/Sx/Labs) during this time frametime frame

• Beware of “Imminent Eclampsia” in a patient Beware of “Imminent Eclampsia” in a patient previously classified as “Mild”previously classified as “Mild”

• Be observant for findings suggestive of HELLP. Be observant for findings suggestive of HELLP. Bleeding mucosal membranes, petechia at Bleeding mucosal membranes, petechia at site of BP cuff, epigastric painsite of BP cuff, epigastric pain

Preeclampsia Preeclampsia SummarySummary• Outpatient management Outpatient management Hospitalize For:Hospitalize For:

– Labile BP >150Labile BP >150SS/>100/>100SS

– Increase proteinuria >1000mgIncrease proteinuria >1000mg– Sx/SxSx/Sx– Lab abnormalitiesLab abnormalities– Non reassuring fetal testing/Repeat equivocal testingNon reassuring fetal testing/Repeat equivocal testing

• ≥≥34 weeks EGA deliver For:34 weeks EGA deliver For:– Severe preeclampsia or Atypical diseaseSevere preeclampsia or Atypical disease– IUGRIUGR– OligohydramniosOligohydramnios– Non reassuring fetal testing / Repeat Equivocal TestingNon reassuring fetal testing / Repeat Equivocal Testing

• ≥≥37 weeks EGA deliver For:37 weeks EGA deliver For:– Only the rare patient should not be deliveredOnly the rare patient should not be delivered – Twin gestationsTwin gestations

• ≥≥38 weeks EGA deliver 38 weeks EGA deliver All delivered All delivered

Lancet 2005:365:785Obstet Gynecol 2003:102:181 Lancet 2009; 374: 979–88