Preeclampsia

Question 1

Generally, the treatment of gestational hypertension or preeclampsia without severe features is. . .

Answer 1

Delivery at 37 weeks

Or, if at or past 37 weeks, delivery now

Question 2

The management of preeclampsia without severe features in a preterm pregnancy is. . .

Answer 2

. . . observation until either

1. severe features are noted
2. term gestation is reached

Question 3

Management of preeclampsia with severe features

Answer 3

If < 34 weeks, begin corticosteroids and magnesium, admit to tertiary care unit for close observation

If at or > 34 weeks, induce labor and begin magnesium

Question 4

First sign of magnesium toxicity

Answer 4

Loss of deep tendon reflexes

Question 5

Therapeutic range for magnesium in the treatment of preeclampsia/eclampsia

Answer 5

4-8 mg/dL magnesium

Question 6

Two ways to receive a diagnosis of chronic hypertension in association with pregnancy

Answer 6

1. Hypertension develops prior to 20 weeks gestation
2. Hypertension that develops after 20 weeks gestation persists beyond 12 weeks postpartum

Question 7

Acute onset severe hypertension in pregnancy

Answer 7

Defined as >160 mmHg systolic OR 110 mmHg diastolic persisting beyond 15 minutes

A hypertensive emergency. High risk for PRES.

Requires IV labetalol, IV hydralazine, or oral nifedipine

Question 8

PRES in the peripartum period

Answer 8

A not uncommon complication of preeclampsia / eclampsia

Will persent as visual disturbance or cerebellar signs +/- headache.

Diagnose with MRI.

Question 9

Formal diagnosis of preeclampsia

Answer 9

Two elevated BPs measured at least 6 hours apart

One of:

• 24 hour urinary protein > 300 mg OR P/Cr ratio > 0.3 OR dipstick >= 1+ protein
• Plt < 100,000
• LFT elevation (2x normal)
• Renal insufficiency (Cr > 1.1 mg/dL)
• Pulmonary edema
• New onset cerebral disturbance or visual impairment

Question 10

“Severe features” that make a dx of preeclampsia with severe features

Answer 10

• SBP > 160 or DBP > 110 on two occasions 4 hours apart
• Plt < 100,000
• Impaired LFTs (2x normal) OR severe persistent epigastric or RUQ pain
• Progressive renal insufficiency (Cr > 1.1 mg/dL)
• Pulmonary edema
• New onset cerebral or visual disturbance

Question 11

Management of superimposed preeclampsia

Answer 11

If < 34 weeks, begin corticosteroids and magnesium, admit to tertiary care unit for close observation

If at or > 34 weeks, induce labor and begin magnesium

Note: The same as preeclampsia with severe features.

Question 12

Management of pregnancies of chronic hypertension patients who are well controlled

Answer 12

Observation with delivery at 38-39 weeks

Question 13

How long does it take to treat a premature patient with corticosteroids?

Answer 13

48 hours

So, there is a balance between prolonging a risky pregnancy and allowing time for fetal lungs to mature.

Generally speaking, a stable patient with preeclampsia with severe features or superimposed preeclampsia can tolerate waiting 48 hours.

However, if the patient is unstable or if the patient is full-on eclamptic, has HELLP, or has PRES, you probably need to deliver now.

Question 14

What medications should a preeclamptic patient NOT receive?

(on top of the regular pregnancy no-no’s)

Answer 14

NSAIDs

NSAIDs may result in elevated post-partum blood pressures in preeclamptic patients, which may in turn precipitate postpartum preeclampsia complications (AKI, PRES, cerebral hemorrhage, etc).

Therefore, we avoid these in preeclamptic patients.

This includes the tocolytic indomethacin.

Question 15

When do you start magnesium for a preeclamptic patient?

When do you stop magnesium for a preeclamptic patient?

Answer 15

Start: During labor or labor induction

Stop: 24 hours postpartum

Question 16

Newly elevated PTT and INR in a preeclamptic patient who is going into nearing term should be a red flag for. . .

Answer 16

. . . DIC

This is an indication for immediate delivery

Question 17

The most common cause of maternal death due to eclampsia

Answer 17

Intracerebral hemorrhage

Question 18

When is it appropriate to control the blood pressure in a preeclamptic patient?

Answer 18

When the HTN is in the severe range. In other words, SBP > 160, DBP > 100.

More mild HTN we will simply observe.

Question 19

Indications for biophysical profile

Answer 19

Some time after 32 weeks when there is some reason to be concerned for fetal complications:

• Gestational diabetes
• Gestational HTN
• Preeclampsia
• C/f IUGR
• C/f macrosomia
• Decreased fetal movement
• Geriatric pregnancy
• Maternal obesity
• etc, etc, etc. You can guess.

Question 20

A biophysical profile will often be done in tandem with. . .

Answer 20

. . . umbilical artery Doppler

Particularly for IUGR, but also generally.

Question 21

Past what point do we not care about corticosteroids anymore for most pregnancies?

Answer 21

After 34 weeks gestation

Question 22

If the “severe feature” in preeclampsia with severe features is ___, immediate delivery should be strongly considered

Answer 22

If the “severe feature” in preeclampsia with severe features is pulmonary edema, immediate delivery should be strongly considered