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Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams

Emergency Medical Minute

Release Date: 09/12/2024

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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

  • Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.

  • Hypertension (HTN) complicates 2-8% of pregnancies

  • The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart

  • There is a range of HTN disorders

    • Chronic HTN which could have superimposed preeclampsia (preE) on top

    • Gestational HTN in which there are no lab abnormalities

    • PreE w/o severe features

      • Protein in urine

      • Urine protein >300 mg in 24 hours

      • Urine Protein to Creatinine ratio of .3

      • +2 Protein on urine dipstick

    • PreE w/ severe features

      • Systolics above 160 mmHg

      • Diastolics above 110 mmHg

      • Headache, especially not going away with meds, or different than previous headaches

      • Visual changes, anything that lasts more than a few minutes

      • RUQ pain, which could present as heartburn

      • Pulmonary edema

      • Low platelets, if <150 perk up ears, <100 definitely look into

      • Renal insufficiency, creatinine 1.1 or higher or doubling of baseline

      • Impaired liver function

      • Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to

  • Treatment

    • Labetalol, IV

      • Avoid in bradycardia, asthma, or myocardial disease

      • Quick up titrate, with dosing regimens such as 20-20-40 or 20-40-80 (mg)

    • Hydralazine, IV

      • 5 mg starting, then another 5 mg then 10 mg if not working

    • Nifedipine, Oral

      • Can cause a headache

    • Goal is not to normalize BP but bring it down slowly

  • How to give magnesium

    • Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function

    • Follow with 2 g per hour or 1 g per hour

    • Don’t give in myasthenia gravis

  • What should you do if the patient progresses to eclampsia (seizures)

    • Magnesium is the best drug

    • Can use phenytoin or benzos IV as an alternate

    • Diazepam is available PR which is a good option if you don’t have IV access

    • IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks

  • Facts about post-partum PreE

    • 20% of women will have HTN post-partum

    • Most resolve by 6 weeks

    • If it lingers past 6 months this is chronic HTN

    • If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor

    • Post-partum is the most common time for strokes

    • Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed

    • Enalapril is safe in breast feeding

    • Some patients might need to give up breast feeding to be on even more aggressive HTN therapy

    • Are NSAIDs safe while breastfeeding?

      • Motrin is pretty safe

    • Pulm edema is a risk, be careful with fluids

  • Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea

 

References

  1. Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6

  2. Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276

  3. Reed, B. (2020, May 2). ‘They didn’t listen to me’: Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death

  4. Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330

  5. Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008

  6. Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653

 

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII