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Preeclampsia, Eclampsia & HELLP – Treatment
Cardiovascular, Obstetrics and Gynecology, Special Populations
- Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm.
- Occurs >20 weeks gestation and up to 6 weeks post partum.
- Most often onset is close to term, while earlier presentations are more severe.
- Preeclampsia = new onset hypertension with proteinuria (most often) or organ dysfunction.
- Preeclampsia with severe features = preeclampsia complicated by severe hypertension or organ dysfunction.
- Eclampsia = preeclampsia with new onset of seizures or coma.
- HELLP Syndrome = severe preeclampsia variant defined by hemolysis, elevated liver enzymes and low platelet count.
- Worldwide approximately 4.6% of pregnancies are complicated by preeclampsia.
- Preeclampsia is a leading cause of maternal and fetal mortality and morbidity.
- Maternal: seizures (eclampsia), stroke, liver dysfunction, pulmonary edema, renal failure, placental abruption.
- Fetal: Stillbirth, preterm, small for gestational age.
- Risk factors: diabetes, hypertension, kidney disease, obesity, prior preeclampsia, nulliparity and multifetal pregnancy, autoimmune disease, maternal age <20 or >35 yrs.
- Presentations: headache, visual disturbances, chest pain, shortness of breath, abdominal pain, nausea/vomiting or acute edema of face, hands or lower extremities.
- Require admission, discharge at obstetrical direction.
- Consult obstetrics.
- Arrange for fetal heart monitoring (in conjunction with OBGYN) +/- ultrasound +/- doppler.
- Severe Hypertension ⩾160mmHg systolic or ⩾110mmHg diastolic.
- 140/90 – 160/110 mmHg in those with cardiac or CNS symptoms, comorbidities (eg. diabetes or renal disease) or postpartum – consult OBGYN.
Pregnancy Safe Options:
Acute management of severe hypertension WITH end-organ damage:
- 20mg IV over 2 minutes. If BP remains elevated at 10 minutes, give 20-80 mg IV over 2 minutes based on previous response. Repeat q10 minute up to maximum of 300mg. If ineffective switch to another antihypertensive.
- 5mg IV over 2 minutes. If BP remains elevated at 20 minutes, give 5-10mg IV over 2 minutes. Repeat in another 20 minutes if needed. Cumulative maximum 30mg. If ineffective switch to another antihypertensive.
- 250 to 500 mg IV over 30 to 60 minutes every 6 hours, up to a maximum of 3 g/day. If ineffective switch to another antihypertensive.
- Oral Nifedipine LONG ACTING 30mg Tablet. DO NOT BREAK capsule. If BP remains elevated after 1-2 hours dose can be repeated. If ineffective switch to another antihypertensive.
Oral options for severe hypertension WITHOUT end-organ damage:
- First Line
- Labetalol – Initial 100 mg PO BID. Maintenance 200-400mg BID.
- Methyldopa – Initial 250 mg PO 2-3 times per day. Maintenance 500mg-2,000mg divided into 2-4 doses.
- Nifedipine – Initial LONG ACTING 30mg Tablet. DO NOT BREAK capsule. Maintenance 30mg-90mg Long acting once daily.
- Other Beta-blockers – acebutolol, metoprolol, pindolol, and propranolol.
- Second line
- Clonidine, hydralazine and thiazides.
DO NOT use ACE Inhibitors and Angiotensin RB in pregnancy or first few weeks post-partum or preterm babies if breastfeeding.
- Aim for <85mmHg diastolic, especially if comorbidities or postpartum.
- Avoid dropping MAP >25 percent in 2 hours to avoid myocardial, cerebral or uteroplacental hypoperfusion.
- Usual seizure management/precautions.
- First Line – Magnesium sulfate (MgSO4)
- MgSO4 Intravenous (PREFERRED):
- Loading dose: 4-6 GRAMS IV over 15 minutes
- Maintenance: 1-2 GRAMS/hr IV
- MgSO4 Intramuscular
- Loading dose: 10 GRAMS IM (5 grams into each buttock)
- Maintenance dose: 5 GRAMS IM q4h
- Renal Insufficiency: Same loading dose. Reduce or withhold maintenance dosing.
- Monitor for magnesium toxicity (eg. loss of reflexes, respiratory depression), if suspected check serum levels and stop maintenance dose – antidote is calcium gluconate.
- May also give additional MgSO4 2-4 GRAMS IV over five minutes.
- MgSO4 Intravenous (PREFERRED):
- Second Line
- Lorazepam 2-4 mg IV over 2 minutes or diazepam 5-10 mg IV
When to start:
- Intrapartum and postpartum for women with preeclampsia.
- Any patient with preeclampsia with severe features, HELLP or eclampsia.
- Follow same dosing of magnesium sulfate as outlined above.
- Prophylactic platelet transfusion indications – Consult obstetrics.
- <50 × 10^9/L prior to delivery (caesarian or vaginal).
- Consult obstetrics, antenatal corticosteroids can be considered for all premature cases.
- Limit maintenance fluids to 80 ml/hour unless there are other ongoing fluid losses.
- Oliguria should not be treated with fluids and should be tolerated to avoid pulmonary edema.
- Strict bed rest is not recommended, reduced activity may be beneficial.
HELLP Syndrome – Additional Management
- Platelet Transfusion – as above.
- Liver Imaging
- Severe RUQ pain to rule out bleed.
- CT/MRI if needed.
- RBC Transfusion – Consult obstetrics.
Criteria For Hospital Admission
- All women with suspected preeclampsia, HELLP or eclampsia are admitted for:
- Diagnosis and Assessment
- Maternal and Fetal Monitoring
- Treatment or Delivery
Criteria For Transfer To Another Facility
- Obtain obstetrical consult.
- Patients with eclampsia require centers which can care for high-risk obstetrics.
- Two risk calculators are available to estimate the chances of adverse events in preeclampsia:
Criteria For Close Observation And/or Consult
- Patients with preeclampsia, HELLP or eclampsia should have close monitoring.
- All patients should have Obstetrics consulted.
- Additional consultations may include neonatology, hematology, anesthesiology or neurology as indicated.
Criteria For Safe Discharge Home
- Obstetrics to decide this.
- Women with preeclampsia with severe features, HELLP or eclampsia are not discharged.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Most evidence comes from various guidelines; guideline agreement is moderate but evidence supporting these guidelines ranges from low to high.
Magee, L. A., Pels, A., Helewa, M., Rey, E., & von Dadelszen, P. (2014). Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health, 4(2), 105-145.
American College of Obstetricians and Gynecologists. (2013). Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy. Obstetrics and gynecology, 122(5), 1122.
Magee, L. A., von Dadelszen, P., Singer, J., Lee, T., Rey, E., Ross, S., … & Gafni, A. (2016). The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study) is severe hypertension just an elevated blood pressure?. Hypertension, 68(5), 1153-1159.
Butalia, S., Audibert, F., Côté, A. M., Firoz, T., Logan, A. G., Magee, L. A., … & Nerenberg, K. A. (2018). Hypertension Canada’s 2018 guidelines for the management of hypertension in pregnancy. Canadian Journal of Cardiology, 34(5), 526-531.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Feb 05, 2020
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