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    Preeclampsia, Eclampsia & HELLP – Treatment

    Cardiovascular, Obstetrics and Gynecology, Special Populations

    Last Updated Feb 05, 2020
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    Context

    • 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.

    Recommended Treatment

    • Consult obstetrics.
    • Arrange for fetal heart monitoring (in conjunction with OBGYN) +/- ultrasound +/- doppler.

    Hypertension Management

     

    Indications:

    • 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:

    • Labetalol
      • 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.
    • Hydralazine
      • 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.
    • Methyldopa
      • 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.
    • Nifedipine
      • 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.

     Targets:

    • Aim for <85mmHg diastolic, especially if comorbidities or postpartum.
    • Avoid dropping MAP >25 percent in 2 hours to avoid myocardial, cerebral or uteroplacental hypoperfusion.

     

    Seizure Management

    • 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
        • OR
      • 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.
    • Second Line
      • Lorazepam 2-4 mg IV over 2 minutes or diazepam 5-10 mg IV
      • Phenytoin
      • Barbiturates

     

    Seizure Prophylaxis

     

     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.

     

    Thrombocytopenia

    • Prophylactic platelet transfusion indications – Consult obstetrics.
      • <50 × 10^9/L prior to delivery (caesarian or vaginal).

     

    Antenatal Corticosteroids

    • Consult obstetrics, antenatal corticosteroids can be considered for all premature cases.

     

    IV Fluids

    • 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.

     

    Bed Rest

    • 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

    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?

    Justification

    Most evidence comes from various guidelines; guideline agreement is moderate but evidence supporting these guidelines ranges from low to high.

    Low-Moderate

    Related Information

    Reference List

    1. UpToDate – Preeclampsia: Management and prognosis


    2. UpToDate – Expectant management of preterm preeclampsia with severe features


    3. UpToDate – Management of hypertension in pregnant and postpartum women


    4. Rosen’s Emergency Medicine: Acute Complications of Pregnancy, Chapter 178, 2237-2258


    5. emDocs – Preeclampsia and Eclampsia: Common Pitfalls in Diagnosis and Management


    6. 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 Health4(2), 105-145.


    7. National, G. A. U. (2019). Hypertension in pregnancy: diagnosis and management.


    8. CORE EM – Preeclampsia and Eclampsia


    9. 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 gynecology122(5), 1122.


    10. UpToDate – Eclampsia


    11. UpToDate – HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)


    12. 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.


    13. 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.


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