Preeclampsia+and+Chronic+Hypertension

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Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

** Preeclampsia, Gestational Hypertension, and Chronic Hypertension **
 * __History of Preeclampsia or Gestational Hypertension in Prior Pregnancy__**
 * Baseline labs in first or second trimester: creat/pro ratio, creat, ALT, AST, CBC
 * Monitor closely (do not space out visits in third trimester) for preeclampsia this pregnancy
 * __Prophylactic ASA 81mg daily__ as soon as viable IUP established, ideally by 12-16 weeks. May start up to 28 weeks EGA if not started earlier per recommendations. See topic Aspirin Prophylaxis in Pregnancy
 * __Chronic Hypertension__**—BP __>__ 140 systolic or 90 diastolic in early pregnancy or already on anti-hypertensive medication
 * Baseline labs in first or second trimester: creat/pro ratio, creat, ALT, AST, uric acid, CBC
 * Monitor closely (do not space out visits in third trimester) for preeclampsia
 * Treat blood pressure > 150 systolic or > 95 diastolic
 * First line med labetalol, second nifedipine, alternative aldomet
 * Do not use ACE inhibitors or ARBs as contraindicated in pregnancy
 * Antepartum testing biweekly starting usually at 32 weeks EGA
 * Consider growth ultrasound at 32 weeks especially if not mild/well controlled, or elevated BMI makes FH unreliable
 * Induction at 38-39 weeks EGA if stable BP elevation (no superimposed preeclampsia)
 * Induction at 38-39 weeks EGA if stable BP elevation (no superimposed preeclampsia)


 * __Gestational Hypertension and Preeclampsia__**
 * Gestational Hypertension repeated new elevation BP 140-160 systolic or 90-110 diastolic, no severe features including
 * Preeclampsia **__without__** severe features BP elevation and creat/pro ration __>__ 300mg
 * Preeclampsia **__with__** severe features as above with at least one severe feature

Initial evaluation to rule out severe features is usually done same day on Labor and Delivery—may be done in clinic if labs can be followed up within 24 hours).

If no severe features and < 37 weeks EGA (normally induced at 37 weeks):
 * Biweekly NST/AFI/BP checks monitoring in antepartum testing at MHC, PHC, or WCHC
 * Growth sono every three weeks (may defer if mild and physical exam consistent with AGA or LGA fetus)
 * PIH labs (creat/pro ratio, creat, ALT, AST, CBC) weekly
 * Review of symptoms including new headache, flashing lights, nausea and vomiting, epigastric pain—patient to go to L and D if present
 * Delivery at 37 weeks 0 days for Preeclampsia and in the 37th week for gestational hypertension
 * Do not treat blood pressure unless determined to be chronic hypertension

__**Postpartum Management**__
 * __Preeclampsia with Severe Features__**
 * Headache
 * Visual changes
 * Creatinine > 1
 * ALT or AST > twice normal
 * BP __>__ 160 systolic or 110 diastolic
 * CALL 925-370-5608 OR PAGE OB ATTENDING AND SEND PATIENT IMMEDIATELY TO LABOR AND DELIVERY **

Postpartum preeclampsia accounted for 24% of preeclampsia related maternal deaths in CA 2002-2004. Postpartum preeclampsia usually occurs within 2 weeks postpartum and has been reported up to 6 weeks postpartum in patients who had or did not have preeclampsia at the time of delivery. The primary goal postpartum is to prevent morbidity and mortality related to delayed severe preeclampsia.
 * The most common cause of maternal death from preeclampsia is cerebral hemorrhage. **Prompt** management of severe range blood pressures ( __>__160/105) is thought to decrease this risk, based on the success of this intervention in the UK.
 * Morbidity postpartum is caused by Posterior Reversible Encephalopathy Syndrome (PRES) characterized by worsening HTN, seizures, altered mental status, headache and vision changes. With prompt blood pressure management and seizure prophylaxis, PRES is usually reversible.

Patients with preeclampsia may be monitored in the hospital longer to insure BPs are stable (typically rise day 2-3 postpartum) Patients with preeclampsia are typically given follow up in 3-7 days or 7-10 days postpartum for a blood pressure check, depending on severity of disease. Patients with preeclampsia may be discharged on antihypertensive, most commonly Nifedipine XL, to be continued until blood pressures normalize, usually by 6 weeks postpartum.


 * All postpartum patients should be aware of symptoms of postpartum preeclampsia (they are given a handout at the hospital)
 * All postpartum patients with BPs new __>__140 SBP or __>__ 90 DBP should be evaluated same day for preeclampsia
 * Patients with severe range BP should be transported urgently to the hospital ER (>160 SBP, 105 DBP)
 * Concerning symptoms include new headache, visual changes, RUQ or epigastric pain, persistent vomiting, SOB.
 * Postpartum patients with BPs at or close to the severe range should be assessed urgently and treated with antihypertensives immediately.
 * CALL 925-370-5608 or OB on call for consultation. Oral labetalol is available in the clinics for use pending transport.