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About the below ... Shelley is a physician and sometimes uses this page as a scratch wiki :-) It's all good! --Brandon
Morning Report 2/20/09 (temporary content)
- Preeclampsia
- New onset htn, proteinuria (0.3g/day) at >20 wks gestation in previously normotensive woman
- Mild or severe. Severe = 1 or more of these: CNS, liver capsule stretch sx, AST/ALT 2x nl, SBP>/=160 or DBP >/- 110 on 2 occ 6 hrs apart, <100K PLT, >/=5g proteinuria in 24 hrs, oliguria, severe fetal GR, pulm edema/cyanosis, CVA.
- Can persist up to 12 wks postpartum (average 16 +/- 9.5 days)
- Pulm edema: high PCWP c/w oncotic pressure esp s/p delivery, LV failure, iatrogenic volume overload, capillary leak
- Heart: no "direct" effects -- but early incr CO, late decr CO and incr SVR
- Systematic review: s/p preeclampia, RR HTN 3.70, CAD 2.16, CVA 1.81 mean f/u around 10-11 yrs; VTE 1.79 at 4.7 yrs. Abs risk for any of these at age 50-59 17.8% vs 8.3%, so NNH = around 10
- patho phys - no one knows. endothelial dysfxn?
- Chronic Htn: >140/90 before preg, before 20 wks, or after 12 wks postpartum
- Preeclampsia superimposed on chronic Htn:
- Gestational Htn: >140/90 but no proteinuria. By definition occurs after 20 wks and resolves after 12 wks postpartum
- Eclampsa = preeclampsia or gestation htn plus sz
Treatment
- Bedrest -- few data to support. One small randomized trial found RR 0.58 or so for going from mild to severe HTN among those who rested at home. LLD posiiton . . .
- Delivery
- Debate re: when to start Rx -- let SBP get too high and you have CVA hemorrhage. But 2 randomized trials of rx for mild to mod htn showed no effect on perinatal mortality, prematurity, abruptio placentae, small for gest age. ? decr resp distress syndrome. MAP drop by 10 = wt drop by 176 g in post-hoc meta-analysis. So . . . UpToDate says to rx if >150/100 or sx. Goal is 130 to 150 over 80-100.
- Acutely, labetolol IV. Onset 5-10 min, lasts 3-6 hrs. Options: hydralazine, diazoxide
- Chronic: methyldopa or labetolol. CCB ok. All drugs cross placenta; no RCTs. BB small for gest age 1.3. HCTZ probably ok as long as no severe volume depletion. Goal for gest htn or chronic htn is 140-150 over 90-100
- Contraindiated: Nitroprusside (cyanide posioning last trimester); ACE-I
- Postpartum breastfeeding: propranolol, labetolol (not as concentrated in breast milk); then long acting nifedipine or verapamil