Gestational Hypertension (PIH), Preeclampsia (Toxemia) and Eclampsia

by Veronica Gillispie, MD, FACOG

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    00:02 Now let's discuss hypertension disorders of pregnancy.

    00:07 There are three disorders that we need to discuss.

    00:09 And we'll start with gestational hypertension.

    00:12 So gestational hypertension or blood pressures greater than 140 over 90.

    00:18 Two blood pressure readings 6 hours apart, diagnosed after 20 weeks of gestation without proteinuria.

    00:25 If those blood pressures exist before 20 weeks, that's considered chronic hypertension.

    00:30 Moving on from gestational hypertension is preeclampsia.

    00:35 Preeclampsia is hypertension with the same blood pressures that we just discussed with proteinuria.

    00:41 So that means protein in the urine.

    00:43 Let's look at preeclampsia in a little more detail.

    00:47 So the blood pressures again greater than 140 over 90, but less than 160 over 110.

    00:52 A protein/creatinine ratio of 0.3.

    00:58 A 24 hour urine protein of greater than 300 milligrams.

    01:02 And absence of severe features.

    01:04 All of these features constitute preeclampsia with mild features.

    01:10 Now preeclampsia can also be diagnosed with severe features.

    01:14 So those are blood pressures greater than 160 over 110.

    01:17 New onsets cerebral or visual disturbances.

    01:21 This often manifest as a unrelenting headache or a headache not relieved by tylenol.

    01:27 Patients will often have visual disturbances such as floaters, spots before their eyes.

    01:32 Any of those would give us the diagnosis of preeclampsia with severe features.

    01:39 Patients may also experience pulmonary edema.

    01:43 Also as part of preeclampsia with severe features is something called HELLP syndrome.

    01:48 Again this is another manifestation of preeclampsia with severe features.

    01:51 So you can have preeclampsia with severe features and not have HELLP syndrome.

    01:56 We're going to talk about help syndrome in a little bit more detail.

    01:59 Also, if the patient has renal insufficiency that gives them diagnosis of pre-eclampsia with severe features.

    02:06 A renal insufficiency is defined by a serum creatinine concentration greater than 1.1 mg/dl, or a doubling of the serum creatinine concentration in the absence of other renal disease.

    02:18 So HELLP syndrome.

    02:19 That stands for Hemolysis Elevated Liver Enzymes and Low Platelets.

    02:25 Hemolysis is diagnosed by an elevated LDH.

    02:29 Elevated liver enzymes means an elevated AST and ALT.

    02:34 And low platelets or platelets less than a 100,000.

    02:38 Now back to our hypertensive disorders of pregnancy.

    02:42 The third and the most concerning is eclampsia.

    02:45 This is hypertension with proteinuria and also seizures.

    02:50 So let's go through a case.

    02:53 Maria is a 37 year old Gravida 1 Para 0 female at 38 weeks gestation that presents to triage with complaint of severe headache.

    03:03 She has no history of migraines or hypertension.

    03:06 On physical exam, her blood pressure is 180 over 110.

    03:10 Her protein/creatinine ratio is 6.

    03:14 What is the next best step in her management? Would you say, A. Immediately move to delivery via C-Section.

    03:21 B. Immediately move to delivery via induction of labor.

    03:25 C. Start a Labetalol IV infusion.

    03:28 or D. Start Magnesium Sulphate infusion.

    03:31 Let's go through the next slides to find that answer.

    03:34 So, when we're talking about hypertensive disorders and how we treat them, let's start with gestational hypertension again.

    03:42 So gestational hypertension is management expectantly.

    03:45 Meaning we don't start any anti-hypertenses.

    03:47 And we deliver at 37 weeks.

    03:50 So let's talk about the treatment for preeclampsia.

    03:54 If it's preeclampsia with mild features, patients should be watched closely and we would expect to deliver it at 37 weeks.

    04:01 But again let's go over what mild preeclampsia is, that's blood pressure greater than 140 over 90 but less than 160 over 110.

    04:10 A protein/creatinine ratio or PC ratio of 0.3.

    04:14 And a 24 hour urine protein of greater than 300 milligrams but less than 5 grams.

    04:21 Now preeclampsia with severe features, we're getting a little worse.

    04:26 So this we now need to give magnesium sulphate.

    04:29 Because we want to make sure these patients don't cease.

    04:31 And they have an increase risk for that.

    04:33 We also want to give anti-hypertensive medications.

    04:36 Especially if our blood pressures starts to get greater than 160 over 110 which is part of diagnosis of preeclampsia with severe features.

    04:44 We do want to control those blood pressures.

    04:46 Now, if the patient is over 34 weeks of gestation, when she is diagnosed with preeclampsia with severe features, we would recommend delivery.

    04:54 As this is the treatment for preeclampsia.

    04:56 So let's go through some of those treatments that we use the medications.

    05:01 So first, magnesium sulphate.

    05:03 We give this for seizure prophylaxis.

    05:06 Not for anti-hypertension and not to lower the blood pressure.

    05:09 Only to prevent seizures.

    05:11 The recommended does is 4 or 6 gram load with 2 grams per hour.

    05:17 And we're not exactly sure how it works to stop seizures but we do know that it is a calcium channel blocker.

    05:24 And this is the proposed method of how it works to actually stop seizures.

    05:28 Now for our medications, alpha methyldopa, labetalol, nifedipine and hydralazine.

    05:34 One has not been proven to be better than another.

    05:37 And so it really is a matter of physician's choice, clinical acumen as to which medication you start with.

    05:44 But you can see here they vary in doses and they vary in the amount that we give.

    05:50 All of them can be used for chronic hypertension.

    05:53 But only labetalol, nifedipine, and hydralazine are used in acute management.

    05:58 Moving on to eclampsia.

    06:02 Now the main thing that we have to do for treatment of eclampsia is to stop the seizures before we do anything, we want to stabilize our patient and stop the seizures.

    06:12 Though delivery is "cure", again we want to start that magnesium sulphate so that we can stop those seizures.

    06:18 So let's go back to our patient Maria.

    06:21 To recap Maria is a 37 year old Gravida 1 Para 0 female at 38 weeks gestation that presents triage with complaint of severe headache.

    06:31 She has no history of migraines or hypertension.

    06:34 On physical exam, her blood pressure is 180 over 110.

    06:38 And her protein/creatinine ratio is 6.

    06:41 What is the next best step in her management? What do you think? The answer is D.

    06:48 We want to start magnesium sulphate.

    06:50 Remember the first thing we want to stabilize our patient and prevent seizures.

    06:54 And that's going to be magnesium sulphate.

    06:56 But let's talk about the other options.

    06:58 So we immediately move to delivery via C-Section or induction of labor.

    07:02 Well the route of delivery, even though delivery is the cure for preeclampsia, the route of delivery depends on the mom.

    07:09 If the mom is remote from delivery then we will say a C-section.

    07:13 However, if the mom stable and she has a favorable cervix meaning, her cervix is thin, dilated.

    07:20 It looks like she is favorable for vaginal delivery.

    07:22 We can proceed with induction of delivery.

    07:25 So while delivery is the treatment for preeclampsia, we don't have to rush to delivery.

    07:30 We always want to remember to stabilize our patient first.

    About the Lecture

    The lecture Gestational Hypertension (PIH), Preeclampsia (Toxemia) and Eclampsia by Veronica Gillispie, MD, FACOG is from the course Antenatal Care. It contains the following chapters:

    • Hypertensive Disorders of Pregnancy
    • Pre-eclampsia
    • Eclampsia
    • Treatment

    Included Quiz Questions

    1. Chronic hypertension
    2. Gestational hypertension
    3. Pre-ecclampsia
    4. Ecclampsia
    5. Can not make a diagnosis of hypertension until you have 3 abnormal blood pressure values each 24 hrs apart
    1. Preeclampsia with severe features
    2. Preeclampsia
    3. Chronic hypertension
    4. Gestational hypertension
    5. Eclampsia
    1. Gestational hypertension
    2. Chronic hypertension
    3. Preeclampsia without severe features
    4. Eclampsia
    5. Preeclampsia with severe features
    1. Preeclampsia with HELLP syndrome, start magnesium sulfate and anti-hypertensives to stabilize the patient.
    2. Preeclampsia with HELLP syndrome, do an immediate cesarean section, then start magnesium sulfate post-partum
    3. Preeclampsia with severe features, start alpha-methyldopa
    4. Ecclampsia, start magnesium sulfate and deliver the baby
    5. Ecclampsia, start magnesium sulfate and labetalol
    1. Elevated creatinine
    2. Elevated lactate dehydrogenase
    3. Elevated aspartate transaminase
    4. Elevated alanine transaminase
    5. Low platelets
    1. Seizures
    2. Proteinuria
    3. Renal insufficiency
    4. Headaches
    5. Blood pressure greater than 160/100
    1. Delivery of the baby
    2. Magnesium sulfate
    3. Anti-hypertensives
    4. Expectant management is sufficient
    5. Anti-epileptics

    Author of lecture Gestational Hypertension (PIH), Preeclampsia (Toxemia) and Eclampsia

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG

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