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Severe PIH Management
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Severe PIH Management
, Preeclampsia Management of Severe Cases, Severe Preeclampsia
See Also
Hypertensive Disorders of Pregnancy
Delivery Indications in PIH
Gestational Hypertension
Management
Mild PIH Management
PIH Blood Pressure Management
PIH Seizure Prophylaxis
HELLP Syndrome
Criteria
One of the following must be present (
Hypertension
,
Proteinuria
or Other Criteria)
Blood Pressure
>160/110 on 2
Blood Pressure
readings 6 hours apart
Start antihypertensives if systolic
Blood Pressure
>160 or diastolic
Blood Pressure
>110 for >15 minutes
See
Severe Hypertension Management in Pregnancy
Assumes normal
Blood Pressure
before pregnancy (and before 20 weeks gestation)
See
Chronic Hypertension in Pregnancy
Proteinuria
Urine Protein 24 Hour
: >5 grams
Urine Protein
(dipstick): 3+
Protein
on 2 samples >4 hours apart
Other criteria: One finding from the list below
Visual disturbance or other neurologic changes
Right Upper Quadrant Abdominal Pain
or
Epigastric Pain
Fetal Growth Restriction
Oliguria
<500 ml in 24 hours (
Serum Creatinine
>0.9 suggests reduced GFR)
Pulmonary Edema
Thrombocytopenia
References
(2002) Obstet Gynecol 99:159-67 [PubMed]
Exam
Maternal Assessment
Schedule
Initial: Every 15-60 minutes until stable
Later: Hourly while on
Magnesium Sulfate
Focus areas
Vital Sign
s
Neurologic Exam
including
Deep Tendon Reflex
es
Symptoms
Headache
Visual changes
Epgastric pain
Signs
Urine Output
<500 ml/24h
Proteinuria
may be severe (although not required for diagnosis)
Urine Protein
>5g/24 hours or
Urinalysis
3 to 4+
Proteinuria
Labs
Initial
Complete Blood Count
with
Platelet
s
Blood Urea Nitrogen
(BUN)
Serum Creatinine
Uric Acid
Liver
transaminases (AST, ALT)
Lactate Dehydrogenase
(LDH)
Start
Urine Protein 24 Hour
collection
Obtain dipstick for
Urine Protein
Repeat lab schedule
Repeat subset of above labs every 4-6 hours based on local protocols
Serum Magnesium
Therapeutic range: 4 to 7 mg/dl
Indications for monitoring while on
Magnesium Sulfate
Elevated
Serum Creatinine
Decreased
Urine Output
Absent
Deep Tendon Reflex
es
High dose or prolonged
Magnesium Sulfate
protocol
Additional lab tests
See
HELLP Syndrome
for additional labs if this is suspected
Diagnostics
Fetal Assessment
Non-Stress Test
on admission
Obstetric Ultrasound
Estimated fetal weight
Biophysical Profile
Amniotic fluid index
Umbilical artery doppler for systolic/diastolic ratio
Management
Gene
ral measures
Hospitalize
Supplemental Oxygen
Strict bedrest
Foley Catheter
Urine Output
maintained at >30 ml/hour
Urine Dipstick
for
Protein
hourly
Careful fluid management
Daily weight
Strict Intake and output
Careful
Intravenous Fluid
s
D5LR 75 cc/hour to keep urine out 30-40 cc/hour
Total fluid volume should not be greater than 125 cc/h (3 Liters per day)
Lung Exam
(assess for
Pulmonary Edema
)
Consider additional fluid restriction
Management
Specific PIH
Related topics
See
HELLP Syndrome
See
Delivery Indications in PIH
See
Eclamptic Seizure
Stabilization (first 24 hours)
See
Gene
ral measures above
Obtain fetal and maternal diagnostics and labs as above for 24 hours
Start
Magnesium Sulfate
and continue for 24 hours
Insititute
Eclamptic Seizure
Precautions
See
Magnesium Sulfate
for dosing and monitoring
Start antihypertensives if systolic
Blood Pressure
>160 or diastolic
Blood Pressure
>110 for >15 minutes
See
Severe Hypertension Management in Pregnancy
Administer
Corticosteroid
s if fetus 24-34 weeks (time 12-24 hours before delivery)
Preparation for anticipated preterm delivery
Betamethasone
12 mg IM every 24 hours for 2 doses or
Dexamethasone
6 mg IM every 12 hours for 4 doses
Triage
See
Preeclampsia Delivery Indications
Includes emergent delivery indications and delayed delivery indications after 48 hours
Include cesarean delivery indications
Observation protocol
Magnesium Sulfate
may be stopped in most cases
Antihypertensive medications and
Corticosteroid
s as above if indicated
Daily monitoring of maternal and fetal well being
References
Fontaine (2000) in ALSO, B:1-36
Marlow (2021) Crit Dec Emerg Med 35(2): 19-23
Sibai in Gabbe (2002) Obstetrics, p. 945-74
(2000) Am J Obstet Gynecol 183(1):S1-22 [PubMed]
Leeman (2008) Am Fam Physician 78:93-100 [PubMed]
Leeman (2016) Am Fam Physician 93(2):121-7 [PubMed]
Zamorski (2001) Clin Fam Pract 3:329-47 [PubMed]
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