Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams

Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide. Hypertension (HTN) complicates 2-8% of pregnancies The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart There is a range of HTN disorders Chronic HTN which could have superimposed preeclampsia (preE) on top Gestational HTN in which there are no lab abnormalities PreE w/o severe features Protein in urine Urine protein >300 mg in 24 hours Urine Protein to Creatinine ratio of .3 +2 Protein on urine dipstick PreE w/ severe features Systolics above 160 mmHg Diastolics above 110 mmHg Headache, especially not going away with meds, or different than previous headaches Visual changes, anything that lasts more than a few minutes RUQ pain, which could present as heartburn Pulmonary edema Low platelets, if Renal insufficiency, creatinine 1.1 or higher or doubling of baseline Impaired liver function Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to Treatment Labetalol, IV Avoid in bradycardia, asthma, or myocardial disease Quick up titrate, with dosing regimens such as 20-20-40 or 20-40-80 (mg) Hydralazine, IV 5 mg starting, then another 5 mg then 10 mg if not working Nifedipine, Oral Can cause a headache Goal is not to normalize BP but bring it down slowly How to give magnesium Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function Follow with 2 g per hour or 1 g per hour Don't give in myasthenia gravis What should you do if the patient progresses to eclampsia (seizures) Magnesium is the best drug Can use phenytoin or benzos IV as an alternate Diazepam is available PR which is a good option if you don't have IV access IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks Facts about post-partum PreE 20% of women will have HTN post-partum Most resolve by 6 weeks If it lingers past 6 months this is chronic HTN If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor Post-partum is the most common time for strokes Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed Enalapril is safe in breast feeding Some patients might need to give up breast feeding to be on even more aggressive HTN therapy Are NSAIDs safe while breastfeeding? Motrin is pretty safe Pulm edema is a risk, be careful with fluids Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea References Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6 Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276 Reed, B. (2020, May 2). 'They didn't listen to me': Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330 Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008 Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653 Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII