8Forms of HTN in Pregnancy Gestational HypertensionPreeclampsiaChronic HypertensionAs a group these occur in 12 to 22% of pregnant patients and are directly responsible for approximately 18% of maternal mortality nationally.
9Chronic Hypertension Pre-existing hypertension Hypertension before 20 weeks in the absence of gestationIf hypertension persists beyond 6 weeks postpartum
10Preeclampsia Hypertension after 20 weeks of gestation Proteinuria- 300mgEdema
11Preeclampsia Hypertension after 20 weeks of gestation Proteinuria- 300mgEdemaBP > 160 systolic or >110 diastolic5grams of protein in 24 hour urineOliguriaCerebral of visual distrubancesPulmonary edema or cyanosisEpigastric or RUQ painImpaired liver functionThrombocytopeniaIUGR
12Risk Factors FACTOR RISK RATIO Nulliparity 3:1 Age > 40 African American1.5:1Chronic hypertension10:1Renal disease20:1Antiphospholipid syndrome
13Risk Factors FACTOR RISK RATIO Family history of PIH 5:1 Diabetes mellitus2:1Twin gestation4:1
14Prevention Low dose ASA ineffective in patients at low risk Calcium supplementation is ineffective (2.0 g of calcium gluconate per day)No compelling evidence that either are harmfulRecent study done with antioxidant (1,000mg VitC and 400mg VitE).Small study that needs to be confirmed.
45Pulmonary Edema Fluid overload Reduced colloid osmotic pressure Occurs more commonly following delivery as colloid oncotic pressure drops further and fluid is mobilized
46Treatment of Pulmonary Edema Avoid over-hydrationRestrict fluidsLasix mg IVUsually no need for albumin or Hetastarch (Hespan)
47Oliguria 25-30 cc per hour is acceptable If less, small fluid boluses of cc as neededLasix is not necessaryPostpartum diuresis is commonPersistent oliguria almost never requires a PA cath
48Persistent Hypertension BP may remain elevated for several daysDiastolic BP less than 100 do not require treatmentBy definition, preeclampsia resolves by 6 weeks
49Disseminated Intravascular Coagulopathy Rarely occurs without abruptionLow platelets is not DICRequires replacement blood products and delivery
50Anesthesia IssuesContinuous lumbar epidural is preferred if platelets normalNeed adequate pre-hydration of 1000 ccLevel should always be advanced slowly to avoid low BPAvoid spinal with severe disease