Severe PIH Management

1. See Also
   1. Hypertensive Disorders of Pregnancy
   2. Delivery Indications in PIH
   3. Gestational Hypertension Management
   4. Mild PIH Management
   5. PIH Blood Pressure Management
   6. PIH Seizure Prophylaxis
   7. HELLP Syndrome
2. Criteria: One of the following must be present (Hypertension, Proteinuria or Other Criteria)
   1. Blood Pressure >160/110 on 2 Blood Pressure readings 6 hours apart
      1. Assumes normal Blood Pressure before pregnancy (and before 20 weeks gestation)
      2. See Chronic Hypertension in Pregnancy
   2. Proteinuria
      1. Urine Protein 24 Hour: >5 grams
      2. Urine Protein (dipstick): 3+ protein on 2 samples >4 hours apart
   3. Other criteria: One finding from the list below
      1. Visual disturbance or other neurologic changes
      2. Right Upper Quadrant Abdominal Pain or Epigastric Pain
      3. Fetal Growth restriction
      4. Oliguria <500 ml in 24 hours (Serum Creatinine >0.9 suggests reduced GFR)
      5. Pulmonary edema
      6. Thrombocytopenia
   4. References
      1. (2002) Obstet Gynecol 99:159-67
3. Exam: Maternal assessment
   1. Schedule
      1. Initial: Every 15-60 minutes until stable
      2. Later: Hourly while on Magnesium Sulfate
   2. Focus areas
      1. Vital signs
      2. Neurologic Exam including Deep Tendon Reflexes
4. Labs
   1. Initial
      1. Complete Blood Count with platelets
      2. Blood Urea Nitrogen (BUN)
      3. Serum Creatinine
      4. Uric Acid
      5. Liver transaminases (AST, ALT)
      6. Lactate Dehydrogenase (LDH)
      7. Start Urine Protein 24 Hour collection
      8. Obtain dipstick for Urine Protein
   2. Repeat lab schedule
      1. Repeat subset of above labs every 4-6 hours based on local protocols
   3. Serum Magnesium
      1. Therapeutic range: 4 to 7 mg/dl
      2. Indications for monitoring while on Magnesium Sulfate
         1. Elevated Serum Creatinine
         2. Decreased urine output
         3. Absent Deep Tendon Reflexes
         4. High dose or prolonged Magnesium Sulfate protocol
   4. Additional lab tests
      1. See HELLP Syndrome for additional labs if this is suspected
5. Diagnostics: Fetal Assessment
   1. Non-Stress Test on admission
   2. Obstetric Ultrasound
      1. Estimated fetal weight
      2. Biophysical Profile
      3. Amniotic fluid index
      4. Umbilical artery doppler for systolic/diastolic ratio
6. Management: General measures
   1. Hospitalize
   2. Supplemental Oxygen
   3. Strict bedrest
   4. Foley Catheter
      1. Urine output
      2. Urine Dipstick for protein hourly
   5. Careful fluid management
      1. Daily weight
      2. Strict Intake and output
      3. Careful Intravenous fluids
         1. D5LR 75 cc/hour to keep urine out 30-40 cc/hour
         2. Total fluid volume should not be greater than 125 cc/h (3 Liters per day)
      4. Lung Exam (assess for Pulmonary Edema)
      5. Consider additional fluid restriction
7. Management: Specific
   1. Related topics
      1. See HELLP Syndrome
      2. See Delivery Indications in PIH
      3. See Eclamptic Seizure
   2. Stabilization (first 24 hours)
      1. See General measures above
      2. Obtain fetal and maternal diagnostics and labs as above for 24 hours
      3. Start Magnesium Sulfate and continue for 24 hours
         1. Insititute Eclamptic Seizure Precautions
      4. Start antihypertensives if systolic Blood Pressure >160 or diastolic Blood Pressure >110
         1. See Severe Hypertension Management in Pregnancy
      5. Administer Corticosteroids if fetus 24-34 weeks (time 12-24 hours before delivery)
         1. Preparation for anticipated preterm delivery
         2. Betamethasone 12 mg IM q24 hours x2 doses or
         3. Dexamethasone 6 mg IM q12 hours x4 doses
   3. Triage
      1. Indications for delivery now
         1. Gestational age >33 weeks
         2. Severe growth retardation at any gestational age
         3. Refractory, Severe Hypertension at any gestational age
         4. Maternal or fetal deterioration
      2. Observation protocol
         1. Magnesium Sulfate may be stopped in most cases
         2. Antihypertensive medications and Corticosteroids as above if indicated
         3. Daily monitoring of maternal and fetal well being
8. References
   1. Fontaine (2000) in ALSO, B:1-36
   2. Sibai in Gabbe (2002) Obstetrics, p. 945-74
   3. (2000) Am J Obstet Gynecol 183(1):S1-22
   4. Leeman (2008) Am Fam Physician 78:93-100
   5. Zamorski (2001) Clin Fam Pract 3:329-47