Pregnancy – Late Complications

Hypertension

  • DDx
    • Gest HTN
      • >140/90
      • > 20 w
    • PreE
      • >140/90
      • > 20 w
      • > 1+ prot on dip
      • Severe features w/o proteinuria
        • HA, CNS, RUQ pain, pulm edema, thrombocytopenia
    • Eclampsia
      • PreE + Neurologic symptoms
    • Chronic HTN in preg – HTN prior to pregnancy
    • PreE/E on chronic HTN
      • Increase in BP > 30 mm Hg systolic or 15 mm Hg diastolic
      • > 20 w
      • Proteinuria
    • HELLP
      • Liver enzymes > 70
      • Platelets < 100K
      • Complications include ARF, retinal detachmet, subcapsular hematoma, pulm edema
  • If < 20 wks very unlike to be PreE
  • ROS – HA, vision changes, RUQ/Epigastric pain, M/S changes
  • W/U – CBC, Chem, LFTs, UA, Mg level if considering tx

 

Management

  • Hypertension of pregnancy
    • Antihypertensives don’t necessarily reduce risk of progressing to PreE
    • But they do decrease progression to worsening HTN
  • PreE or severe HTN
    • Labetalol 10-20 mg IV q 10 min, hydralazine 5-10 mg IV q/ 10 min, nifedipine 10-20 mg PO q 20 min
    • Nifedipine or clevidipine gtt also consider for critically ill pt
  • Mg – for severe features or severe range pressure – 4-6 mg load then 2 g/hr
    • Reduces progression to Eclampsia by 50%
  • Eclampsia – If magnesium not terminating seizure, consider other causes for sz beyond eclampsia
  • Magnesium toxicity – LOTS of Calcium – i.e. 20 amps

 

Post-Partum HA

  • DDx
    • Post dural HA
    • PreE
    • Meningitis
    • Sheehan’s syndrome
    • Dural sinus thrombosis
    • Other serious causes – up to 10%

T2-3 Bleeding

  • DDx
    • Abruption
      • Painful vaginal bleeding
      • Bleeding can be concealed
      • Uterine tenderness
      • Non-reassuring FHR pattern – (most important)
      • RF’s include cocaine abuse
      • Labs – Fibrinogen, KB
      • US only 25-60% sensitive
    • Placenta/Vasa Previa
      • Generally painless
      • Prior C/S is a major RF
    • Uterine rupture
    • Delivery
  • Don’t digitally examine the cervix
  • TVUS is Safe

 

Peripartum Dyspnea

  • DDx
    • Peripartum cardiomyopathy
    • PE
    • Amniotic fluid embolus – up to 15 d out
      • Hypotension, hypoxemia, DIC, coma/seizures
      • Usual supportive care
      • Could consider ECMO earlier
    • PreE
    • Post partum volume overload
    • PNA
    • MI