• Take BP in the same manner each visit
• Use a seated or upright position (I would also say take it after she’s been sitting 1-2 minutes to avoid white coat syndrome)
• Proper size cuff: The cuff should be at least 1.5 times the circumference of the woman's upper arm AND the cuff bladder should cover 80%of the arm circumference.
• Use Korotkoff phase 5 sounds disappearance - listen for the systolic pulse then the diastolic

• 6-17% frequency in healthy nulliparous patients
• 2-4% frequency in healthy multiparas

• Increased rates of induction
• Increased rates of C/S (failed induction and dystocia)

• Increased maternal and fetal/neonatal morbidity and mortality including:
• Abruption
• Preterm birth
• Small for gestational age

Uterine Vascular Changes

Vascular Endothelial Damage/Inflammation

Genetics/Gene Imprinting

Changes in Prostanoids; Lipid Peroxide/Free Radicals/Antioxidants

(Way more info on our objectives)

Nulliparity

Preeclampsia in a previous pregnancy

Age >40 years or <18 years

Family history of preeclampsia

Chronic hypertension

Chronic renal disease

Antiphospholipid antibody syndrome or inherited thrombophilia

Vascular or connective tissue disease

Diabetes mellitus (pregestational and gestational)

Multifetal gestation

High body mass index

Black race

Male partner whose mother or previous partner had preeclampsia (so weird!!!)

Hydrops fetalis

Unexplained fetal growth restriction

Woman herself was small for gestational age

Fetal growth restriction, abruptio placentae, or fetal demise in a previous pregnancy

Prolonged interpregnancy interval

Partner related factors (new partner, limted sperm exposure [eg, previous use of barrier contraception])

Hydatidiform mole

Susceptibility genes

CRITERIA FOR DIAGNOSING SEVERE PRE-ECLAMPSIA

• Blood Pressure:
• Systolic pressure >= 160 mm Hg
• Diastolic pressure >= 110 mm Hg
• on 2 occasions at least 6h apart while on bed rest
• Central Nervous System:
• Headache (that doesn’t go away with Tylenol), visual disturbances
• Lungs:
• Pulmonary Edema
• Cyanosis
• Liver:
• Epigastric pain or right upper quadrant pain
• Elevated liver enzymes
• Kidney:
• >=5 g/24 h protein
• >=3+ on urine dip on 2 urines at least 4h apart
• Oliguria (<500 ml/24 h)
• Blood:
• Platelets <100,000/mm3
• Fetus: fetal growth restriction

• Hemolysis: microangiopathic hemolysis with an abnormal smear (schistocytes, burr cells, echinocytes)
• LDH increased >2x upper limits of normal, indirect billi
• Significant drop in hemoglobin
• Elevated Liver Enzymes:
• Transaminase >2x upper limits of normal
• Low Platelets (<100,000)

-Contraction stress test to see how baby will tolerate labor (if modified BPP is non-reassuring)
-Magnesium sulfate if severe, if mild it is provider choice (doesn’t have evidence to support it)

Severe preeclampsia is a reason for delivery, regardless of gestational age, due to the sudden nature of complications.

<34 weeks may consult with maternal-fetal med specialist

Likely 37 weeks.

(From obj: This trial showed that preeclamptic women benefited from early intervention, without incurring an increased risk of operative delivery or neonatal morbidity. This trial showed that preeclamptic women benefited from early intervention, without incurring an increased risk of operative delivery or neonatal morbidity.)

Outpatient care is a cost-effective option for women with stable mild preeclampsia. Patients offered outpatient monitoring should be able to comply with frequent maternal and fetal evaluations (every one to three days) and should have ready access to medical care.

Restricted activity is typically recommended since blood pressure is lower in rested patients; however, there is no evidence that bedrest improves pregnancy outcome

At minimum:

platelet count

serum creatinine

serum AST

These tests should be repeated once or twice weekly in women with mild preeclampsia to assess for disease progression, and more often if clinical signs and symptoms suggest worsening disease

• Daily fetal movement counts
• Twice weekly fetal nonstress testing with assessment of amniotic fluid volume, or twice weekly biophysical profiles.
• Sonographic estimation of fetal weight be performed to look for growth restriction and oligohydramnios at the time of diagnosis of preeclampsia and then repeated every three weeks if the initial examination is normal
• Umbilical artery doppler velocimetry results was associated with a 29 percent reduction in perinatal death (so may also be useful)

Testing is repeated immediately if there is an abrupt change in maternal condition.

Normal pregnancy WBC

Labs in Pre-e/HELLP?

6-16

Same with pre-e and HELLP

Normal Hgb in pregnancy?

Labs with pre-e/HELLP

10-13

May be<10(hemolysis)
or >13 (hemoconcentration)

Normal platelets in pregnancy?

W/pre-e or HELLP

140-400

<100 = SEVERE Pre-eclampsia

AST

pre-e/hellp

5-40

>40 = SEVERE

Pregnancy ALT

pre-e/hellp

7-56

>56 = SEVERE

ALK PHOS Pregnancy range

possible elevation x 2-4

not changed by pre-e or hellp

TOTAL BILI normal pregnancy range

pre-e/hellp

0.2-1.3

>1.3

CREATININE normal pregnancy

pre-e/HELLP

<0.9

>= 0.9

PROTEINURIA normal pregnancy range

pre-e/HELLP range

<300mg/day

>300mg (>=5G/day is severe)

• edema (facial) and pitting edema of the lower extremities
• sudden weight gain
• nausea and vomiting past the first trimester
• decrease in urine output or change in color (cola colored is a bad sign)
• URQ abdominal pain
• shoulder pain (as though someone is pinching you along your neck or bra strap) or it is painful to lie on right side
• headaches that don’t go away
• vision changes-blurry, flashing lights, aura, light sensitivity or spots
• mental confusion, racing pulse, shortness of breath, sense of impending doom

increased risk of maternal mortality (0.2%)

increased rates of maternal morbidities (5%) including:

convulsions

pulmonary edema

acute renal or liver failure

liver hemorrhage

disseminated intravascular coagulopathy

stroke.

These complications are usually seen in women who develop preeclampsia before 32 weeks’ gestation and in those with preexisting medical conditions.

• State of hypercoagulability
• increased venous stasis
• decreased venous outflow
• compression of the inferior vena cava and pelvic veins by the enlarging uterus and decreased mobility

pregnancy-related maternal thrombosis

late fetal death

early severe preeclampsia

fetal growth restriction

recurrent pregnancy loss

• Occurrence of one or more otherwise unexplained thrombotic or thromboembolic events.
• One or more specific adverse outcomes related to pregnancy.
• Otherwise unexplained thrombocytopenia or prolongation of a test of blood coagulation (eg, activated partial thromboplastin time, aPTT).

Initial diagnostic test is compression ultrasonography of the proximal veins. When results are negative and iliac vein thrombosis is not suspected, routine surveillance may be a reasonable option.

When results are negative or equivocal and iliac vein thrombosis is suspected, additional confirmatory imaging with magnetic resonance imaging is recommended.

Alternatively, depending on the clinical circumstances, empiric anticoagulation may be a reasonable option

Both ventilation–perfusion scanning and computed tomographic (CT) angiography are associated with relatively low radiation exposure for the fetus.

The concerns about maternal breast radiation exposure with CT angiography must be weighed against the potential consequences of withholding appropriate imaging and failing to make a proper diagnosis.

Management of newly diagnosed venous thromboembolism requires therapeutic anticoagulation with either unfractionated heparin or LMWH. Hospitalization for the initiation of anticoagulation therapy may be indicated.

Intravenous unfractionated heparin can be considered in the initial treatment of PE and in situations in which delivery, surgery, or thrombolysis (indicated for life-threatening or limb-threatening thromboembolism) may be necessary.

When patients appear to be hemodynamically stable, therapeutic LMWH can be substituted in anticipation of discharge from the hospital.