Chronic Hypertension Monitoring Q 3-4 week growth scans starting at viability If IUGR found, screen with UA doppler as adjunct to antenatal testing Start antenatal testing if medication needed If HTN controlled, not recommended to deliver before 38 weeks

Chronic Hypertension Treatment Treat if SBP > 160 or DBP >105 Labetalol, nifedipine, and methyldopa are first line Thiazides may be continued but should be stopped if preeclampsia Goal is 120-160 SBP and 80-105 DBP Avoid ACE inhibitor, ARB, mineralocorticoids

Gestational Hypertension Manage like preeclampsia (expectant monitoring and deliver at 37 weeks)

Pre-e without severe features Expectant mangement < 37 weeks May include: Weekly labs Fetal kick counts Twice/week BP monitoring Biweekly NST Weekly AFI Growth scan q 3-4 weeks UA dopplers if IUGR present

Preeclampsia with Severe Features: MANAGEMENT Should be hospitalized Need careful fluid management (monitor urine output, total fluids total fluids restricted to 125-150cc/h including mag) Seizure prevention Lower BP to prevent end organ damage Treat when SBP >160 DBP >110 Target 140-150/90-100 Delivery expedited taking into account fetal maternal well being and gestation age

Magnesium Sulfate for Pre-e or GHTN with severe features 4-6 gm loading dose, then 2 gm/hour mixed in 100 mL of water, 5% dextrose solution, or 0.9% normal saline intravenously over 15 to 20 minutes Monitor reflex, mentation, respiratory status and urinary output Monitor mag levels (4-8 mg/dl is target) if loss of reflexes, concern for kidney function, or other sx MgSO4 prevents eclamptic seizures (NNT = 100) and placental abruption (NNT = 100) in women who have preeclampsia with severe features

Dosing of anti-hypertensives for severe BP Labetalol 20 mg IV if not effective double to 40 mg and then to 80 mg every 10 minutes If still high after 80 mg, switch to hydralazine; max dose is 300 mg/24 hrs Hydralazine 5-10 mg IV over 2 min, if still >160/110 after 20 min  10 mg IV If still high after 20 min, switch to labetalol Nifedipine 10 mg PO , if still high after 30 min give 20 mg, if still high after 30 min give another 20 mg May give 10-20 mg PO every 4-6 hours

Eclampsia Seizures usually last 60-90 seconds Fetal bradycardia usually recovers Mg is drug of choice, give 2 gm if already received 4-6 gm bolus Maintain airway, place on left side, have intubation available Bed seizure precautions Avoid immediate c-section for isolated seizure

Not recommended to give magnesium to women who do not have severe features number needed to treat [NNT] = 400 for asymptomatic women with BP less than 160/110 mm Hg, assuming that 50% of seizures are preventable