Management of severe hypertension, Preecalmpsia and Heelp

Management of severe hypertension,
Preecalmpsia and Heelp

Department of Obstetrics and Gynaecology

Severe hypertension is conformed with a diastolic blood pressure = 110 mm Hg (Korotkoff phase 5) or a systolic blood pressure = 170 mm Hg on two occasions and that together with significant proteinurea (at least 1 g/L ~ 2+.
An important variant is HELLP syndrome (haemolysis, elevated liver encymes and low plateled count).

Clinical fetures
Severe headache, visual disturbances, epigastric pain and or vomiting, liver tenderness, sign of clones, platelet below 100 abnormal liver enzymes (ALT or AST) rising above 70 IE/L. If > 150 IE/L it associated with increased morbidity to the mother.
Because of high false positive rate with dipsticks, 24 hour urine collection is recommended to confirm significant proteinuria.

There is an increased capillary permeability (low albumin). Combined with increased vascular resistance with high pulmonary wedge pressure results in increased risk of pulmonary edema.

Steroids are given before 34 weeks for fetal lung maturity (for HELLP se later).

Induction/Cesarean section especially after 32 weeks when patient has stabilized.

If blood pressure is less than 160/110 mmHg, and no other signs appear, immediate delivery is not indicated, but in case of:

Maternal symptoms, e.g. severe headache, epigastric pain
Eclampsia
Rapidly worsening biochemistry/hematology.

Fetal consequensces

Fetal distress: (biophysical profile and CTG)
Severe intrauterine growth retardation
Absent or reverse diastolic flow in umbilical artery
Brain sparring

Monitoring
Full blood count, urea creatinine, electrolytes, liver function test, uric acids, DIC test, urinary output
Half hourly pressure recording and after each dose of hypertensive given
Early use of invasive monitoring if satisfactory response on treatment.

Women who had early severe preeclampsia or preeclampsia associated with fetal growth restriction, stillbirth or abruption, may be tested for thrombophilia.

High dose Glucocorticoid Therapy to improve laboratory abnormalities in patients with HELLP syndrome.

For most patients with HELLP syndrome, 10 mg intravenous dexamethasone every 6 hours for 2 doses followed by 6 mg intravenous dexamethasone every 6 hours for 3 additional doses.

For selected patients at highest risk, include those with profound thrombocytopenia (<20,000 mm3) or with central nervous system dysfunction (ie, blindness, paralysis) 20 mg intravenous dexamethasone every 6 hours for up to 4 doses).