You stroll into work, coffee in hand, and you’re feeling great today. Your first patient is being escorted to her room. She’s young, maybe in her early 30s, walking without difficulty, chatting with the person showing her the room. You think to yourself, why is she here? You sign into the computer and you see the chief complaint: elevated blood pressure. But she’s so young you say to yourself. You wait for the nurse to load the blood pressure in the computer and take a sip of your coffee. It loads: 162/98. You ask if the patient has any other symptoms. The nurse says no and lets you know that the patient has no past medical history. You smile to yourself thinking easy discharge! You take another sip of coffee (well deserved).
Now, let’s really throw a wrench in this. She’s pregnant (you should gasp here!). Let’s say she’s over 20 wga! You now want to grab that nurse, repeat that blood pressure in 15 minutes, run that urine and start getting your labetolol IV drawn up. Because you want to:
Or at least treat that BP!
What’s going on? If that urine comes back with significant proteinuria, you have yourself a case of preeclampsia. Preeclampsia is a nasty bugger of a disease that needs to be immediately recognized and treated.
Preeclampsia is the onset of the below after 20wga and can occur up to 6-8 weeks postpartum, and comes in a few different flavors:
- Preeclampsia defined as:
- BP >140/90 on two occasions at least four hours apart with proteinuria
- Preeclampsia with severe features defined as either
- BP> 160/110 with proteinuria OR
- BP> 140/90 with new onset of
- cerebral or visual disturbances (scotomata, severe headache, AMS)
- severe persistent RUQ, epigastric pain, elevated LFTS >2x upper limit normal
- progressive renal insufficiency (cr>1.1 or doubling from baseline)
- pulmonary edema
- <100,000 platelets/microL
So you think to yourself, what do I do? 162/98 is not that high! DUN DUN DUN think again! If she hasn’t had a documented blood pressure above 160/110, repeat that blood pressure in 15 minutes, and if it’s still elevated you TREAT it. (If she has had a documented blood pressure at that level before, treat without a repeat measurement.)
So what will work to treat it? First line options are Labetolol IV or Hydralazine IV, or if you’re really in a bind with no access, nifedipine PO. I’ll help you out even further because I’m nice like that, the first doses are 20mg Labetolol, 10 mg Hydralazine or 10mg Nifedipine. Once you get that far, there’s an algorithm to go down and specifics of when to repeat the blood pressure and retreat if it’s still above 160 systolic or 110 diastolic. Here’s the tables: (Data from: American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol 2015; 125:521)
Rush Protocol
- If SBP>160 or DBP>110, then need to treat with antihypertensives within 30 minutes. Anti-hypertensives are given until BP is below this range
- Labetalol is preferred first-line as faster onset of action and patients will often then be transitioned to PO labetalol. If co-associated bradycardia, then hydralazine would likely be better first-line choice
- If difficult IV access, then give Nifedipine IR (Procardia) 10 mg PO, and re-check in 20 minutes (should give enough time to get IV)
- Protocol
- Labetalol 20 mg IV over 2 minutes. Recheck BP in 10 minutes
- Labetalol 40 mg IV over 2 minutes. Recheck BP in 10 minutes
- Labetalol 80 mg IV over 2 minutes. Recheck BP in 10 minutes
- Labetalol 80 mg IV over 2 minutes. Recheck BP in 10 minutes
- Hydralazine 5 mg IV over 2 minutes. Recheck BP in 20 minutes (slower onset of action than labetalol)
- Hydralazine 10 mg IV over 2 minutes. Recheck BP in 20 minutes
Now don’t forget to continue further work up after getting that BP down. Send off the CBC, CMP (basic labs save the day, and you want to rule out HELLP) and of course add on urine protein and creatinine to help diagnose preeclampsia. I know you’re not an OB but preeclampsia is not without gnarly complications, including but not limited to: Eclampsia, DIC, hemorrhage, renal failure, HELLP, cardiac arrest all in mom- but don’t forget, the whole reason we are even talking about this- that 20+ week old fetus. In a preeclamptic mother, fetal complications include acidosis and FHR decelerations.
Now, after you treat, run the labs, and call OB/GYN for their wisdom, you really deserve a sip of that coffee because you just saved TWO lives! Way to go you! Treat Yo Self!