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Case History- Hypertension : Management

After 24 hours of observation, her blood pressure is 150-160/100-110, with 3+ proteinuria. She has developed epigastric pain. You should:

Click on your choice:
 A. reassure the patient that bedrest will resolve the problem

 B. obtain clotting studies to evaluate for HELLP Syndrome (hemolysis, elevated liver enzymes, low platelets), and plan on expedited delivery

 C. begin Aldomet 250 mg qid and mylanta for heartburn

 D. perform a cesarean section

Delivery is the only definitive treatment for PIH. Therefore, delivery is generally recommended for women at term with PIH of any severity, and in preterm women with severe disease. In women with severe PIH at gestational ages <32 weeks observation, magnesium sulfate therapy, and treatment with antihypertensives (labetelol or apresoline) may improve their condition sufficiently to allow the pregnancy to continue days to weeks longer. Corticosteroids to induce fetal lung maturation and reduce the incidence of intraventricular hemorrhage is appropriate at gestational ages less than 34 weeks. Patients who develop PIH prior to 34 weeks may have antiphospholipid antibodies. These antibodies portend an increased risk of adverse pregnancy outcomes and an increased risk of recurrent severe PIH in future pregnancies.

Clinical approaches to reduce the incidence of PIH have included low dose aspirin (60-80mg) and in a number of studies in women at high risk for preeclampsia a reduction in the incidence of preeclampsia. However, in nulliparous women not necessarily at high risk for the development of PIH an increased incidence of placental abruption was seen. Therefore, administration of low dose aspirin (60-80mg) may be appropriate for women at high risk for the development of PIH, but it is not recommended for PIH prophylaxis in a nonselected, normotensive multiparous or nulliparous patients. Calcium may also reduce the incidence of preeclampsia.

Magnesium sulfate is used to improve cerebral blood flow and oxygen consumption in women with PIH, thereby reducing the seizure threshold. It also is believed to dilate human umbilical vessels and increase fetoplacental blood flow. It is administered by intravenous loading dose of 4 grams over 20 minutes followed by a 1-3 gram/hour infusion via a controlled infusion device. The infusion should be stopped if the patient looses deep tendon reflexes, has a respiratory rate less than 12/min, or a decrease in urinary output to <25 ml/hr. The therapeutic range for magnesium sulfate is 4-8 mg/dl. Magnesium sulfate effects can be reversed by intravenous calcium gluconate (1 gm = 10ml of a 10% solution) over 2 minutes. Magnesium sulfate does not appear to have antihypertensive effects.