Severe PIH Management

Aka: Severe PIH Management, Preeclampsia With Severe Features, Preeclampsia Management of Severe Cases, Severe Preeclampsia, Gestational Hypertension with Severe Features

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II. Criteria: One of the following must be present (Hypertension, Proteinuria or Other Criteria)

  1. Blood Pressure >160/110 on 2 Blood Pressure readings 4 hours apart
    1. Start Antihypertensives if systolic Blood Pressure >160 or diastolic Blood Pressure >110 for >15 minutes
      1. See Severe Hypertension Management in Pregnancy
    2. Refers to onset of Hypertension in Pregnancy
      1. Preeclampsia
      2. Gestational Hypertension
    3. Assumes normal Blood Pressure before pregnancy (and before 20 weeks gestation)
      1. See Chronic Hypertension in Pregnancy
  2. Proteinuria
    1. Urine Protein 24 Hour: >5 grams
    2. Urine Protein (dipstick): 3+ Protein on 2 samples >4 hours apart
  3. Other criteria: One finding from the list below (end organ injury)
    1. Urine Output decreased (Oliguria)
      1. Urine Output less than 500 ml in 24 hours
    2. Increased Serum Creatinine >1.1 (or more than twice baseline)
    3. Thrombocytopenia (Platelet Count <100k)
    4. Right upper quadrant or Epigastric Pain (seen in HELLP Syndrome)
    5. Pulmonary Edema
    6. Increased hepatic transaminases (>2 fold over baseline)
    7. New Headache or Vision change
    8. Altered Mental Status
    9. Fetal Growth Restriction (included in prior criteria)
  4. References
    1. (2002) Obstet Gynecol 99:159-67 [PubMed]

III. Symptoms

  1. Headache
  2. Visual changes
  3. Epgastric pain

IV. Signs

  1. Urine Output <500 ml/24h
  2. Proteinuria may be severe (although not required for diagnosis)
    1. Urine Protein >5g/24 hours or
    2. Urinalysis 3 to 4+ Proteinuria

V. Labs

  1. Initial
    1. Complete Blood Count with Platelets
    2. Blood Urea Nitrogen (BUN)
    3. Serum Creatinine
    4. Liver transaminases (AST, ALT)
    5. Lactate Dehydrogenase (LDH)
    6. Urine Protein to Creatinine Ratio (consider Urine Protein 24 Hour collection)
  2. Repeat lab schedule
    1. Repeat subset of above labs every 4-6 hours based on local protocols
  3. Serum Magnesium
    1. Therapeutic range: 4 to 7 mg/dl
    2. Indications for monitoring while on Magnesium Sulfate
      1. Elevated Serum Creatinine
      2. Decreased Urine Output
      3. Absent Deep Tendon Reflexes
      4. High dose or prolonged Magnesium Sulfate protocol
  4. Additional lab tests
    1. See HELLP Syndrome for additional labs if this is suspected

VI. Evaluation: Maternal Assessment

  1. Schedule
    1. Initial: Every 15-60 minutes until stable
    2. Later: Hourly while on Magnesium Sulfate
  2. Focus areas
    1. Vital Signs
    2. Neurologic Exam including Deep Tendon Reflexes

VII. Evaluation: Fetal Assessment

  1. Non-Stress Test (on admission and repeated daily)
  2. Obstetric Ultrasound (on admission and every 3-4 weeks until delivery)
    1. Estimated fetal weight
    2. Biophysical Profile
    3. Amniotic fluid index
    4. Umbilical artery doppler for systolic/diastolic ratio

VIII. Management: General measures

  1. Hospitalize
  2. Supplemental Oxygen as needed
  3. Strict bedrest
  4. Foley Catheter
    1. Urine Output maintained at >30 ml/hour
    2. Urine Dipstick for Protein hourly
  5. Careful fluid management
    1. Daily weight
    2. Strict Intake and output
    3. Careful Intravenous Fluids
      1. D5LR 75 cc/hour to keep urine out 30-40 cc/hour
      2. Total fluid volume should not be greater than 125 cc/h (3 Liters per day)
    4. Lung Exam (assess for Pulmonary Edema)
    5. Consider additional fluid restriction

IX. Management: Specific PIH

  1. Related topics
    1. See HELLP Syndrome
    2. See Delivery Indications in PIH
    3. See Eclamptic Seizure
  2. Stabilization (first 24 hours)
    1. See General measures above
    2. Obtain fetal and maternal diagnostics and labs as above for 24 hours
    3. Start Magnesium Sulfate and continue for 24 hours
      1. Insititute Eclamptic Seizure Precautions
      2. See Magnesium Sulfate for dosing and monitoring (e.g. reflexes, apnea)
    4. Start Antihypertensives if systolic Blood Pressure >160 or diastolic Blood Pressure >110 for >15 minutes
      1. See Severe Hypertension Management in Pregnancy
    5. Administer Corticosteroids if fetus 24-34 weeks (time 12-24 hours before delivery)
      1. Preparation for anticipated preterm delivery
      2. Betamethasone 12 mg IM every 24 hours for 2 doses or
      3. Dexamethasone 6 mg IM every 12 hours for 4 doses
  3. Delivery versus Observation
    1. See Preeclampsia Delivery Indications
      1. Delivery at >34 weeks (earlier if unstable, decompensation)
      2. Includes emergent delivery indications and delayed delivery indications after 48 hours
      3. Include cesarean delivery indications
    2. Observation protocol
      1. Magnesium Sulfate may be stopped in most cases
      2. Antihypertensive medications and Corticosteroids as above if indicated
      3. Daily monitoring of maternal and fetal well being

X. Management: Postpartum

  1. Continue Magnesium Sulfate for the first 24 hours
  2. Hypertension
    1. Worsening with mobilization of third spaced fluids (peaks at 3 to 6 days)
    2. Titrate home Blood Pressure medications to target <150/100 mmHg
    3. Most Antihypertensives are safe in Lactation
      1. See Blood Pressure Management in Pregnancy for continuation doses of Antihypertensives
      2. Thiazide Diuretics may reduce available Breast Milk
  3. Follow-up
    1. Home Blood Pressure Monitoring
    2. Outpatient recheck within 7 to 10 days

XI. References

  1. Fontaine (2000) in ALSO, B:1-36
  2. Marlow (2021) Crit Dec Emerg Med 35(2): 19-23
  3. Sibai in Gabbe (2002) Obstetrics, p. 945-74
  4. (2000) Am J Obstet Gynecol 183(1):S1-22 [PubMed]
  5. Farahi (2024) Am Fam Physician 109(3): 251-60 [PubMed]
  6. Leeman (2008) Am Fam Physician 78:93-100 [PubMed]
  7. Leeman (2016) Am Fam Physician 93(2):121-7 [PubMed]
  8. Zamorski (2001) Clin Fam Pract 3:329-47 [PubMed]

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