Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5549_Библиотеки_им_академика_М_И_Перельмана.pdf
53
possible. Prompt, coordinated interdisciplinary care can be lifesaving for both the
mother and fetus. Ultimately, management depends on maternal stability and gesta-
tional age; many patients will require emergent cesarean delivery.
Key Points
• A pregnant woman past 20weeks gestation with sudden onset painless vaginal
bleeding has placenta previa until proven otherwise.
• Digital cervical exams are contraindicated until placenta previa has been
excluded.
• Placental abruption may present with or without vaginal bleeding; the amount of
bleeding does not correlate with the severity of the abruption.
• Ultrasound is used to diagnose placenta previa; it cannot reliably exclude placen-
tal abruption.
• Obstetric consultation should be obtained early in the ED course of all patients
with late pregnancy bleeding.
References
1. Amokrane N, Allen ERF, Watereld A, Datta S.Antepartum haemorrhage. Obstet Gynaecol
Reprod Med. 2016;26(2):33–7.
2. Chilaka VN, Konje JC, Clarke S, Taylor DJ.Practice observed: is speculum examination on
admission a necessaryprocedure in the management of all cases of antepartum haemorrhage?
J Obstet Gynaecol. 2000;20:396–8.
3. Horvath S, Goyal V, Traxler S, etal. Contraception. 2022;114:1–5.
4. Silver RM.Abnormal placentation: placenta previa, vasa previa, and placenta accreta. Obstet
Gynecol. 2015;126(3):654–68.
5. Jauniaux E, Alrevic Z, Bhide AG, etal. Placenta Praevia and Placenta Accreta: diagnosis and
management: green-top guideline No. 27a. BJOG. 2019;126(1):e1–e48.
6. Cresswell JA, Ronsmans C, Calvert C, Filippi V. Prevalence of placenta praevia by world
region: a systematic review and meta-analysis. Trop Med Int Health. 2013;18(6):712–24.
7. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-
analysis of observational studies. J Matern Fetal Neonatal Med. 2003;13:175–90.
8. Mustafa SA, Brizot ML, Carvalho MH, Watanabe L, Kahhale S, Zugaib M.Transvaginal ultra-
sonography in predicting placenta previa at delivery: a longitudinal study. Ultrasound Obstet
Gynecol. 2002;20:356–9.
9. Kim SW, Hamm RF, Schwartz N.A resolved Placenta Previa is still associated with postpar-
tum Hemorrhage. Am J Perinatol. 2024;41(S 01):e928–e933.
10. DeBolt CA, Rosenberg HM, Pruzan A, etal. Patients with resolution of low-lying placenta
and placenta previa remain at increased risk of postpartum hemorrhage. Ultrasound Obstet
Gynecol. 2022;60(1):103–8.
11. Anderson-Bagga FM, Sze A.Placenta Previa. [Updated 2023 Jun 12]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih.
gov/books/NBK539818. Accessed Feb 2025.
12. King LJ, Dhanya Mackeen A, Nordberg C, Paglia MJ.Maternal risk factors associated with
persistent placenta previa. Placenta. 2020;99:189–92.
4 Bleeding After 20Weeks
54
13. Dola CP, Garite TJ, Dowling DD, Friend D, Ahdoot D, Asrat T.Placenta previa: does its type
affect pregnancy outcome? Am J Perinatol. 2003;20(7):353–60.
14. Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician.
2007;75(8):1199–206.
15. Abbrescia K, Sheridan B.Complications of second and third trimester pregnancies. Emerg
Med Clin North Am. 2003;21(3):695–710.
16. Leerentveld RA, Gilberts EC, Arnold MJ, Wladimiroff JW.Accuracy and safety of transvagi-
nal sonographic placental localization. Obstet Gynecol. 1990;76:759–62.
17. Smith RS, Lauria MR, Comstock CH, Treadwell MC, Kirk JS, Lee W, Bottoms SF.Transvaginal
ultrasonography for all placentas that appear to be low-lying or over the internal cervical os.
Ultrasound Obstet Gynecol. 1997;9(1):22.
18. Timor-Tritsch IE, Yunis R.Conrming the safety of transvaginal sonography in patients sus-
pected of placenta previa. Obstet Gynecol. 1993;81(5Pt 1):742.
19. Sunna E, Ziadeh S.Transvaginal and transabdominal ultrasound for the diagnosis of placenta
praevia. J Obstet Gynaecol. 1999;19(2):152.
20. Sherman SJ, Carlson DE, Platt LD, Medearis AL.Transvaginal ultrasound: does it help in the
diagnosis of placenta previa? Ultrasound Obstet Gynecol. 1992;2(4):256.
21. Oyelese KO, Holden D, Awadh A, Coates S, Campbell S.Placenta praevia: the case for trans-
vaginal sonography. Contemp Rev Obstet Gynaecol. 1999;11:257–61.
22. Practice Bulletin No. 159: management of preterm labor. Obstet Gynecol. 2016;127:29–38.
23. Bose DA, Assel BG, Hill JB, Chauhan SP.Maintenance tocolytics for preterm symptomatic
placenta previa: a review. Am J Perinatol. 2011;28(1):45–50.
24. Hladky K, Yankowitz J, Hansen WF. Placental abruption. Obstet Gynecol Surv.
2002;57:299–305.
25. Rasmussen S, Irgens LM, Bergsjo P, Dalaker K. The occurrence of placental abruption in
Norway 1967–1991. Acta Obstet Gynecol Scand. 1996;75:222–8.
26. Tikkanen M.Placental abruption: epidemiology, risk factors and consequences. Acta Obstet
Gynecol Scand. 2011;90(2):140–9.
27. Kyrklund-Blomberg NB, Gennser G, Cnattingius S.Placental abruption and perinatal death.
Paediatr Perinat Epidemiol. 2001;15(3):290–7.
28. Gyam-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44:
management of bleeding in the late preterm period. Am J Obstet Gynecol. 2018;218(1):B2–8.
29. Boisramé T, Sananès N, Fritz G, et al. Placental abruption: risk factors, management and
maternal-fetal prognosis. Cohort study over 10 years. Eur J Obstet Gynecol Reprod Biol.
2014;179:100–4.
30. Oyelese Y, Ananth CV.Placental abruption. Obstet Gynecol. 2006;108(4):1005–16.
31. Tikkanen M, Nuutila M, Hiilesmaa V, etal. Clinical presentation and risk factors of placental
abruption. Acta Obstet Gynecol Scand. 2006;85(6):700–5.
32. Yeo L, Ananth CV, Vintzileos AM.Placental abruption. Glob. libr. women’s med., (ISSN:
1756-2228) 2008; https://doi.org/10.3843/GLOWM.
33. Ananth CV, Berkowitz GS, Savitz DA, etal. Placental abruption and adverse perinatal out-
comes. JAMA. 1999;282:1646–51.
34. Brandt JS, Ananth CV.Placental abruption at near-term and term gestations: pathophysiology,
epidemiology, diagnosis, and management. Am J Obstet Gynecol. 2023;228(5S):S1313–29.
35. Fadl SA, Linnau KF, Dighe MK. Placental abruption and hemorrhage-review of imaging
appearance. Emerg Radiol. 2019;26(1):87–97.
36. Glantz C, Purnell L.Clinical utility of sonography in the diagnosis and treatment of placental
abruption. J Ultrasound Med. 2002;21:837–40.
37. Jha P, Melendres G, Bijan B, etal. Trauma in pregnant women: assessing detection of post-
traumatic placental abruption on contrast-enhanced CT versus ultrasound. Abdom Radiol
(NY). 2017;42(4):1062–7.
38. Greco PS, Day LJ, Pearlman MD.Guidance for evaluation and management of blunt abdomi-
nal trauma in pregnancy. Obstet Gynecol. 2019;134(6):1343–57.
M. Van Winkle and D. R. Lane
55
39. Witlin AG, Sibai BM.Perinatal and maternal outcome following abruptio placentae. Hypertens
Pregnancy. 2001;20:195–203.
40. Kayani SI, Walkinshaw SA, Preston C. Pregnancy outcome in severe placental abruption.
BJOG. 2003;110:679–83.
41. Zhang W, Geris S, Al-Emara N, Ramadan G, Sotiriadis A, Akolekar R.Perinatal outcome
of pregnancies with prenatal diagnosis of vasa previa: systematic review and meta-analysis.
Ultrasound Obstet Gynecol. 2021;57:710–9.
42. Oyalese KO, Turner M, Lees C, Campbell S. Vasa previa: an avoidable obstetric tragedy.
Obstet Gynecol Surv. 1999;54:138–4.
43. Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey RG, Odibo AO, Dashe
JS. #37: diagnosis and management of vasa previa. Am J Obstet Gynecol. 2015;213(5):615.
44. Hasegawa J, Nakamura M, Sekizawa A, Matsuoka R, Ichizuka K, Okai T.Prediction of risk for
vasa previa at 9-13 weeks’ gestation. J Obstet Gynaecol Res. 2011;37(10):1346–51.
45. Kruitwagen RF, Nijhuis JG.Ruptured vasa praevia complicated by a sinusoidal fetal heart rate
pattern: a case report. Eur J Obstet Gynecol Reprod Biol. 1991;39:147–50.
46. Odunsi K, Bullough CH, Henzel J, Polanska A.Evaluation of chemical tests for fetal bleeding
from vasa previa. Int J Gynaecol Obstet. 1996;55(3):207.
47. Al-Zirqi I, Stray-Pedersen B, Forsén L, Daltveit AK, Vangen S.Uterine rupture: trends over 40
years. BJOG. 2016;123:780–7.
48. Sugai S, Yamawaki K, Haino K, Yoshihara K, Nishijima K.Incidence of recurrent uterine rup-
ture: a systematic review and meta-analysis. Obstet Gynecol. 2023;142(6):1365–72.
49. McEvoy A, Corbett G, Nolan C, Daly R, Murnane M, Higgins S, Malone F, O'Connell M,
Hehir M, Walsh J.Outcomes of uterine rupture in the setting of the unscarred compared with
the scarred uterus. Obstet Gynecol. 2023;141(4):854–6.
50. Sgayer I, Dabbah S, Farah R, Wolf M, Ashkar N, Lowenstein L, Odeh M.Spontaneous rupture
of the unscarred uterus: a review of the literature. Obstet Gynecol Surv. 2023;78(12):759–65.
51. Ozdemir I, Yucel N, Yucel O.Rupture of the pregnant uterus: a 9-year review. Arch Gynecol
Obstet. 2005;272(3):229.
52. Bujold E, Mehta SH, Bujold C, Gauthier RJ.Interdelivery interval and uterine rupture. Am J
Obstet Gynecol. 2002;187(5):1199–202.
53. Leung AS, Leung EK, Paul RH.Uterine rupture after previous cesarean delivery: maternal and
fetal consequences. Am J Obstet Gynecol. 1993;169(4):945–50.
54. Rodriguez MH, Masaki DI, Phelan JP, Diaz FG. Uterine rupture: are intrauterine pressure
catheters useful in the diagnosis? Am J Obstet Gynecol. 1989;161(3):666–9.
55. Johnson C, Oriol N. The role of epidural anesthesia in trial of labor. Reg Anesth.
1990;15(6):304–8.
56. Al-Zirqi I, Daltveit AK, Vangen S.Infant outcome after complete uterine rupture. Am J Obstet
Gynecol. 2018;219(1):109.e1–109.
57. Melamud K, Wahad SA, Smereka PN, et al. Imaging of antepartum and postpartum hemor-
rhage. Radiographics. 2024;44(4):e230164.
4 Bleeding After 20Weeks
57
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
J. Borhart (ed.), Emergency Department Management of Obstetric
Complications, https://doi.org/10.1007/978-3-032-10261-4_5
5
Hypertensive Disorders ofPregnancy
WhitneySherman, EdwardDescallar, andJoelleBorhart
Introduction
Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and
perinatal morbidity and mortality, and the incidence in increasing. Between 2017
and 2019, the prevalence of HDP increased from 13.3% to 15.9%, affecting approx-
imately one in seven delivery hospitalizations [1]. It is estimated that for every
preeclampsia- related death, 50–100 women experience a “near-miss” event result-
ing in signicant health risk and morbidity [2, 3]. There are also signicant racial
disparities in HDP prevalence, with Black women being disproportionately affected.
The patient’s past medical history is often unremarkable; most cases of preeclamp-
sia occur in women with no risk factors [4]. Many patients in the second half of
pregnancy present to the emergency department (ED) for a variety of reasons, and
emergency clinicians are in a unique position to identify and treat patients with a
hypertensive disorder of pregnancy before serious complications occur.
Classification ofHypertensive Disorders ofPregnancy
The American College of Obstetricians and Gynecologists (ACOG) regularly publishes
updated, evidence-based guidelines for the diagnosis and management of hypertensive
disorders of pregnancy, most recently in 2020 [4]. ACOG divides hypertension in
W. Sherman
Department of Emergency Medicine, Wellspan York Hospital, York, PA, USA
E. Descallar
Department of Emergency Medicine, HCA Florida Orange Park Hospital, Orange Park,
FL, USA
J. Borhart (
*)
Department of Emergency Medicine, MedStar Georgetown University Hospital & MedStar
Washington Hospital Center, Washington, DC, USA
e-mail: joelle.c.borhart@medstar.net
58
Table 5.1
Classication of Hypertensive Disorder of Pregnancy
Hypertensive Disorder of
Pregnancy Diagnostic Criteria
Preeclampsia New onset hypertension (blood pressure >140mmHg
systolic and/or >90mmHg diastolic) after 20weeks AND
proteinuria
Or in the absence of proteinuria:
New onset hypertension after 20weeks AND signs/
symptoms of end organ damage (Box 5.1)
Eclampsia New onset seizures in woman with preeclampsia
Chronic Hypertension Hypertension that predates pregnancy or is diagnosed before
20weeks
Chronic Hypertension with
Superimposed Preeclampsia
Patients with chronic hypertension that develop preeclampsia
Gestational Hypertension New onset hypertension after 20weeks without proteinuria
or signs/symptoms of preeclampsia
Adapted from American College of Obstetricians and Gynecologists, Task Force on Hypertension
in Pregnancy [6]
pregnancy into four categories: (1) preeclampsia/eclampsia, (2) chronic hypertension,
(3) chronic hypertension with superimposed preeclampsia, and (4) gestational hyperten-
sion (Table5.1). Hypertension in pregnancy is dened as either a systolic blood pressure
of 140mmHg or greater and/or a diastolic blood pressure of 90mmHg or greater. Blood
pressure should be elevated on at least two separate occasions more than 4h apart before
the diagnosis of hypertension is made. However, even an isolated elevated blood pres-
sure reading is concerning, especially if the blood pressure is greater than 160mm Hg
systolic and/or 110mmHg diastolic (severe range).
Preeclampsia has traditionally been dened as new onset of hypertension
plus proteinuria after 20weeks of gestation. Proteinuria is dened as excretion
of 300mg or more of protein in a 24-h urine collection or a random protein/
creatinine ratio of at least 0.3mg/dL.Urine dipstick is discouraged to diagnose
proteinuria unless other methods are unavailable, in which case a measurement
of 2+ or greater is strongly suggestive of clinically signicant proteinuria [5].
Since 2013, the presence of proteinuria is not required to make the diagnosis
of preeclampsia [6]. In the absence of proteinuria, preeclampsia can be diag-
nosed in the setting of hypertension after 20weeks gestation plus signs or symp-
toms of end- organ damage, also called “severe features” (Box 5.1). Preeclampsia
diagnosed before 34 weeks is considered early-onset and is associated with
more complications, including fetal growth restriction and preterm birth.
Eclampsia is dened as new-onset tonic-clonic, focal, or multifocal seizures in
women with no alternative cause (e.g., pre-existing seizure disorder, intracranial
lesion, drug use) and can occur before, during, or after labor. Most eclamptic
seizures are heralded by symptoms such as severe headache, altered mental sta-
tus, or blurred vision. However, eclamptic seizures can occur without warning,
and there is not always a linear progression from preeclampsia to eclampsia.
Importantly, up to 38% of women may not have documented high blood pres-
sure or proteinuria prior to seizing [7].
W. Sherman et al.
59
HELLP syndrome is an acronym for hemolysis (H), elevated liver enzymes (EL),
and low platelets (LP). ACOG considers HELLP syndrome to be a more severe form
of preeclampsia, though hypertension may be mild or absent in patients with HELLP
syndrome [4] (Box 5.2). Chronic hypertension is hypertension that predates preg-
nancy or is diagnosed before 20weeks gestation. Patients with chronic hypertension
may develop preeclampsia, and this is referred to as superimposed preeclampsia.
Gestational hypertension is hypertension that occurs after 20weeks without protein-
uria or other signs or symptoms of preeclampsia. However, gestational hypertension
is not a benign diagnosis—up to 50% of women with gestational hypertension will
go on to be diagnosed with preeclampsia [4]. The risk of this progression is higher
when hypertension is developed before 34weeks of gestation [8].
Pathophysiology
The concept of preeclampsia/eclampsia has been recognized since ancient times,
yet the exact pathophysiology leading to the disorder remains unclear [9]. Maternal,
fetal, and placental mechanisms have been proposed [10]. Recent research has
Box 5.2 Diagnosis of HELLP Syndrome
• Evidence of hemolysis:
– Schistocytes on peripheral smear
– Lactate dehydrogenase >600IU/L
– Total bilirubin 1.2mg/dL)
• Elevated aspartate aminotransferase (>70IU/L)
• Thrombocytopenia (platelets <100,000/microliter)
Adapted from Olsen-Chen and Seligman [23]
Box 5.1 Severe Features of Preeclampsia
• Systolic blood pressure >160mmHg or diastolic >110mmHg
• Thrombocytopenia (platelet count <100,000/microliter)
• Impaired liver function (twice normal)
• Severe persistent right upper quadrant or epigastric pain unresponsive to
medication
• Renal insufciency (creatinine >1.1 mg/dL or doubling of creatinine in
absence of other renal disease)
• Pulmonary edema
• New-onset cerebral or visual disturbances
Adapted from American College of Obstetricians and Gynecologists, Task
Force on Hypertension in Pregnancy [6]
5 Hypertensive Disorders ofPregnancy
60
established that poor placentation is fundamental to the development of preeclamp-
sia. In a healthy pregnancy, the spiral uterine arteries penetrate the myometrium and
remodel to allow for high capacitance and low resistance blood ow to the placenta.
Failure of this remodeling leads to placental hypoperfusion, hypoxia, and insuf-
ciency causing a complex cascade of endothelial dysfunction leading to many of the
clinical features observed in preeclampsia [11, 12].
Emergency Department Management
Evaluation
Pregnant patients that are greater than 20weeks gestational age presenting to the
ED for any reason and are noted to be hypertensive must be evaluated for signs and
symptoms of end-organ damage to rule out preeclampsia. Patients should be asked
about the presence of headache, visual changes, abdominal pain (specically right
upper quadrant or epigastric pain), chest pain, and shortness of breath. As many
women with preeclampsia may have no symptoms [13], laboratory tests are neces-
sary. Minimum laboratory test includes complete blood count to evaluate for throm-
bocytopenia, complete metabolic panel to assess creatinine level and liver enzymes,
and urinalysis or urine protein/creatinine ratio to evaluate for proteinuria. Additional
tests can include lactate dehydrogenase to evaluate for hemolysis if there is concern
for HELLP syndrome, coagulation studies, and baseline magnesium level. Serum
uric acid may also be ordered as signicantly elevated levels are seen in severe pre-
eclampsia, eclampsia, and HELLP syndrome and have moderate prognostic value
for detecting adverse perinatal outcomes [14].
Treatment
Delivery is the denitive treatment for preeclampsia, eclampsia, and HELLP syn-
drome, and the timing depends on gestational age of the fetus. Delivery is recom-
mended for patients with gestational hypertension or preeclampsia without severe
features at or beyond 37weeks 0/7days. For patients diagnosed with preeclampsia
with severe features at or beyond 34weeks 0/7days, delivery is also recommended.
Management prior to 34weeks is dependent on maternal and fetal stability [4]. ED
treatment of the preeclamptic or eclamptic patient includes controlling blood pres-
sure, initiating seizure prophylaxis, treating seizures if they occur, and obtaining
emergent obstetric consultation.
Control ofBlood Pressure
Pregnant women with blood pressure >160mmHg systolic or >110mmHg diastolic
require antihypertensive therapy to reduce the risk of stroke and other maternal
complications. The goal is to achieve a blood pressure of 135/85mmHg or less [15],
W. Sherman et al.
61
though sudden drops in blood pressure should be avoided so as not to cause addi-
tional complications such as fetal distress or uterine hypoperfusion. Antihypertensives
should be initiated as soon as possible and ideally within 30–60min.
There is no consensus on an ideal agent for treating blood pressure in preeclamp-
sia [16, 17]. Clinicians should select a drug based on maternal characteristics/con-
traindications and their own familiarity and experience with a medication. All
antihypertensive drugs used in pregnancy cross the placenta, so possible effects on
the fetus should also be taken into consideration. The most used agents are labetalol,
hydralazine, and nifedipine. All three drugs may be considered rst-line therapy.
Suggested dosing regimens and drug characteristics are outlined in Tables 5.2 and
5.3 respectively. Magnesium is not recommended as an antihypertensive agent.
Seizure Prophylaxis andTreatment
For women with preeclampsia with severe features, magnesium sulfate should be
given as prophylaxis against eclampsia. A Cochrane Review published in 2023
compared different regimens for administration of magnesium sulfate used in
patients with preeclampsia, eclampsia, or both. Comparisons included different
dose regimens, different routes (IV vs. IM), and different durations of therapy. The
authors concluded that no one regimen is more effective than another [18]. ACOG
suggests 4–6g IV loading dose over 20–30min, followed by a maintenance dose of
Table 5.2 Initial approach for management of severe antepartum, intrapartum, or postpartum
hypertension
If BP remains >160mmHg systolic or >110 diastolic for more than 15 min:
Labetalol Hydralazine Nifedipine
Give 20mg IV over 2min
Repeat BP in 10min
Give 5–10mg IV over
2min
Repeat BP in 20min
Give 10mg orally
Repeat BP in 20min
If BP remains >160mmHg systolic or >110 diastolic:
Give 40mg IV over 2min
Repeat BP in 10min
Give 10mg IV over
2min
Repeat BP in 20min
Give 20mg orally
Repeat BP in 20min
If BP remains >160mmHg systolic or >110 diastolic:
Give 80mg IV over 2min
Repeat BP in 10min
Give labetalol 20mg IV
over 2min
Repeat BP in 10min
Give 20mg orally
Repeat BP in 20min
If BP remains >160mmHg systolic or >110 diastolic:
Give hydralazine 10mg IV over 2min
Repeat BP in 20min
Give labetalol 40mg IV
over 2min
Repeat BP in 10min
Give labetalol 20mg IV
over 2min
Repeat BP in 10min
If BP remains >160mmHg systolic or >110 diastolic:
Obtain emergent consultation from obstetrics, maternal-fetal medicine, or critical care
subspecialists and treat as recommended
Once target BP reached, repeat BP every 10min for 1 h, then every 15min for 1h, then every
30min for 1 h, then every hour for 4 h
Adapted from American College of Obstetricians and Gynecologists [16]
Abbreviations: BP blood pressure, IV intravenous
5 Hypertensive Disorders ofPregnancy
62
Table 5.3
Characteristics of antihypertensive drugs commonly used for severe hypertension in
pregnancy
Drug
Mechanism
Contraindications/Cautions
Labetalol
Non-selective beta-
blocker, some alpha-
blocking activity
Avoid in women with asthma, heart disease,
congestive heart failure. May cause neonatal
bradycardia and hypoglycemia
Hydralazine Direct vasodilator, relaxes
arteriolar smooth muscle
May cause maternal hypotension, tachycardia,
headache, ushing, nausea/vomiting, palpitations
Nifedipine Calcium channel blocker May cause maternal tachycardia, ushing,
palpitations, headache
Adapted from Olsen-Chen and Seligman [23]
1–2g/h [4]. Treatment with magnesium sulfate has been shown to reduce the risk of
eclampsia by more than half [19].
If seizures develop, magnesium sulfate is still the drug of choice and has been
shown to be superior to diazepam and phenytoin in reducing maternal death and
further seizures [20, 21]. If magnesium has not yet been started, administer 4g IV
over 5min, followed by 1g/h infusion. If the patient is already receiving magne-
sium and seizes, an additional 2–4g IV over 5min may be given, and the infusion
may be increased to 2g/h [22]. Eclamptic seizures are generally short in duration
(less than 1min). If seizures continue after additional magnesium doses, the authors
recommend giving a benzodiazepine (either lorazepam 2mg IV push or midazolam
5mg IV push) followed by a loading dose of an antiepileptic such as phenytoin
1250mg IV at a rate of 50mg/min [4].
Cerebral imaging should be considered for patients with prolonged or repeated
seizures and for patients with a focal neurologic decit to rule out possible intracra-
nial hemorrhage or other neurologic complication. Endotracheal intubation should
also be considered for airway protection.
Patients receiving magnesium should be closely monitored for signs of magne-
sium toxicity. Symptoms of magnesium toxicity include loss of deep tendon reexes,
respiratory depression, somnolence, and cardiac arrest. If magnesium toxicity is
suspected, the infusion should be stopped immediately, and 10mL of 10% calcium
gluconate can be administered [23]. There is theoretical concern that treatment with
both nifedipine and magnesium sulfate could result in increased risk of magnesium-
related maternal side effects such as neuromuscular blockade and severe hypoten-
sion, but this has not been shown to be the case [24].
Disposition
The progression of preeclampsia is unpredictable and can be rapid; therefore, hos-
pital admission to an obstetrics unit is usually indicated. If a labor and delivery unit
is on-site, the emergency department and obstetrical teams may consider develop-
ing a triage pathway to expedite treatment and transfer to labor and delivery
(Fig.5.1). The emergency clinician must also decide if the current facility has the
capacity and capability to provide the level of maternal-fetal-neonatal care needed
W. Sherman et al.
63
*Signs and Symptoms- new onset headache, visual disturbances, severe persistent right upper quadrant or
epigastric pain unresponsive to medication, pulmonary edema, systolic blood pressure > 160 mmHg or diastolic
>110 mmHg, thrombocytopenia (platelet count < 100,000/microliter), impaired liver function (twice normal), renal
insufficiency (creatinine >1.1 mg/dL or doubling of creatinine in absence of other renal disease)
ED = Emergency Department; SPB = Systolic blood pressure; DBP = diastolic blood pressure; ESI = Emergency
severity index; OB= Obstetrics; L&D = Labor & Delivery; EP= Emergency Physician
Patient presents to ED and triage
SBP ≥ 140 and/or DBP ≥ 90
Due to potential severity and risk
for seizures these patients they are
categorized as ESI 1.
Take patient directly back
to team and notify EP
immediately
EP notifies OB
attending in L&D
Patient is discharged from
the ED and transferred to
L&D unit with ED nurse
EP may order magnesium and
antihypertensive to administer
immediately if severe features
present while arranging transfer to
L&D.
Do not delay the medications
ordered
EP assess patient for
signs/symptoms* of preeclampsia
Fig. 5.1 Triage Pathway for Patients >20weeks Pregnant or <6 weeks Postpartum Presenting
with Hypertension. *Signs and Symptoms- new onset headache, visual disturbances, severe persis-
tent right upper quadrant or epigastric pain unresponsive to medication, pulmonary edema, systolic
blood pressure >160mmHg or diastolic >110mmHg, thrombocytopenia (platelet count <100,000/
microliter), impaired liver function (twice normal), renal insufciency (creatinine >1.1mg/dL or
doubling of creatinine in absence of other renal disease). ED Emergency Department, SPB Systolic
blood pressure, DBP diastolic blood pressure, ESI Emergency severity index, OB Obstetrics, L&D
Labor & Delivery, EP Emergency Physician
or if the patient would benet from transfer to a higher level of care. Transfer of
patients to a facility with sufcient obstetric and neonatal resources has been shown
to reduce maternal, fetal, and neonatal morbidity and mortality. Since the denitive
treatment of preeclampsia and eclampsia is delivery, the decision of when and
where to transfer is often based on gestational age and the need for obstetric and
neonatal specialists [25]. Neonatal mortality is signicantly lower if preterm babies
5 Hypertensive Disorders ofPregnancy