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| __NOTOC__ | | __NOTOC__ |
| {{Pre-eclampsia}} | | {{Pre-eclampsia}} |
| {{CMG}}; {{AE}} {{Ochuko}} | | {{CMG}}; {{AE}} {{Sara.Zand}} {{Ochuko}} |
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| ==Overview== | | ==Overview== |
| | *The aim of therapy is starting treatment in [[blood pressure]]≥ 140/90 mmHg in office or clinic and [[blood pressure]] ≥ 135/85 mmHg at home and reaching the target [[systolic blood pressure]] 110-140 mmHg and [[diastolic blood pressure]] less than 85 mmHg regardless the type of [[hypertension]] in [[pregnancy]]. |
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| The only known treatment for eclampsia or advancing preeclampsia is [[childbirth|delivery]], either by [[induction (birth)|induction]] or [[Caesarean section]]. However, post-partum pre-eclampsia may occur up to 6 weeks following delivery even if symptoms were not present during the pregnancy. Post-partum pre-eclampsia is dangerous to the health of the mother since she may ignore or dismiss symptoms as simple post-delivery headaches and edema. Hypertension can sometimes be controlled with anti-hypertensive medication, but any effect this might have on the progress of the underlying disease is unknown. Studies have suggested that the father's semen when introduced into the mother, most effectively orally but also through intercourse,<ref>PMID 10706945</ref> prior to pregnancy reduces chances of preeclampsia, as it exposes the mother to foreign proteins of her partner.==Treatment==
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy=== | | ===Medical Therapy=== |
| | * The mainstay of therapy for [[hypertension]] in [[preeclampsia]] is [[oral methyldopa]], [[labetalol]], [[oxprenolol]], and [[nifedipine]], and second or third line agents include [[hydralazine]] and [[prazosin]]. |
| | *For patients who have [[proteinuria]] with [[severe hypertension]] or [[hypertension ]] with [[neurologic]] signs and symptoms, treatment is [[magnesium sulfate]] ([[MgSO4]]) for [[convulsion]] prophylaxis. |
| | * Urgent therapy for [[severe hypertension]]( [[blood pressure]] >160/110) is oral [[nifedipine]] or intravenous [[labetalol]] or [[hydralazine]] or oral [[labetalol]].<ref>{{cite journal|doi=10.1161/HYP.0000000000000065Hypertension.}}</ref><ref name="pmid32443079">{{cite journal |vauthors= |title=Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222 |journal=Obstet Gynecol |volume=135 |issue=6 |pages=e237–e260 |date=June 2020 |pmid=32443079 |doi=10.1097/AOG.0000000000003891 |url=}}</ref> |
| | {| class="wikitable" |
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| | ! align="center" style="background: #4479BA; color: #FFFFFF |Serum [[Magnesium]] Concentration (mg/dL) !! align="center" style="background: #4479BA; color: #FFFFFF |Effect |
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| | |5–9 || Therapeutic range |
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| | | >9|| Loss of [[patellar reflexes]] |
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| | | > 12 || Respiratory paralysis |
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| | | > 30 || [[Cardiac arrest]] |
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| | |} |
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| | | {| class="wikitable" |
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| | | ! align="center" style="background: #4479BA; color: #FFFFFF |Drugs for urgent controlling of [[hypertension]] in [[preeclampsia]]<ref>{{cite journal|title=Gestational Hypertension and Preeclampsia|journal=Obstetrics & Gynecology|volume=135|issue=6|year=2020|pages=e237–e260|issn=0029-7844|doi=10.1097/AOG.0000000000003891}}</ref> |
| | | ! align="center" style="background: #4479BA; color: #FFFFFF |Dose !! align="center" style="background: #4479BA; color: #FFFFFF |Specific considration !! align="center" style="background: #4479BA; color: #FFFFFF |Onset of action |
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| | | | [[Labetalol]]|| 10–20 mg IV, then 20–80 mg every 10–30 minutes upto a maximum dosage of 300 mg; or infusion 1–2 mg/min IV || Contraindications: |
| | | *[[Asthma]] |
| | | * [[Decompensated heart failure]], |
| | | * [[ Heart block]] |
| | | * [[Bradycardia]] |
| | | || 1-2 minutes |
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| | | | [[Hydralazine]] || 5 mg IV or IM, then 5–10 mg IV every 20–40 minutes upto a maximum dosage of 20 mg or keeping infusion of 0.5–10 mg/hr || Side effects in higher dosage: |
| | | * maternal [[hypotension]] |
| Regardless of the hypertensive disorder of pregnancy, BP requires urgent treatment in a monitored setting when severe (>160/110 mm Hg); acceptable agents for this include oral nifedipine or intravenous labetalol or hydralazine. Oral labetalol may be used if these treatments are unavailable.
| | * [[Headaches]] |
| 2.
| | *Abnormal [[fetal heart rate]] tracings |
| Regardless of the hypertensive disorder of pregnancy, BPs consistently at or >140/90 mm Hg in clinic or office (or ≥135/85 mm Hg at home) should be treated, aiming for a target diastolic BP of 85 mm Hg in the office (and systolic BP of 110–140 mm Hg) to reduce the likelihood of developing severe maternal hypertension and other complications, such as low platelets and elevated liver enzymes with symptoms. Antihypertensive drugs should be reduced or ceased if diastolic BP falls <80 mm Hg. Acceptable agents include oral methyldopa, labetalol, oxprenolol, and nifedipine, and second or third line agents include hydralazine and prazosin.
| | || 10-20 minutes |
| 3.
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| Women with preeclampsia should be assessed in hospital when first diagnosed; thereafter, some may be managed as outpatients once it is established that their condition is stable and they can be relied on to report problems and monitor their BP.
| | | [[Nifedipine]] ||10–20 mg orally, repeat in 20 minutes if needed; then 10–20 mg every 2–6 hours, maximum daily dose is 180 mg|| Side effect: |
| 4.
| | * Reflex [[tachycardia]] |
| Women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms, should receive magnesium sulfate (MgSO4) for convulsion prophylaxis.
| | * [[Headache]] |
| 5.
| | || 5-10 minutes |
| Fetal monitoring in preeclampsia should include an initial assessment to confirm fetal well-being. In the presence of fetal growth restriction, a recommended schedule for serial fetal surveillance with ultrasound is detailed within these recommendations.
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| 6.
| | |} |
| Maternal monitoring in preeclampsia should include BP monitoring, repeated assessments for proteinuria if it is not already present, clinical assessment including clonus, and a minimum of twice weekly blood tests for hemoglobin, platelet count, and tests of liver and renal function, including uric acid, the latter being associated with worse maternal and fetal outcomes.
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| 7.
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| Women with preeclampsia should be delivered if they have reached 37 weeks’ (and zero days) gestation or if they develop any of the following:
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| Repeated episodes of severe hypertension despite maintenance treatment with 3 classes of antihypertensive agents;
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| Progressive thrombocytopenia;
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| Progressively abnormal renal or liver enzyme tests;
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| Pulmonary edema;
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| Abnormal neurological features, such as severe intractable headache, repeated visual scotomata, or convulsions;
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| Nonreassuring fetal status.
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| {{MedCondContrAbs | |
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| |MedCond = Pre-eclampsia |Warfarin| | |
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| }}
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| ===Other investigated treatments===
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| ====Maternal Vitamin D Deficiency Increases the Risk of Preeclampsia.<!--
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| --><ref name="JCEM-preeclampsia-vitamin-D">{{cite journal | author=Lisa M. Bodnar, Janet M. Catov, Hyagriv N. Simhan, Michael F. Holick, Robert W. Powers, James M. Roberts |title=Maternal Vitamin D Deficiency Increases the Risk of Preeclampsia. | journal= | year=2007
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| url=http://jcem.endojournals.org/cgi/content/abstract/92/9/3517}}</ref>====
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| Studies into supplementation with [[antioxidant]] vitamins C and E found no change in preeclampsia rates.<!--
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| --><ref name="NEJM2006-Rumbold">{{cite journal | author=Rumbold A, Crowther C, Haslam R, Dekker G, Robinson J | title=Vitamins C and E and the risks of preeclampsia and perinatal complications. | journal=N Engl J Med | volume=354 | issue=17 | pages=1796-806 | year=2006 | id=PMID 16641396}}</ref>
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| Doctors Padayatty and Levine with NIH in a "Letter to the Editor" stated that the studies and another "Letter to the Editor" overlooked a key reason for the lack of vitamin C on the prevention of preeclampsia. Because plasma ascorbate concentrations were not reported, we estimated them from known data, the placebo and treatment groups in the study probably had similar plasma and tissue ascorbate concentrations. Doses of 1 g per day have little effect on plasma or intracellular ascorbate concentrations.<!--
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| --><ref name="Padayatta">{{cite journal | author= Padayatty SJ, Levine M. | title=Vitamin C and E and the Prevention of Preeclampsia - Letter | journal=NEJM | volume=355 |issue=10 | pages=1065-1066 | year=2006 | url=http://www.health.adelaide.edu.au/og/research/ACTS%20Published%20letter1065.pdf | format=PDF}}</ref>
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| Calcium supplementation in women with low-calcium diets found no change in preeclampsia rates but did find a decrease in the rate of severe preeclamptic complications.<!--
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| --><ref name="AmJObstetGynecol2006-Villar">{{cite journal | author=Villar J, Abdel-Aleem H, Merialdi M, Mathai M, Ali M, Zavaleta N, Purwar M, Hofmeyr J, Nguyen T, Campódonico L, Landoulsi S, Carroli G, Lindheimer M | title=World Health Organization randomized trial of calcium supplementation among low calcium intake pregnant women. |journal=Am J Obstet Gynecol | volume=194 | issue=3 | pages=639-49 | year=2006 | id=PMID 16522392}}</ref>
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| Aspirin supplementation is still being evaluated as to dosage, timing, and population and may provide a slight preventative benefit in some women, however significant research has been done on aspirin and the results thus far are unimpressive.<!--
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| --><ref name="Cochrane2004-Duley">{{cite journal | author=Duley L, Henderson-Smart D, Knight M, King J | title=Antiplatelet agents for preventing pre-eclampsia and its complications. | journal=Cochrane Database Syst Rev | year=2004 | issue=1 | pages=CD004659 | id=PMID 14974075}}</ref>
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| There is insufficient evidence to recommend either exercise<!--
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| --><ref name="Cochrane2006-Meher-exercise">{{cite journal | author=Meher S, Duley L | title=Exercise or other physical activity for preventing pre-eclampsia and its complications. | journal=Cochrane Database Syst Rev | month=Apr 19 | year=2006 | issue=2 | pages=CD005942 | id=PMID 16625645}}</ref><!--
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| --> or bedrest<!--
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| --><ref name="Cochrane2006-Meher-rest">{{cite journal | author=Meher S, Duley L | title=Rest during pregnancy for preventing pre-eclampsia and its complications in women with normal blood pressure. | journal=Cochrane Database Syst Rev | month=Apr 19 | year=2006 | issue=2 | pages=CD005939 | id=PMID 16625644}}</ref><!--
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| --> as preventative measures. Studies of protein/calorie supplementation have found no effect on preeclampsia rates, and dietary protein restriction does not appear to increase preeclampsia rates.<!--
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| --><ref name="Cochrane2003-Kramer">{{cite journal | author=Kramer M, Kakuma R | title=Energy and protein intake in pregnancy. | journal=Cochrane Database Syst Rev | year=2003| issue=4 | pages=CD000032 | id=PMID 14583907}}</ref>
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| ====Sexual Health====
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| It has been suggested that fellatio may, through "immune modulation", have a beneficial role in preventing dangerous complications during pregnancy. Specifically, a research group reported that pre-eclampsia, a life threatening complication that sometimes arises in pregnancy, is much less frequent in couples who have practiced oral sex, and even more rare in couples where fellatio ended with the semen swallowed. Both results were statistically significant. This is consistent with other evidence that semen contains an agent that prevents preeclampsia, and with the theory that preeclampsia is an immunological condition. According to that view, preeclampsia is caused by a failure of the mother organism to accept the fetus and placenta, which both contain "foreign" proteins from the father's genes. Regular exposure to the father's semen might cause her immune system to gradually "grow accustomed" to their proteins. Other studies also found that, while any exposure to the partner's sperm during sex appears to decrease the chances of various disorders, women in couples who have practiced "other sex acts" than intercourse are half as likely to suffer pre-eclampsia. It is not known whether this represents a protective effect of "other sex acts" including oral sex, or a correlation between these sexual practices and some other protective factor: for example, greater overall frequency of sex. The standard way to resolve such questions (confounding) in medical science would be through a randomized trial, but there are unique challenges to research in sexual health.
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| When reporting the findings of the first research group mentioned above, New Scientist magazine thought it worth mentioning that some of the research team were women (including the lead author). Candidates for a protective agent in semen may include serum hormone leutinizing agent and transforming growth factor beta.
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| ==References== | | ==References== |
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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