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                                 Suspected Preeclampsia (PEC) Algorithm

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                                 Suspected Preeclampsia (PEC) Algorithm

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Moyer, K.M. (2017).

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                                               Differential Diagnosis 4- Gestational hypertension

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                                               Differential Diagnosis 4- Gestational hypertension

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S ymptoms
* Often asymptomatic
Diagnostic Criteria
* Elevation of B/P after 20 weeks gestation (often near term) without proteinuria (DynaMed Plus, 2016).
* Initial diagnosis is provisional as does not resolve until weeks by 12 weeks postpartum so definitive diagnosis is made later (ACOG, 2013).
Pertinent Positives
* Benign proteinuria (ACOG, 2013)
Pertinent Negatives
* No proteinuria or other features of preeclampsia. (Jordan, 2014)

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                  Differential Diagnosis 3- Chronic hypertension w/ superimposed preeclampsia 

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                  Differential Diagnosis 3- Chronic hypertension w/ superimposed preeclampsia 

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(ACOG, 2013; DynaMed Plus, 2016)
Symptoms
* Neurological symptoms
* Epigastric or RUQ abdominal pain
* Nausea and vomiting
* Vaginal bleeding
* Fetal movement - decreased
Diagnostic Criteria
* Sudden increase in B/P that was previously well controlled or escalation in medications to control B/P
* New onset proteinuria or sudden increase in proteinuria with previously known proteinuria
* Severe range B/P despite the escalation of antihypertension therapy
* Thrombocytopenia
* Elevated liver transaminases
* New onset or worsening renal insufficiency
* Pulmonary edema
* Persistent visual or cerebral disturbances
Categories
* Superimposed Preeclampsia without severe features: systolic >140-159, diastolic > 90-109 mm Hg, or both and proteinuria
* Superimposed Preeclampsia with severe features: with organ dysfunction.
Pertinent Positives
* Increasing B/P
* New symptoms associated with preeclampsia
Pertinent Negatives
* B/P not controlled by previous medication

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                                                  Differential Diagnosis 2- Chronic hypertension

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                                                  Differential Diagnosis 2- Chronic hypertension

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(ACOG, 2013; DynaMed Plus, 2017)
Symptoms
* Asymptomatic
* Hypertensive retinopathy
* Carotid bruits
* S3 or S4
* Abdominal bruits (suggests renovascular hypertension)
* Hepatomegaly
* Decreased, absent, and/or delayed peripheral pulses (peripheral arterial disease)
* Femoral bruits (peripheral arterial disease)
* Neurologic deficit may suggest prior stroke
Diagnostic Criteria
* High BP is known to predate conception or detected before 20 weeks gestation
Pertinent Positives
* Previously documented high B/P, antihypertensive medications
Pertinent Negatives
* No proteinuria

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                                                                          Follow-Up  

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                                                                          Follow-Up  

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(Jordan, 2014)

CBC, liver enzymes, and serum creatinine labs drawn every week.

Per protocol, Kelly will deliver the baby at 37 weeks gestation (three weeks from now). Sooner if her condition worsens (see below).

Although Kelly is a nurse and had preeclampsia before, she needs to be vigilant in reporting changes in signs and symptoms that will require further follow-up, evaluation, and testing.

The symptoms to watch for will include:

persistent headache

visual changes such as blurred vision or seeing spots

pain in the epigastric region

feelings of general malaise

sudden weight changes or facial edema

Kelly will be instructed to immediately return to the hospital if she begins to suffer from the following:

abdominal pain

contractions

persistent symptoms

vaginal spotting

ruptured membranes

reduction in fetal movements

Immediate hospitalization is also required if:

severe preeclampsia develops (SBP >160, DBP >110)

evidence of fetal growth restriction

increased liver enzymes

thrombocytopenia

We will confirm that Kelly has all of the pertinent contact information for her various care providers and specialists so she can reach them immediately if her condition changes.

It is responsible to communicate the long-term possible risks involved with preeclampsia even after the delivery of a healthy child. According to Jordan (2014) there is a strong association between preeclampsia and cardiovascular disease. The research states that the risk for hypertension is fourfold and a twofold risk for stroke, heart disease, and thromboembolism. The risks are even greater for a woman who developed preeclampsia during multiple pregnancies (Jordan2014). An increased risk of diabetes is also a concern. This education should be shared with ALL pregnant women and those who are trying to become pregnant as improved diet, weight management, and exercise habits can reduce these risks of hypertension and preeclampsia.

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                                                 Differential Diagnosis 1- Preeclampsia/Eclampsia

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                                                 Differential Diagnosis 1- Preeclampsia/Eclampsia

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(DynaMed Plus, 2016)
Symptoms
* May be asymptomatic.
* Severe hypertensive disorders in pregnancy may present with rapid weight gain, generalized edema (affecting face and hands), visual disturbances, such as blurred vision, scotomata, and rarely cortical blindness, severe headache, nausea and/or vomiting, epigastric or right upper quadrant pain, oliguria, hyperreflexia, chest pain, dyspnea.
Diagnostic Criteria
* The occurrence of new-onset hypertension plus new onset proteinuria
OR
* No proteinuria, HTN in association w/ thrombocytopenia (platelet count <100k/ microliter, impaired liver function (elevated serum transaminases to twice the normal concentration), new development of renal insufficiency (elevated serum creatinine greater than 1.1 mg/dL or a doubling of serum creatinine in absence of other renal diseases), pulmonary edema, or new-onset cerebral or visual disturbances.
* Eclampsia is new onset grand mal seizures in a woman with preeclampsia.
Pertinent Positives
* Previous pregnancy with preeclampsia, inherited thrombophilias, increased prepregnancy triglyceride levels, interpregnancy interval (increased risk if ≥ 10 years or < 2 years), early-onset cardiovascular disease
* Work outside the home
* Choroidal ischemia
* Generalized edema
* Hyperreflexia, memory deficits, increased deep tendon reflexes (some asymmetric)
* Visual perception deficits
* Visual information processing deficits
* Altered mental status
* Cranial nerve deficits
Pertinent Negatives
* No seizures
* No history of systemic lupus erythematosus (SLE)
* Negative cocaine use
* No signs of sepsis
* No history of migraines
* No symptoms of acute fatty liver disease, such as jaundice, anorexia, polyuria and polydipsia

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                                                                                      Diagnostic Definitions

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                                                                                      Diagnostic Definitions

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Diagnostic Definitions (American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy [ACOG], 2013)

HTN- dx by two readings at least four hours apart of systolic >140, diastolic > 90 mm Hg, or both. Considered mild until systolic >160, diastolic > 110 mm Hg. Can be dx in a shorter time period if HTN is severe.

Proteinuria- dx by 24 hour urine > 0.3 g/day, OR creatinine ratio for single void is > 30 mg/mmol (DynaMed Plus, 2016). Urine dipstick of 1+ is only used if other quantitative methods are unavailable d/t high possibility of false- positive and false-negative results.

Preeclampsia is a diagnosis and cannot be classified further, e.g. “mild” or “severe”. Instead can be categorized as with or without severe features.

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                                                                                   Objective Data

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                                                                                   Objective Data

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General Appearance

Vital Signs with SpO2, Weight

Rationale: Assess the overall health of the woman, assess B/P as Kelly is at higher risk for preeclampsia d/t previous history. Pulse oximetry to assess oxygen saturation (SpO₂ < 97% associated with increased risk of severe complications), weight to assess for onset of edema (DynaMed Plus, 2016)

Constitutional (age, race, gender, general appearance, mental status)

Physical Exam

HEENT- ophthalmoscopy

Rationale: choroidal ischemia seen on ophthalmoscopy in patient with pregnancy-induced hypertension (DynaMed Plus, 2016)

Lungs- rales or crackles

Rationale: indicating pulmonary edema (DynaMed Plus, 2016)

Heart- listen for S3/S4

Rationale: Can indicate chronic hypertension (DynaMed Plus, 2017)

Abdomen- abdominal bruits; RUQ or epigastric pain; fetal movement, fetal heart tones

Rationale: bruits can indicate chronic hypertension (DynaMed Plus, 2017); RUQ or epigastric pain common with preeclampsia; assess fetal status (DynaMed Plus, 2016)

Neurological: Reflexes, CN, vision screening, mental status

Rationale: hyperreflexia, memory deficits, increased deep tendon reflexes (some asymmetric), visual perception deficits, visual information processing deficits, altered mental status, cranial nerve deficits can indicate preeclampsia (DynaMed Plus, 2016).

Extremities- generalized edema (including face and hands)

Rationale: common with preeclampsia (DynaMed Plus, 2016)

Diagnostics & Labs (recent and available at visit)
- Obtain new and review previous B/P measurements and baseline labs
- Dipstick urinalysis

- Rapid screening albumin:creatinine ratio

- Ultrasound for fetal growth (available at this office)

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                                                           Priority Diagnosis: Preeclampsia

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                                                           Priority Diagnosis: Preeclampsia

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Plan of Care
Diagnostics: Important to check for organ dysfunction. (Hacker, Gambone, & Hobel, 2016; Hurt, 2015)

Initial Labs: CBC, platelet count, LDH: if abnormal, order d-dimer, coagulation panel, and smear.

Renal studies: serum BUN creatinine and uric acid, urinalysis, 24hr-urine for protein and creatinine, or protein/creatinine ration.

Liver function tests: AST, ALT, and bilirubin

Fetal evaluation: ultrasound to determine gestational age, fetal growth, amniotic fluid index (AFI), and the umbilical artery Doppler resistance index or systolic/diastolic ratio, and a nonstress test (NST).

Treatment:  (Hacker, Gambone, & Hobel, 2016; Hurt, 2015)

Hospitalization to LDR and Consultation with OB for initial evaluation of severe PEC. If severe criteria not met and no evidence of fetal distress, may continue to monitor as outpatient with:

* Frequent maternal reassessment of symptoms and BP (4 times a day),  weekly labs.
* Frequent monitoring of fetal activity, daily kick counts, fetal heart tones, serial NST/AFI or
BPP (1-2x/wk), and serial fetal growth US (q3-4wk).

Indications for prompt delivery: deterioration in condition (uncontrolled HTN, deteriorating renal function, pulmonary edema, evidence of HELLP syndrome or  coagulopathy, worsening of liver function, CNS symptoms, abruption, or abnormal fetal testing, or attainment of ≧34 wks gestation, but not >37 wks.

Pharmacological treatment if BP >160/110: Goal is to keep BP < 140/90

Acute HTN Inpatient collaborative treatment with OB:
Labetalol 20mg IV q10min may increase dose by 10mg each time up to 80mg max dose at one time,              total max dose of 300mg.  OR
Hydralazine 5mg IV over 1-2mins, repeat at 20 min intervals, max dose 20mg at one time. OR
Nifedipine 10-20mg PO q30min
Oral Outpatient collaborative treatment with OB:
Labetalol 100-800mg PO BID-TID (max daily dose 2400mg)
Methyldopa 250mg PO BID (max daily dose 3000mg)
Nifedipine XR 30-90mg PO daily (max daily dose 120mg)

Education: (Hacker, Gambone, & Hobel, 2016; Hurt, 2015; Jordan, 2014)
If severe preeclampsia is ruled out, we will continue to monitor Kelly on an outpatient basis since Kelly is a registered nurse, who readily understands medical terminology. Having been pregnant, previously preeclamptic, and giving birth at 32 weeks, Kelly understands the seriousness of her elevated blood pressure and is committed to the necessary monitoring.

Since Kelly is presumed to have preeclampsia, there are several things that she needs to keep in mind throughout the remainder of her pregnancy.

Key education points include:

Frequent maternal reassessment of symptoms and BP at home and in the office,  weekly labs.

Frequent monitoring of fetal activity, daily kick counts, fetal heart tones, serial NST/AFI or

BPP (1-2x/wk), and serial fetal growth US (q3-4wk).

Although her preeclampsia is not considered to be severe, Kelly’s condition can quickly advance to a severe level thereby increasing the potential danger to her and her unborn child.

Increased rest is beneficial to a preeclamptic patient. Periodic resting on the left, lateral side is recommended as this places less stress on the vena cava and maintains adequate maternal blood flow to the placenta and fetus (Jordan, 2014).

Bed rest is not necessary with mild preeclampsia and research shows no difference in pregnancy outcomes. It is advised that Kelly stops working for the duration of her pregnancy (Jordan, 2014).

No medications are recommended at this time for mild preeclampsia but this could change if her condition advances to a severe level (Jordan, 2014).

Kelly may continue to consume a regular, balanced diet with no restrictions on sodium  (Jordan, 2014).

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                                    Week 9 Team Case Kelly--Hypertension in Pregnancy

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                                    Week 9 Team Case Kelly--Hypertension in Pregnancy

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Kelly is a 36 year-old G5 P3104 at 34 weeks gestation. Her OB history is significant for a Cesarean birth for severe preeclampsia at 32 weeks with her last baby. She is in the office for her routine OB check ; her BP is 144/94. Her urine protein is 2+ per the dipstick.

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                                                                    Subjective Data 

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                                                                    Subjective Data 

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O(nset): Discuss with the patient if they have been monitoring their blood pressure at home on a regular basis and when has the blood pressure (BP) increased. Also discuss if the patient has had any severe headaches, vision changes, chest pain, shortness of breath or rapid weight gain (DynaMed, 2016, July 22).
L(ocation): Discuss with the client where, when, and how often they are taking their blood pressure and what time of day as well as which arm.
D(uration): If the patient has a BP record, review to see changes in the blood pressure.
C(haracter): Is there any pattern to the high blood pressure recordings in the patient.
A(lleviating/Agrevating Factors): What activities and things have you done that makes your blood pressure higher as well as what helps the blood pressure to lower.
R(elieving): What has the patient done to help lower blood pressure when high readings are recorded. Have yo been resting and elevating your feet?
T(iming): What time of day is the blood pressure being taken (day or evening). The timing of any other symptoms (vision changes, shortness of breath, etc).
S(severity): How high has the blood pressure readings been and how often have they been recorded as high readings.
Rationale: Using OLDCARTS will help aid in the patient assessment and help the provider understand the concern and related happenings for symptoms and blood pressure elevations.

Medications
Ask what medications the patient is taking including all prescriptions, over the counter medications, as well as any complementary alternative therapy.
Rationale: A variety of medications can cause an increase in patient blood pressure.

ROS
Ask about rapid weight gain, generalized edema, visual disturbances, headache, nausea and/or vomiting, abdominal pain, oliguria, chest pain, and dyspnea
Rationale: These symptoms can be related to severe hypertension in pregnancy (DynaMed, 2016, July 22).
GYN
Ask about the fetal activity.
Rationale: Reports of decreased fetal movement can allow the provider to perform additional fetal assessments. Decreased fetal movement can be associated with an increased risk of fetal death (Jordan, Engstrom, Marfell & Farley, 2014).

Ask about the duration of sexual relationship with the current partner.
Rationale:  Short duration of sexual relationship with the current partner increases the risk of preeclampsia (DynaMed, 2016, July 22). Also, you want to consider the risk of STIs with a new partner.

Past Medical History
Ask about prior, preexisting hypertension, previous preeclampsia (especially if severe or preeclampsia before 32 weeks), diabetes, renal disease, and autoimmune diseases.
Rationale: These are all risk factors for preeclampsia (DynaMed, 2016, July 22).

Ask about the history of thyroid disorders.
Rationale: Subclinical hypothyroidism is associated with hypertension in pregnancy (DynaMed, 2016, July 22).
Social
Ask about cocaine and methamphetamine use.
Rationale: The use of these drugs can increase blood pressure (DynaMed, 2016, July 22).

Ask if the woman works outside of the home.
Rationale: Increases blood pressure among hypertensive pregnant patients who work outside of the home (stress) (DynaMed, 2016, July 22).
Family
Ask about the family history of preeclampsia or early onset of cardiovascular disease.
Rationale: Family history of these disorders in a first-degree relative increases the risk of preeclampsia (DynaMed, 2016, July 22 & Jordan, Engstrom, Marfell & Farley, 2014).