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Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Jun 11, 2020

In this podcast, Matt Bigos, MD, FACOG an obstetrician/gynecologist with OB-GYN West, presented at Ridgeview Medical Center's Live Friday CME Series on March 13, 2020. At the event, Dr. Bigos talked about hypertension in the OB patient.

Enjoy the podcast!

OBJECTIVES:  
  Upon completion of this podcast, participants should be able to:

  • Identify signs and symptoms of gestational hypertension and pre-eclampsia.
  • Identify signs and symptoms of acute onset severe hypertension.
  • Express when to promptly initiate treatment.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

Note: CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.

FACULTY DISCLOSURE ANNOUNCEMENT 

It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

SHOW NOTES:

PART 1:
Hypertension in pregnancy is one of the worldwide leading causes of mortality, affecting 2-8% globally. That's 76,000 maternal and 500,000 infant deaths per year in the world.

RISK FACTORS:

  • Nulliparity
  • Multiple gestation
  • Size of placenta/multiple placentas
  • Hx of preeclamsia
  • HTN hx
  • Gestational diabetes
  • Thrombophilia
  • Lupus
  • Obesity before pregnancy
  • Antiphospholipid aby syndrome
  • Older pregnancy
  • Kidney dz
  • IVF
  • OSA

Exact mechanisms is unknown, but probably due to the placenta itself. Many theories exist, and there is a familial component.

Physiology changes with pre-eclampsia. With pregnancy in general, blood volume increases by 50%. Most of which is serum. In preeclampsia, oncotic pressure in the blood vessels decreases, and fluid leaking occurs, hence edema. Kidneys also lose protein which aids in losing intravascular volume. Be cautious with IV hydration in preeclampsia. Intense vasospasm also occurs. Thrombocytopenia occurs due to overuse of platelets. Hemolysis occurs as well. Look for elevations of LDH and bilirubin. Schistocytes can be seen if you can find a microscope. Periportal necrosis leads to elevated AST>ALT. Coagulation factors won't produce as well either. In the kidney, protein leaks through porous glomeruli. Urine output will decrease due to intrarenal vasospam. Uric acid levels can help differentiate chronic vs new HTN in pregnancy. Less amniotic fluid and smaller fetus size occurs. Placental abruption may happen, in addition.

PART 2:
Gestational HTN is a BP of 140/90 (either or both) or greater. These must be noted on two separate occasions at least four hours apart. Diagnosed after 20 weeks of gestation in a woman with previously normal BP.

Preeclampsia is the same criteria, along with proteinuria. 24-hour urine collection for protein is the historic best way to check. Protein: Creatinine ration is the easiest to do, though. 2+ protein on the urine dipstick may also suffice.

Preeclampsia with severe features: BP 160/110 or both (= or >) on 2 occasions, 4 hrs apart. Or if you move to treating the BP, this would signify "severe" feature. Other features include: Mild HTN with platelets <100. Transaminases twice normal w/ or w/o RUQ/epig pain. Creatinine elevation, which must be double the baseline normal. Pulmonary edema, headache. Headache should be treated more aggressively than merely Tylenol if it isn't going away. Visual disturbances of any sort.

HELLP: Hemolysis, Elevated LFTs, Low platelets. Some patients only have two of the three. This can even show up postpartum.

Eclampsia is all of the above with onset, focal, multifocal or tonic/clonic seizures. HA, vision change, hyperreflexia and PRES (posterior reversible encephalopathy syndrome) on head imaging may be seen as well. Preeclampsia may not always precede eclampsia. It's not necessarily a steady progression.

PART 3:
Acute HTN in pregnancy is BP 160/110, persistent over 15 minutes or more. Treatment should ensure promptly. Complications such as CHF, MI, stroke and kidney injury may develop quickly.

Three major drugs are used, and most of these have been used for many years. Labetalol, Hydralzine and Ca++ channel blockers. All are equally efficacious. Labetalol can be given PO and IV and has a quick onset. Avoid contraindications to B-blockers though.

Hydralazine is given IV or IM, and lasts a little longer than labetalol. Nifedipine is an oral medication and can be started easily in the office or while awaiting hospitalization and preparing for an IV, etc. Ridgeview has specific treatment algorithms in our order sets along with dosing for these medications.

Thanks so much to Dr. Bigos for his time and expertise on the topic of hypertensive disorders in pregnancy.