From the Editor

Reduce maternal morbidity by the expeditious and decisive treatment of severe hypertension in pregnancy

OBG Manag. 2017 November;29(11):10, 13-15

References

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Stevens S, Shih T, Incerti D, et al. Short-term costs of preeclampsia to the United States health care system. Am J Obstet Gynecol. 2017;217(3):237–248.e16.
Committee on Obstetric Practice. Committee Opinion No. 692: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2017;129(4):e90–e95.
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5. Preeclampsia plus thrombocytopenia complicates anesthesia options

If the platelet count falls too low (for instance, <70,000 platelets per µL), many anesthesiologists will not provide a regional anesthetic for delivery because of the risk of peridural bleeding. In addition, a low platelet count (<50,000 platelets per µL) significantly increases the risk of obstetric hemorrhage. Transfer of the patient to an obstetrics unit with a full-service blood bank capable of supporting multiple platelet transfusions may be warranted.

6. Preeclampsia plus dyspnea or chest pain increases the risk of severe maternal morbidity

Authors of a prospective study of 2,023 women with preeclampsia reported an increase in adverse maternal outcomes when the following factors were present: early gestational age, dyspnea, chest pain, oxygen saturation of SpO₂ <93%, thrombocytopenia, elevated creatinine, or elevated aspartate transaminase concentration.¹⁰ If dyspnea is present, the patient may have pulmonary edema, pulmonary embolism, heart failure, acute asthma, or pneumonia. If the patient has chest pain the differential diagnosis includes pulmonary embolism, cardiac ischemia, cardiomyopathy, or another cardiac disease.

Consider obtaining a chest radiograph for pregnant women with dyspnea and a computed tomography pulmonary angiogram or lung scintigraphy (ventilation perfusion scan) if the chest radiograph is normal for women with chest pain.^6,11 We obtain a transthoracic echocardiogram in cases of pulmonary edema to evaluate for the possibility of peripartum cardiomyopathy.

7. HELLP syndrome

The triad of hemolysis, elevated liver enzymes, and low platelet count (HELLP) is associated with an increased risk of maternal mortality and severe morbidity.¹² In a study of 171 women with HELLP, factors that increased the risk for adverse maternal outcomes included¹²:

aspartate aminotransferase (AST) levels >316 U/L
alanine aminotransferase (ALT) levels >217 U/L
total bilirubin levels >2.0 mg/dL
lactate dehydrogenase (LDH) levels >1,290 U/L
blood urea nitrogen test results >44 mg/dL
platelet count <50,000 platelets per µL.

The clinical course of HELLP syndrome is characterized by progression and the potential for sudden and catastrophic deterioration. For example, some women with HELLP will suddenly develop a ruptured liver, pulmonary edema, or a stroke. The Society for Maternal-Fetal Medicine recommends against expectant management of women with HELLP syndrome.¹³

8. Delivery or expectant management?

Currently the only cure for preeclampsia is delivery. The Society for Maternal-Fetal Medicine recommends against expectant management of severe preeclampsia if certain problems occur (BOX).¹³ For women with preeclampsia who are less than 34 weeks’ gestation and do not have a contraindication to expectant management, consider transferring the patient to a tertiary maternal care center. In our practice, pregnant women with a hypertensive disorder are scheduled for an induction of labor and delivery at 37 weeks’ gestation.

The Society for Maternal-Fetal Medicine recommends delivery (not expectant management) in the presence of severe preeclampsia if any of the following are present¹³:

eclampsia
pulmonary edema
disseminated intravascular coagulation
renal insufficiency
abruptio placentae
abnormal fetal testing
HELLP syndrome or persistent symptoms of severe preeclampsia.

In the United States, major obstetric causes of pregnancy-related death include sepsis, venous thromboembolism-pulmonary embolism, hemorrhage, and hypertensive disease of pregnancy. Other important causes of pregnancy-related death include cardiac disease, stroke, and pre-existing major medical disease including advanced cancer. In the United States there are approximately 17 pregnancy-related maternal deaths per 100,000 live births.¹ Obstetricians are dedicated to reducing this excessively high rate of maternal death.

Given the US maternal death rate of 1 maternity death per 5,880 live births, over the course of a 40-year career, most obstetrician-gynecologists will have 1 or 2 of their pregnant patients die. From the perspective of an individual clinician, maternal death is an extremely rare event, with 1 death during every 20 years of practice. However, from a population perspective, maternal death in the United States is all too common compared to other developed countries. We can only reduce the rate of maternal death by working in interdisciplinary teams to ensure our obstetrics units are prepared to expeditiously diagnose and treat the most common obstetric causes of death and severe morbidity.

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