Master the board step 3

Obstetrics
Treatment
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Blood pressure control:
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Don’t treat unless BP > 160/100 mm Hg (antihypertensives decrease uteroplacental
blood flow)
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Goal SBP is 140–150 mm Hg and DBP is 90–100 mm Hg
--
Maintenance therapy:
∘∘
First line therapy is methyldopa or labetalol (alpha and beta blocker that
preserves blood flow to uterus and placenta).
∘∘
Second line therapy is nifedipine (calcium channel blocker).
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Acutely elevated BP/treatment of severe preeclampsia or eclampsia:
∘∘
Intravenous hydralazine or labetalol
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Never give ACE inhibitors, ARBs, or renin inhibitors, or start thiazide
diuretics during pregnancy.
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Seizure management and prophylaxis:
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Protect the patient’s airway and tongue
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Give IV MgSO 4 (magnesium sulfate) bolus for seizure and infusion for
continued prophylaxis
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Monitoring:
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Serial sonograms (evaluate for intrauterine growth restriction [IUGR])
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Serial BP monitoring and urine protein
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Labor:
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Induce labor if ≥ 36 weeks with mild preeclampsia: attempt vaginal delivery
with IV oxytocin if mother and fetus are stable.
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Aggressive, prompt delivery is the best step for severe/superimposed preeclampsia
or eclampsia at any gestational age.
--
Give intrapartum IV MgSO 4 and hydralazine and/or labetalol to manage BP.
A 32-year-old multigravida at 36 weeks’ gestation was found to have BP 160/105
on routine prenatal visit. Previous BP readings were normal. She complained of
some right-upper-quadrant abdominal pain. Urinalysis showed 3+ proteinuria.
She is emergently induced for labor and delivers an 8 lb. 3 oz. boy. Two days after
delivery, routine labs reveal elevated total bilirubin, lactate dehydrogenase, alanine
aminotransferase (ALT), and aspartate aminotransferase (AST). Platelet
count is 85,000. Postpartum evaluation reveals that she has no complaints of
headache or visual changes. Which of the following is the most likely diagnosis?
a. Cholecystitis
b. HELLP syndrome
c. Hepatitis
d. Gestational thrombocytopenia
e. Preeclampsia
Gestational
thrombocytopenia:
• Most common cause of
thrombocytopenia in
pregnancy
• Mild: Counts > 70,000
• Not associated with
other abnormalities, and
no symptoms
• Usually develops in third
trimester
Answer: B. Patient has evidence of hemolysis (elevated LDH), elevated liver enzymes,
and thrombocytopenia.
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