Pregnancy and Peri-Partum Problems MDM
MDM Templates
Preeclampsia Without Severe Features
Patient >20 weeks EGA presents with blood pressure elevation.
No severe features (no visual disturbances, no pulmonary edema, no AKI, platelets >100k, transaminases normal, no severe headache unresponsive to treatment).
OBGYN consulted.
Plan: IV labetalol for acute BP management.
Disposition: Admit to OBGYN for monitoring, serial labs, and delivery planning.
**If postpartum: Patient <6 weeks postparteum presents with blood pressure elevation.
Preeclampsia With Severe Features / Eclampsia
Patient >20 weeks EGA presents with severe hypertension and *** (headache/visual changes/RUQ pain/pulmonary edema).
Findings consistent with preeclampsia with severe features.
Plan:
– Magnesium sulfate 4 g IV bolus then 1-2 g/hr infusion for seizure prophylaxis.
– IV labetalol or hydralazine for acute BP control (target SBP <160, DBP <110).
– OBGYN consulted emergently
Disposition: Admit to L&D.
If seizure (eclampsia): Magnesium sulfate 4-6 g IV bolus is first-line, NOT benzodiazepines. Secure airway, left lateral decubitus positioning. OBGYN and anesthesia emergently — definitive treatment is delivery.
Postpartum Hemorrhage
Patient *** days postpartum presents with vaginal bleeding consistent with secondary postpartum hemorrhage.
Hemodynamically *** (stable/unstable).
OBGYN consulted.
Plan:
– IV access, type and screen, consider transfusion if indicated.
– Uterotonic agents if uterine atony suspected (oxytocin first-line).
Disposition: Admit to OBGYN for monitoring, serial labs, and possible intervention (D&C for retained products, surgical management if refractory).
Endometritis — Admit
Patient *** days postpartum presents with fever, uterine tenderness, and purulent discharge consistent with endometritis.
Plan:
– IV clindamycin plus gentamicin.
– Pelvic ultrasound to evaluate for abscess or retained products.
OBGYN consulted.
Disposition: Admit for IV antibiotics and monitoring.
Peripartum Cardiomyopathy
Patient in ***late pregnancy / early postpartum presents with dyspnea, orthopnea, and lower extremity edema concerning for acute heart failure.
Bedside echo shows reduced EF.
Presentation consistent with peripartum cardiomyopathy.
Plan: Diuresis, afterload reduction (hydralazine/nitrates if still pregnant — NO ACE/ARB until postpartum).
Cardiology and OBGYN consulted.
Disposition: Admit to monitored setting.
Clinical Education
Preeclampsia Classification: With and Without Severe Features
Definition and Criteria. Preeclampsia is new-onset hypertension (systolic ≥140 mmHg or diastolic ≥90 mmHg) in pregnancy or the first postpartum week, occurring after 20 weeks gestation, accompanied by new-onset proteinuria or other end-organ dysfunction[1]. Preeclampsia is classified as with or without severe features based on clinical and laboratory findings.
Severe Features Criteria. Preeclampsia with severe features includes ≥1 of: systolic BP ≥160 mmHg or diastolic ≥110 mmHg (severe hypertension), platelet count <100,000/mL, doubled serum creatinine or >1.1 mg/dL (if baseline <0.8), pulmonary edema, visual disturbances, cerebral symptoms, RUQ/epigastric pain, or hemolysis/elevated liver enzymes (HELLP)[1].
HELLP Syndrome. HELLP is a variant of severe preeclampsia with hemolysis, elevated liver enzymes (AST ≥2x upper limit of normal), and low platelets (<100,000/mL)[1]. HELLP confers higher maternal and fetal morbidity and mortality and mandates urgent delivery.
Acute Hypertension Management in Pregnancy
IV Labetalol. Labetalol is first-line antihypertensive in pregnancy[2]. Initial dose is 20 mg IV bolus; if inadequate response, repeat at 40 mg, then 80 mg at ~10-20 minute intervals (max cumulative 220 mg in first hour). Labetalol works rapidly (onset 5-10 minutes, peak effect 10-20 minutes). Effective in most cases of acute hypertension in pregnancy.
IV Hydralazine. Hydralazine 5-10 mg IV bolus, repeat every 20-30 minutes as needed (max 20 mg per dose) for additional BP reduction[2]. Onset is 10-20 minutes. Hydralazine is often used as second-line or in combination with labetalol if additional reduction needed. Note: direct vasodilation may cause reflex tachycardia and is less predictable than labetalol.
Oral Nifedipine. Immediate-release nifedipine 10 mg PO can be used for acute BP reduction in pregnancy[2]. Takes 15-30 minutes for effect but is convenient if IV access difficult. Can repeat after 30 minutes if inadequate response. Extended-release formulations are NOT for acute use.
Target BP. In acute hypertensive emergencies in pregnancy, target is to reduce systolic BP to <160 mmHg and diastolic to <110 mmHg to prevent maternal stroke and eclampsia. Avoid excessive reduction that risks placental hypoperfusion and fetal compromise.
Eclampsia Management: Magnesium is First-Line
Magnesium Sulfate for Seizure Prophylaxis. Magnesium sulfate is the first-line medication for seizure prevention in preeclampsia with severe features and for acute seizure management in eclampsia[1]. Standard dosing is 4 g IV bolus over 20-30 minutes, followed by 1-2 g/hour infusion. Benzodiazepines are NOT first-line and should not be used for initial management of eclamptic seizures.
Acute Seizure Management. If seizure occurs (eclampsia), immediately administer magnesium sulfate 4-6 g IV bolus (fast push over 3-5 minutes if seizure actively occurring). Position patient in left lateral decubitus to prevent aspiration and improve placental perfusion. Secure airway with bag-valve-mask if needed. Ensure IV access and cardiac monitoring. Call OBGYN and anesthesia emergently. Supplemental oxygen and continuous monitoring are essential.
Magnesium Toxicity Monitoring. Signs of magnesium toxicity include loss of patellar deep tendon reflexes (first sign), somnolence, muscle weakness, nausea, and respiratory depression. Severe toxicity manifests as respiratory paralysis and cardiac arrhythmias. Monitor reflexes regularly in patients receiving magnesium infusion. Calcium gluconate 1 g IV is the antidote for magnesium toxicity (reverses neuromuscular effects). Renal clearance is normal in most patients; dose adjustment needed only if severe renal impairment (Cr >2.0).
Postpartum Hemorrhage: The 4 T’s and Uterotonic Ladder
The 4 T’s Framework. Postpartum hemorrhage (PPH) is excessive bleeding after delivery (>500 mL vaginal, >1000 mL cesarean). The cause is rapidly assessed using the “4 T’s”: Tone (uterine atony — flaccid, boggy uterus), Tissue (retained placenta or products), Trauma (lacerations, uterine rupture), and Thrombin (coagulopathy)[3]. Quick assessment of uterine consistency, placental completeness, and vaginal bleeding source guides initial treatment.
Uterotonic Agents Ladder. Treatment of uterine atony proceeds in a stepwise fashion[3]: (1) Oxytocin 10 units IV or IM is first-line — effective, rapid onset, well-tolerated. (2) Misoprostol 800 mcg rectal (or 600 mcg oral) if oxytocin fails or unavailable — slower onset but effective. (3) Methylergonovine 0.2 mg IM (avoid IV bolus due to hypertension risk) if above fail. (4) Carboprost 250 mcg IM every 15 minutes (max 8 doses) as last pharmacologic step. If all agents fail, consider massive transfusion protocol, surgical intervention (D&C, balloon tamponade, or hysterectomy), and transfer to higher level of care.
Early Recognition and Aggressive Intervention. Don’t wait for ongoing bleeding to escalate — move through the uterotonic ladder quickly. Obtain IV access x 2 large-bore lines, type and cross, and transfuse red cells, FFP, and platelets per massive transfusion protocol if Hgb drops significantly or shock develops. Contact OBGYN early, establish patient is not febrile (rules out infection as primary cause), and prepare for potential OR transfer.
Safe Medications in Pregnancy: Quick Reference
Antibiotics in Pregnancy. Penicillins and cephalosporins are safe throughout pregnancy (FDA pregnancy category B/safe)[4]. Macrolides (azithromycin, erythromycin) are safe. Avoid fluoroquinolones, tetracyclines, and trimethoprim-sulfamethoxazole in first trimester or at term. Metronidazole is Category B and safe. Gentamicin is safe for short-term use with dose optimization (extended-interval dosing preferred).
Antihypertensives in Pregnancy. Labetalol, nifedipine, and methyldopa are safe first-line agents[2]. ACE inhibitors and ARBs are absolutely contraindicated in pregnancy (teratogenic — fetopathy, renal dysgenesis, oligohydramnios). Hydrochlorothiazide is relatively safe. Atenolol is safe but labetalol preferred.
Anticoagulation in Pregnancy. Warfarin is teratogenic in first trimester (fetal warfarin syndrome); use enoxaparin or unfractionated heparin (UFH) in first trimester instead[4]. All trimesters: heparin and enoxaparin are safe (do not cross placenta). Avoid DOACs (apixaban, rivaroxaban, dabigatran) — insufficient data in pregnancy. At delivery, transition to UFH (shorter half-life) to allow neuroaxial anesthesia.
Antiepileptics in Pregnancy. Lamotrigine and levetiracetam carry lowest teratogenic risk[4]. Valproic acid is teratogenic (neural tube defects, developmental delay) — avoid if possible. Phenytoin is relatively safe but older. Carbamazepine is safe. Phenobarbital carries some risk of developmental effects. Counsel on need for seizure control balanced against drug risks.
PROM Management: Timing and Approach
Preterm PROM (pPROM). Rupture of membranes before 37 weeks EGA is preterm PROM. Risk of infection and umbilical cord prolapse increases over time. For pPROM between 34-37 weeks, many manage with admission, antibiotics (ampicillin or amoxicillin plus erythromycin for 7 days), and consideration of corticosteroids. For pPROM <34 weeks, admission, antibiotics, and corticosteroids (betamethasone or dexamethasone) for fetal lung maturation are standard. OBGYN consultation is mandatory; do not send home[5].
Term PROM (≥37 weeks). Rupture of membranes at term is often followed by spontaneous labor within 24 hours. Confirm rupture (pooling, ferning, positive nitrazine). Avoid digital cervical exam if possible (risks infection). Most term PROM is managed with expectant management, induction at 24 hours if labor hasn’t begun, and antibiotics (GBS prophylaxis if unknown status). Some high-risk patients (maternal fever, nonreassuring FHT) go directly to delivery.
Avoid Digital Exams. Digital cervical examination increases infection risk in PROM; use sterile speculum exam instead to visualize pooling and obtain swabs (GBS culture if not done in pregnancy)[5].
Peripartum Cardiomyopathy: Diagnosis and Management
Timing and Definition. Peripartum cardiomyopathy (PPCM) is acute systolic heart failure (ejection fraction ≤45%) that presents in late pregnancy (third trimester) or in the postpartum period (up to 5 months postpartum, though most within 2-4 weeks of delivery)[6]. There is no known prior history of heart disease. Incidence is approximately 1 per 3,000-4,000 live births but varies geographically and by demographics.
Clinical Presentation. Patients present with dyspnea, orthopnea, fatigue, lower extremity edema, and sometimes chest pain. Exam may show crackles, S3 gallop, elevated JVP. Bedside echo or formal echocardiography confirms reduced ejection fraction. Differential includes valvular disease, myocarditis, and ischemic cardiomyopathy — diagnosis of exclusion[6].
Management Considerations by Trimester. In pregnancy, afterload reduction is achieved with hydralazine/isosorbide dinitrate (ACE inhibitors and ARBs are contraindicated)[6]. Diuretics for pulmonary edema are appropriate. Beta-blockers are safe. Delivery or induction should be planned in consultation with high-risk OB and cardiology. Postpartum, ACE inhibitors and beta-blockers become standard. Consider anticoagulation if EF <35% (risk of mural thrombus). Recovery varies; some patients regain normal EF over months, others have persistent cardiomyopathy. Recurrence risk in subsequent pregnancy is significant (up to 50% relapse or deterioration).
References
- ACOG. Hypertension in pregnancy. Washington DC: American College of Obstetricians and Gynecologists; 2023.
- Magee LA, Pels A, Helewa M, et al. Diagnosis, evaluation, and management of the hypertensive emergencies of pregnancy. J Obstet Gynaecol Can. 2014;36(5):416-441.
- ACOG. Prevention and management of obstetric hemorrhage. Washington DC: American College of Obstetricians and Gynecologists; 2021.
- Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation. 11th ed. Philadelphia: Wolters Kluwer; 2017.
- ACOG. Preterm labor and birth. Washington DC: American College of Obstetricians and Gynecologists; 2022.
- Bauersachs J, Arrigo M, Hilfiker-Kleiner D, et al. Current management of peripartum cardiomyopathy. Eur Heart J. 2016;37(21):1683-1691.
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