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DM, HTN, and PTL:Pearls for the Bedside

Berry Campbell, MD

USC School of Medicine

Director, Maternal Fetal Medicine

Berry Campbell, MD

USC School of Medicine

Director, Maternal Fetal Medicine

18 Year Old G1 @ 36 weeks• Presents in labor

• Presumed gastroenteritis (N&V 3 days)

• Ctx q 3 minutes, decreased variability, late decels

• CBC normal

• Routine (limited) prenatal care – negative history

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What interventions?

• IVF

• Oxygen

• Position change

• Terbutaline

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Next Step?

• DELIVERY!!!!!!

• General anesthesia

Primary Cesarean Section• 8 lb 2oz male

• 2/3/5 Apgars

• Cord gas pH 6.9

• Placenta large and edematous; excessive AF upon amniotomy (polyhydramnios)

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Intra-operative Course

• BP low

• Pulse > 140

• 02 sats < 92%

• Labs → pH 6.9

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Thoughts??

• Abruptio

• Pulmonary embolus

• Amniotic fluid embolus

• Other?

• Labs: Cr 1.7, K+ 7.2, Na+ 129, HCO3

• Glucose 433

DIAGNOSIS

Diabetic Ketoacidosis!

Missed glucola, never had 3rd trimester labs

Gestational DM?

Pregestational?

Diabetes Mellitus Complications

• Macrosomia, IUGR

• Birth defects

• Stillbirth

• Neonatal hypoglycemia, trauma, polycythemia, jaundice

• HTN, preeclampsia

• Diabetic ketoacidosis

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DKA

• Maternal mortality

• Perinatal asphyxia, acidosis (ketones)

• Perinatal mortality up to 70%

Diabetic Ketoacidosis• pH < 7.3

• Serum HCO3 - Low

• Serum acetone positive

• BS ≥ 300 (200 in pregnancy)

• Other findings: Elevated K then low, low Na, Cl and HCO3

• Literally, DKA is deficiency of insulin

Insulin

• ↓ FFA release from adipose

• ↓ Liver FFA oxidation and Ketogenesis

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DKADecreased Insulin

↓

↑ FFA

↓

↑ Ketone release

↓

Metabolic Acidosis, Respiratory Compensation (Kussmaul breathing)

DKA

Hyperglycemia

↓

Osmotic Diuresis

↓

Excessive Urine Loss of water, Na, K

↓

Volume Contraction

Fetal Death

• Hyperglycemia →

hyperinsulinemia

• Insulin ↑ metabolic rate, ↑oxygen consumption & ↓O2 delivery stillbirth

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• Precipitating factors

– Prolonged emesis from any cause

– Infection

– Insulin omission/pump failure

– Non-compliance

– Alcohol/drug use

– Steroids

DKA

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DKA TreatmentIV Insulin 0.2-0.4 units/kg – Load

2.0-10.0 units/hour maintenance

Na Cl 0.9% 4-6L first 12 hours1 L first hour

500-1000ml/hr x 4 hours250 ml/hr

D5 NS When glucose 200-250

Potassium elevated initially Replace 20 meq/L when normal

Bicarb 1 Amp/L if pH < 7.1

DKA

Allow in utero resuscitation if possible before delivery

Hypovolemia, acidosis, impaired O2 delivery

↓

Fetal death

Diabetic Ketoacidosis

• Most often in long standing pre-gestational diabetics

• Non-compliance the single most common issue

• Repeated episodes are common, related to higher risk of vascular complications

• History: Ever have DKA? When was last time?

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24 year old G1P0 @ 28 weeks• C/O HA, visual spots

• BP 140/90; 1 + protein

• Fetal size CWD, normal fluid and BPP

• No history HTN

Management

• Admit obs

• Labs: LFT’s, CBC, Cr, 24 hour urine

• Treat HA

• Consider Steroids

• No change in status, BP and symptoms disappear, no protein

• Diagnosis?

• HTN in pregnancy (gestational HTN)

• Management?

• Outpatient obs with no BP meds; ?steroids?

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Oral Agents

Obstetrical Classification of Hypertensive Disorders in Pregnancy

1. Hypertension in pregnancy

2. Severe-range hypertension

3. Chronic hypertension

4. Chronic hypertension with superimposed preeclampsia

Diagnosis of Hypertensive Disorders in Pregnancy

Hypertension in pregnancy

• Systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg, or both

• Measured on two occasions at least 4 hours apart

• Includes preeclampsia, eclampsia and gestational hypertension

• Diagnosed if ≥ 20 weeks gestation

Severe range hypertension in pregnancy

• Systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg, or both

• Measured on two occasions at least 4 hours apart

• Also includes preeclampsia, eclampsia and gestational hypertension

• Diagnosed if ≥ 20 weeks gestation

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Diagnosis of Hypertensive Disorders in Pregnancy

Chronic hypertension

• Hypertension diagnosed or present before pregnancy or before 20 weeks gestation

• Also hypertension diagnosed for the 1st time in pregnancy and that does not resolve in the postpartum period

Chronic hypertension with superimposed preeclampsia

• Preeclampsia in any woman with chronic hypertension

Same patient………but now

• BP 180/110; 1 + protein; O2 sats 92%

• LFT’s normal Cr 1.1

• Hb 12.3 plt 142k

• HA and visual changes improve

• NST Rx

• Management?

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• BP management

• CXR, consider BNP

• Strict I&Os

• Weight

• IVF, magnesium sulfate, steroids

• Oxygen

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Intrapartum Management: Medications for Acute-onset, Severe BP

• ***Goal is NOT to normalize BP, but a mild hypertensive BP range (140-150/90-100 mm Hg)***

• First line medication management choices include: IV labetalol, IV hydralazine, OR immediate release oral nifedipine

• Magnesium sulfate is NOT used as an antihypertensive medication but is the drug of choice for seizure prophylaxis

Loading dose 4-6 g over 15 min IV, then 1-2 g/hr

Target serum concentration 4-8 mg/dL

Toxicity corrected with calcium gluconate, IVF, loop diuretics or hemodialysis

Intrapartum Management: Medications for Acute-onset, Severe BP

• Suggested protocols (just pick one):

1. Initial 1st line management with immediate release oral nifedipine

2. Initial 1st line management with IV hydralazine

3. Initial 1st line management with IV labetalol

HOWEVER: Clinical situation may benefit a specific choice over others!

• CXR increased interstitial markings

• BNP 442

• What BP med?

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PREECLAMPSIA

Vasospasm …….↑ BP

↓

Endothelial Injury…….. Edema,

Platelet

consumption,

Proteinuria

PreeclampsiaOrgan System Involvement

• Renal - GFR, Cr, Protein spill

• Liver – Fibrin deposits with LFT’s

• Hematologic – Low platelets, Hct, coagulopathy

• CNS - HA, visual changes, seizures

• Respiratory – Pulmonary Edema

BP Management with Pulmonary Edema

• Prefer after-load reduction (vasodilator)

• Choices:

Hydralazine

Procardia

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Hydralazine

Nifedipine

24 year old G1P0 @ 28 weeks• Same as before, severe HTN

• BUT………….

• Fetal weight 5% tile

• FHT reassuring

• Doppler flow abnormal (IRDF)

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BP Management?

• Remember, fetus is teetering on the edge!

• High BP may be the only thing perfusing placenta (UPI)

• SLOWLY decrease BP, maybe slower admin of meds

• Extreme care if use Procardia (other IV choices better as can titrate starting with lower doses)

Labetalol

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BP Management

• Same patient with serum Cr 1.8, poor UOP?

• Procardia shown to improve renal perfusion, UOP

Same case• c/o HA with loss of vision

• Seizure begins!

• Supportive: Airway, O2 sats

• Magnesium sulfate IV (continue or start)

• BP meds

• FHR monitoring

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Management• Seizure recovers

• Continue Magnesium sulfate

• Move to delivery

• Induction vs. CS

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Preeclampsia ComplicationsEclampsia <1%

Abruptio 1-9%

Renal Failure <1%

DIC <1%

Low Platelet 2-12%

Pulmonary edema 2-6%

Stillbirth <1%

Maternal death <1%

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Preeclampsia, Severe Features• BP ≥ 160/110

• Protein > 5g / 24 hour urine (no more)

• Oliguria (< 400ml/24Hour)

• Visual changes

• Epigastric Pain

• Pulmonary Edema

• Abnormal liver

• Low platelets

• IU GR (no more)

Remember!If decreased UOP, Lower magnesium infusion!

If on magnesium sulfate and decide to use Procardia………

DON’T FORGET POTENTIAL TOXICITY OF CALCIUM CHANNEL BLOCKADE!!!!!!!

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Hypertensive Emergencies• Require immediate control of BP; defined as SBP > 180 mmHg or

DBP > 120 mmHg and/or acute target organ damage; ICU admission

• Present with cerebral infarction, pulmonary edema, hypertensive encephalopathy, CHF

• Esmolol load 0.25-0.5 mg/kg IVP over 1 minute, then 0.05-0.1 mg/kg/min IV for 4 minute

• Nicardipine IV infusion at 5 mg/hr and titrated by 2.5 mg/hr every 5 min to max rate of 15 mg/hr

• Nitroglycerin IV infusion at 5 µg/min increased every 3-5 min until max dose of 100 µg/min

• Sodium nitroprusside IV infusion at 0.25 to 5.0 µg/kg/min; onset immediate w/ short half-life (extreme cases only)

• Epidural analgesia can be helpful for reduction in SVR

Hypertensive Emergencies

***Goal to reduce SBP by max of 25% in 1st hour, then aim for 160/100 over next 2-6 hours, then cautiously titrate to normal over next 24-48 hours

*Key to hypertension in pregnancy; have an established action plan / protocol in place before actual event. In other words, know what you know and if you don’t know get help

Prevention of Preeclampsia

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• 38 yo G1 at 28 weeks

• Presents with uterine contractions, spotting, watery mucous discharge

• IVF pregnancy

• Uncomplicated course to this point

• FHT reactive, ctx every 3-5 minutes

• Palpate moderate intensity

• Pelvic no ROM

• Cervix digitally 4cm/70%/-1

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Management??

• IV Fluids

• Betamethasone

• Rule/out infection (UTI, GC, etc)

• Transfer/keep (NICU capabilities)

• Tocolytics?

• Magnesium sulfate: Ca channel blocker. SE: toxicity (resp)

• Indomethacin: NSAID. SE: renal, GI, bleeding

• Terbutaline: Betamimetic. SE: cardiac, ↑BS

• Procardia (short acting): Ca channel blocker. SE: HA, cardiac

Preterm Labor

• IV magnesium sulfate 4-6 g bolus then 2-3 g/hr

• SQ terbutaline 0.25 q 30 min up to 3 doses with pulse < 130

• Indocin 25-50 mg po q 4; nifedipine 10-20 mg po q 4

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• Don’t forget—

• Age risks.

• IVF risks.

Preterm Labor

• Betamethasone 12mg IM x 2 doses, 24 hours apart

• Goal: attain 48 hours from 1st dose—lowers risk of RDS, ICH, NEC

• Precipitating/associated factors: UTI, other infections, previa, abruptio, prior PTL, twins, smoking, drug abuse

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• Cervix 6cm/100%/0 station

• 1 hour ground transport

• Transfer/ keep?

• Presentation make any difference?

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Preterm Labor (<37 weeks)

• Contractions

• Cervical change or >2cm/50% on 1st exam with contractions

• Early preterm <34 weeks

• Late preterm 34-36w 6d

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Thank You!!

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• Potassium

• Deficit often 5 – 10 mEq/kg

• Do not replace in during the first 2-4 hours

– Levels usually normal to mildly elevated at outset

– As acidosis corrected, levels fall quickly due to intracellular shift ---H+/K+ transporter

• Replacement

– 40 mEq/h when serum K<3

– 30 mEq/h if between 3 and 4

– 20 mEq/h if between 4 and 5

– No replacement if >5

• Monitor UOP carefully, may use KCl, KPhos

DKA

• The Basics

– Patient transferred to ICU

– Fetal monitoring if at viable gestational age

– Detailed flow chart

• Dates/times

• Serial glucose measurements

• Serum ketones

• Electrolytes

• ABGs

• AG

• Insulin

• I/Os

DKA

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• Diagnosis in pregnancy

– Serum pH <7.30

– Serum bicarbonate < 15

– Serum ketones > 1:2 dilution

– Any glucose level (non-pregnant needs to be >300)

• Often leukocytosis present, not necessarily indicative of infection, look for left shift

• AG in DKA often >15 [Na-(Cl+HCO3)]

• Serum osmolality correlates with mental status

– [2(Na+K)+serum glucose/18], value >320 mOsm/L significant, coma > 340

DKA

• Clinical presentation

– Develops over 3-7 days

– Polyuria, polydipsia, blurred vision, anorexia, nausea/vomiting, abdominal pain, weight loss

– Abdominal symptoms from elevated ketones

– May have mental status changes, Kussmaul breathing, fruity odor, dry mucous membranes

– Sinus tachycardia and orthostatic hypotension

DKA

• Ketones

– Moderately strong acids

– Body reacts to correct the metabolic acidosis

• Respiratory

– Kussmaul breathing – increase respiratory rate and depth

– Blow-off CO2

– Compensatory “respiratory alkalosis”

• Bicarbonate declines

• Hyperglycemia osmotic diuresis

DKA

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Preeclampsia• 7% incidence

• Nulliparous, family history, multiples, Renal Disease, HTN, IDDM, previous preeclampsia, African Americans

HELLP• Hemolysis

• Elevated Liver

• Low Platelet

• 2-12% of preeclampsia

HELLP• Epigastric Pain

• Nausea/Vomiting

• HTN, Edema, Proteinuria

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Preeclampsia Management

• Supportive care

• Magnesium sulfate – seizure prophylaxis

• Betamethasone if < 34 weeks

• Delivery

Eclampsia

• Think ABCs

• Magnesium sulfate

• Stabilize

• Deliver if pregnant once stable

DiagnosisMagnesium Toxicity

Loss reflex 8-10 mg%

Slurred speech 10-12mg%

Muscle paralysis, respiratory difficulty 15-17mg%

Cardiac arrest 30-35mg%

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