3.HELLPSyndromea.Presentation:Symptomsare oftennonspecificalaise, abdominal pain, vomiting, shortness ofbreath, bleeding.b.Differentialdiagnosis:Becauseofpresentation, HELLP syndrome must bedifferentiated from other disorders
a. Presentation: Symptoms are often nonspecific alaise, abdominal pain, vomiting, shortness of breath, bleeding. b. Differential diagnosis: Because of presentation, HELLP syndrome must be differentiated from other disorders
C.Management is the same as for severe pre-eclampsiaDelivery ata Perinatal CenterIf the only presenting symptom is thrombocytopenia,without elevated levels on liverfunction tests,antepartum treatment with steroids may be used toencourage platelet production but should be restrictedtolessthan28weeks'gestation
C.Management is the same as for severe pre-eclampsia. Delivery at a Perinatal Center If the only presenting symptom is thrombocytopenia, without elevated levels on liver function tests, antepartum treatment with steroids may be used to encourage platelet production but should be restricted to less than 28 weeks' gestation
Dosageis 10mg intramuscular/intravenous (IV)dexamethasone every12hours until platelets exceed100,000/mm3.If no response is seen by 24 to48hours or the patient's condition worsens,the patientshould bedelivered.Postpartum patients withthrombocytopenia maybesimilarlytreated with dexamethasone.The average time for resolution of symptoms is 4 days
Dosage is 10 mg intramuscular/intravenous (IV) dexamethasone every 12 hours until platelets exceed 100,000/mm3. If no response is seen by 24 to 48 hours or the patient's condition worsens, the patient should be delivered. Postpartum patients with thrombocytopenia may be similarly treated with dexamethasone. The average time for resolution of symptoms is 4 days
4.Seizureprophylaxis duringlabor and for 24hours postpartum is recommended for allpatients with pre-eclampsia. Some patients withseverepre-eclampsia need seizureprophylaxisfor longer periods before and after delivery
4. Seizure prophylaxis during labor and for 24 hours postpartum is recommended for all patients with pre-eclampsia. Some patients with severe pre-eclampsia need seizure prophylaxis for longer periods before and after delivery
a.Magnesium Sulfate (MgSO4)agent of Choicefor Seizure Prophylaxis.Magnesium sulfate hasbeen shown to decrease the risk of progressiontoeclampsiabygreaterthan50% (15).Loading dose is 6 g IV administered over 15 to20minutes.Maintenance dosage is 2g/hr IV and may betitrated to higher doses
a. Magnesium Sulfate (MgSO4) agent of Choice for Seizure Prophylaxis. Magnesium sulfate has been shown to decrease the risk of progression to eclampsia by greater than 50% (15). Loading dose is 6 g IV administered over 15 to 20 minutes. Maintenance dosage is 2 g/hr IV and may be titrated to higher doses
MgSO4(50% solution)may also be givenintramuscularly into the upper quadrant of thebuttocks.Loading dose is 5g ineachbuttocks.Maintenance dose is 3g inalternating buttocks every4hours.Therapeutic range and monitoring are the sameas with IV administration.Thetherapeuticmagnesiumlevel is 4to6mEq/LMagnesium level should be checked 4hours afteradministering the loading dose,then every 6 hours asneeded
MgSO4 (50% solution) may also be given intramuscularly into the upper quadrant of the buttocks. Loading dose is 5 g in each buttocks. Maintenance dose is 3 g in alternating buttocks every 4 hours. Therapeutic range and monitoring are the same as with IV administration. The therapeutic magnesium level is 4 to 6 mEq/L. Magnesium level should be checked 4 hours after administering the loading dose, then every 6 hours as needed
MagnesiumtoxicityThe patient should bemonitored hourly for signs andsymptoms of magnesium toxicity.Loss of patellar reflexes occurs at 8 to 10 mEa/Lrespiratorydepression or arrestoccurs at 12 mEq/Land mental status changes may occur at levels higherthan 12 mEq/L.Electrocardiogram (ECG) changesand arrhythmias may occur if toxicity is severe
Magnesium toxicity The patient should be monitored hourly for signs and symptoms of magnesium toxicity. Loss of patellar reflexes occurs at 8 to 10 mEq/L, respiratory depression or arrest occurs at 12 mEq/L, and mental status changes may occur at levels higher than 12 mEq/L. Electrocardiogram (ECG) changes and arrhythmias may occur if toxicity is severe
Treatment of magnesium toxicity.Magnesiumadministration should be discontinued and plasmamagnesium level determined.Therapy should beginhowever,based on a clinical diagnosis.Airway andoxygenation should be maintained;mechanicalventilation may be necessary. Ventilation andoxygenation should be monitored by pulse oximetryCalcium gluconate should be administered in a doseof 1gIV overat least3 minutes.Diureticagents(furosemide,mannitol)maybe administered
Treatment of magnesium toxicity. Magnesium administration should be discontinued and plasma magnesium level determined. Therapy should begin, however, based on a clinical diagnosis. Airway and oxygenation should be maintained; mechanical ventilation may be necessary. Ventilation and oxygenation should be monitored by pulse oximetry. Calcium gluconate should be administered in a dose of 1 g IV over at least 3 minutes. Diuretic agents (furosemide, mannitol) may be administered
b.Phenytoin (Dilantin)Loading dose is based on maternal weightThefirst750mgoftheloadingdoseshouldbegiven at 25 mg/min and the remainder at 12.5mg/min.If the patient shows a normal cardiacrhythm and has no history of heart diseasebefore initiation of therapy, ECG monitoring isnot necessary at this rate of infusion
b. Phenytoin (Dilantin) Loading dose is based on maternal weight. The first 750 mg of the loading dose should be given at 25 mg/min and the remainder at 12.5 mg/min. If the patient shows a normal cardiac rhythm and has no history of heart disease before initiation of therapy, ECG monitoring is not necessary at this rate of infusion
At30to60minutesafterinfusion,aserumphenytoinlevel should be obtained. The therapeutic level ishigher than 12mg/mL.If the findings show levelslower than 10 mg/mL, reloading with 500 mg shouldbeperformed andthelevel rechecked in30to 60minutes.If levels of 10 to 12 mg/mL are found, areloading dose of 250 mg should be administered andthe level rechecked in 30 to 60 minutes.If theserum phenytoin level is therapeuticat 30 to60minutes,the level should be recheckedin 12 hours
At 30 to 60 minutes after infusion, a serum phenytoin level should be obtained. The therapeutic level is higher than 12 mg/mL. If the findings show levels lower than 10 mg/mL, reloading with 500 mg should be performed and the level rechecked in 30 to 60 minutes. If levels of 10 to 12 mg/mL are found, a reloading dose of 250 mg should be administered and the level rechecked in 30 to 60 minutes. If the serum phenytoin level is therapeutic at 30 to 60 minutes, the level should be rechecked in 12 hours