What is the management of hypotension (low blood pressure) post medical termination of pregnancy?

Management of Hypotension Post Medical Termination of Pregnancy

Prompt fluid resuscitation with crystalloids (1-2 L) should be administered within 60-90 minutes as the first-line treatment for hypotension following medical termination of pregnancy, followed by vasopressors if hypotension persists. 1

Initial Assessment and Management

Immediate Actions

• Position patient in left lateral tilt to increase venous return and cardiac output 1, 2
• Establish two large-bore (14-16 gauge) IV lines 3
• Administer oxygen to maintain saturation >95% 3
• Monitor vital signs continuously (blood pressure, heart rate, oxygen saturation)

Fluid Resuscitation

• First-line treatment: Crystalloid fluid bolus (1-2 L) administered within 60-90 minutes 1
• If signs of shock or persistent hypotension after initial fluid bolus, administer total 30 cc/kg within 3 hours 1
• Crystalloid coload is recommended as the most appropriate fluid regimen 4

Vasopressor Therapy

If hypotension persists after adequate fluid resuscitation (SBP <90 mmHg or MAP <65 mmHg):

First-Line Vasopressor

• Ephedrine: Initial dose 5-10 mg IV bolus, additional boluses as needed (not to exceed total 50 mg) 5
  • Titrate to effect based on blood pressure response
  • Prepare a 5 mg/mL solution by diluting 1 mL (50 mg) with 9 mL of normal saline or 5% dextrose 5

Alternative Vasopressors

If inadequate response to ephedrine or tachyphylaxis develops:

• Norepinephrine: Start at 0.02 μg/kg/min, can increase to 0.1-0.2 μg/kg/min 1
• Vasopressin: May be added (0.04 units/min) if MAP remains inadequate despite norepinephrine 1

Monitoring and Additional Management

Continuous Monitoring

• Blood pressure measurements every 5-15 minutes until stabilized
• Continuous cardiac monitoring
• Urine output monitoring
• Clinical assessment for bleeding

Laboratory Assessment

• Complete blood count
• Coagulation panel including fibrinogen (target >200 mg/dL) 1, 3
• Serum lactate (repeat within 6 hours if initially elevated) 1

Special Considerations

• If hypotension is associated with tachycardia and respiratory distress, consider amniotic fluid embolism (AFE) 6, 7
• For Rh-negative patients, administer anti-D immunoglobulin 3
• Consider Kleihauer-Betke test to quantify fetal-maternal hemorrhage in Rh-negative patients 3

Escalation of Care

If hypotension persists despite fluid resuscitation and vasopressors:

• Engage rapid response team or critical care consultation 1
• Consider invasive arterial blood pressure monitoring 1
• If cardiac dysfunction is suspected, consider adding epinephrine 1
• For persistent elevated lactate or increasing vasopressor requirements, continue fluid resuscitation using non-invasive hemodynamic monitoring 1

Important Cautions

• Avoid using vasopressors as first-line treatment before adequate fluid resuscitation 3
• Be cautious when using ephedrine with oxytocic drugs as serious postpartum hypertension can occur 5
• Be aware of potential tachyphylaxis with repeated ephedrine administration; have alternative pressors available 5
• Monitor for signs of pulmonary edema during aggressive fluid resuscitation 1