What are the key components in the management of Pregnancy-Induced Hypertension (PIH)?

Management of Pregnancy-Induced Hypertension (PIH): A Comprehensive PowerPoint Presentation

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Slide 1: Title Slide

Management of Pregnancy-Induced Hypertension (PIH) A Clinical Approach to Maternal and Fetal Safety

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Slide 2: Learning Objectives

By the end of this session, you will be able to:

• Classify hypertensive disorders in pregnancy accurately 1
• Identify blood pressure thresholds requiring immediate intervention 2
• Select appropriate first-line antihypertensive agents for pregnant patients 2
• Recognize indications for hospitalization and delivery 1, 2
• Counsel patients on long-term cardiovascular risks 2

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Slide 3: Classification of Hypertensive Disorders in Pregnancy

Four Main Categories:

1. Chronic (Pre-existing) Hypertension

• BP ≥140/90 mmHg present before pregnancy or diagnosed before 20 weeks gestation 2, 1
• Persists beyond 42 days postpartum 1

2. Gestational Hypertension

• New-onset BP ≥140/90 mmHg after 20 weeks gestation 2, 3
• No proteinuria 1
• Resolves within 42 days postpartum 1
• Critical point: 25% progress to preeclampsia, especially if diagnosed <34 weeks 1, 3

3. Preeclampsia

• Gestational hypertension PLUS proteinuria (>300 mg/24h or dipstick ≥2+) 1
• Can occur with or without chronic hypertension 1

4. Chronic Hypertension with Superimposed Gestational Hypertension/Preeclampsia

• Pre-existing hypertension with worsening BP and proteinuria ≥3 g/24h after 20 weeks 1

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Slide 4: MCQ #1 (Hard Level)

A 28-year-old G2P1 at 22 weeks gestation presents with BP 148/94 mmHg on two occasions. She has no proteinuria, no symptoms, and normal labs. Her BP was 118/72 mmHg at her first prenatal visit at 8 weeks. What is the MOST appropriate next step?

A) Admit for immediate delivery
B) Start methyldopa 250 mg TID and follow as outpatient
C) Observe with close supervision, activity limitation, and weekly BP monitoring
D) Start labetalol 100 mg BID and schedule delivery at 37 weeks
E) Admit for 48 hours of observation then discharge on nifedipine

Answer: C 1, 3

Rationale: This patient has mild gestational hypertension (BP 140-149/90-95 mmHg) without severe features. Non-pharmacological management with close supervision is appropriate initially 1. Treatment thresholds are BP ≥140/90 mmHg in women with gestational hypertension WITH organ damage or symptoms, but ≥150/95 mmHg in uncomplicated cases 1, 2.

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Slide 5: Blood Pressure Thresholds - The Critical Numbers

When to Treat:

Immediate Treatment Required (Hypertensive Emergency):

• BP ≥160/110 mmHg = EMERGENCY requiring hospitalization within 15 minutes 1, 2
• Goal: Reduce mean BP by 15-25% initially 1
• Target: SBP 140-150 mmHg and DBP 90-100 mmHg 1

Chronic Treatment Thresholds:

• BP ≥140/90 mmHg: Treat if gestational hypertension, preeclampsia, chronic HTN with superimposed gestational HTN, or any hypertension with organ damage/symptoms 1, 2
• BP ≥150/95 mmHg: Treat in all other pregnant women with chronic hypertension 1, 2

Treatment Target:

• Diastolic BP: 85 mmHg 1, 2
• Systolic BP: 110-140 mmHg 1, 2
• Stop or reduce medications if DBP <80 mmHg 1

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Slide 6: MCQ #2 (Hard Level)

A 32-year-old G1P0 at 34 weeks with preeclampsia has BP 168/112 mmHg. She has mild headache but no visual changes. Which medication should you AVOID as first-line treatment?

A) Oral immediate-release nifedipine
B) Intravenous labetalol
C) Intravenous hydralazine
D) Oral methyldopa
E) Intravenous magnesium sulfate

Answer: C 1

Rationale: Intravenous hydralazine should no longer be considered first-line because it is associated with more perinatal adverse effects than other drugs 1. First-line options for severe hypertension are oral immediate-release nifedipine or IV labetalol 2, 1. Methyldopa is too slow-acting for emergencies 1. Magnesium sulfate is for seizure prophylaxis, not BP control 2.

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Slide 7: Acute Management of Severe Hypertension (BP ≥160/110 mmHg)

First-Line Options:

1. Oral Immediate-Release Nifedipine 2

• Preferred by ACOG
• Rapid onset
• NEVER give with magnesium sulfate (risk of severe hypotension) 2, 4

2. Intravenous Labetalol 1, 2

• Equally effective
• Can be given as boluses or infusion
• NEVER give with calcium channel blockers (risk of severe hypotension) 2

3. Intravenous Hydralazine 1

• No longer first-line due to increased perinatal adverse effects 1
• Still used as second/third-line 1

Special Situations:

Preeclampsia with Pulmonary Edema:

• Nitroglycerin is the drug of choice 1

Hypertensive Crisis:

• Sodium nitroprusside remains treatment of choice 1
• Risk: Prolonged use causes fetal cyanide poisoning 1

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Slide 8: Chronic Blood Pressure Management - First-Line Agents

The Three Preferred Medications:

1. Methyldopa 2, 5

• Dose: Start 250 mg BID-TID, max 3 g/day 5
• Only agent with long-term pediatric follow-up data (7.5 years) 5
• AVOID postpartum (risk of postnatal depression) 2
• Start evening doses to minimize sedation 5

2. Labetalol 1, 2

• Efficacy comparable to methyldopa 1
• Can be used IV or PO
• NEVER combine with calcium channel blockers 2

3. Long-Acting Nifedipine 1, 2

• Calcium channel blocker
• Effective for chronic control
• NEVER combine with magnesium sulfate or labetalol 2

Second/Third-Line Agents:

• Hydralazine 1
• Prazosin 1
• Oxprenolol 1

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Slide 9: MCQ #3 (Hard Level)

A 35-year-old G3P2 at 28 weeks with gestational hypertension is started on methyldopa 250 mg TID. Three days later, her BP is 138/88 mmHg but she complains of severe fatigue interfering with daily activities. What is the BEST management?

A) Continue methyldopa and reassure that side effects will resolve
B) Increase methyldopa to 500 mg TID
C) Switch to labetalol and dose in the evening
D) Add nifedipine to methyldopa
E) Stop all medications since BP is controlled

Answer: C 5, 2

Rationale: Methyldopa causes sedation, which can be minimized by starting doses in the evening 5. However, if sedation is severe and interfering with function, switching to labetalol (which has comparable efficacy) is appropriate 1, 2. The BP is still elevated (target DBP 85 mmHg), so stopping medication is inappropriate 2.

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Slide 10: Medications to ABSOLUTELY AVOID

Contraindicated in Pregnancy:

ACE Inhibitors and Angiotensin Receptor Blockers 1, 2

• Cause severe fetotoxicity, especially in 2nd and 3rd trimesters 1
• Associated with fetopathy 2
• If taken inadvertently in 1st trimester: switch immediately and perform close fetal ultrasound monitoring 1

Direct Renin Inhibitors 1

• Strictly contraindicated

Atenolol (with caution) 1

• Associated with fetal growth retardation when used long-term 1
• Duration-dependent effect 1

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Slide 11: Non-Pharmacological Management

Appropriate for BP 140-149/90-95 mmHg without severe features 1, 2

Recommended Interventions:

• Close supervision with frequent BP monitoring 1, 3
• Activity limitation and some bed rest in left lateral position 1
• Normal diet WITHOUT salt restriction 1
• Monitor for progression to preeclampsia 3

What DOESN'T Work:

NOT Recommended for Prevention:

• Calcium supplementation (2 g/day) - inconsistent benefits 1
• Fish oil supplementation 1
• Vitamin/nutrient supplements 1
• Weight reduction during pregnancy in obese women (may reduce neonatal weight) 1

Low-Dose Aspirin (75-100 mg/day):

• ONLY for women with history of early-onset preeclampsia (<28 weeks) 1
• Start pre-pregnancy or before 16 weeks gestation 1
• Administer at bedtime 1
• Continue until delivery 1

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Slide 12: MCQ #4 (Hard Level)

A 29-year-old G1P0 at 18 weeks has chronic hypertension on enalapril 10 mg daily from before pregnancy. BP today is 152/96 mmHg. She reports she has been taking her medication regularly. What is the MOST appropriate management?

A) Increase enalapril to 20 mg daily
B) Add hydrochlorothiazide to enalapril
C) Stop enalapril immediately, start methyldopa, and arrange urgent fetal ultrasound
D) Continue enalapril and add labetalol
E) Stop enalapril, observe for 1 week, then start methyldopa if BP remains elevated

Answer: C 1, 2

Rationale: ACE inhibitors are absolutely contraindicated in pregnancy due to severe fetotoxicity 1, 2. If taken inadvertently, immediate discontinuation with switch to safe alternative (methyldopa, labetalol, or nifedipine) and close fetal ultrasound monitoring are required 1. Waiting one week is inappropriate given the teratogenic risk and uncontrolled BP.

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Slide 13: Indications for Hospitalization

Admit Immediately for:

Severe Hypertension:

• BP ≥160/110 mmHg 1, 2, 3

Development of Preeclampsia Features:

• New-onset proteinuria 3
• Neurological signs or symptoms (headache, visual disturbances, altered mental status) 1, 2, 3
• Hepatic tenderness (risk of rupture) 1
• Laboratory abnormalities (thrombocytopenia, elevated liver enzymes, rising creatinine) 1, 3

Inadequate Blood Pressure Control:

• Inability to control BP with ≥3 antihypertensive drug classes 2

Maternal Warning Signs: 1

• Heart rate <50 or >130 bpm
• Oxygen saturation <95% on room air
• Oliguria (<35 mL/h for ≥2 hours)
• Maternal agitation, confusion, or unresponsiveness
• Non-remitting headache
• Shortness of breath

Fetal Concerns:

• Fetal distress 1
• Suspected growth restriction requiring intensive monitoring 1

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Slide 14: Monitoring Requirements

Maternal Monitoring in Preeclampsia:

Clinical Assessment: 1

• BP monitoring (frequency depends on severity)
• Assessment for clonus
• Evaluation for symptoms (headache, visual changes, epigastric pain)

Laboratory Tests (at least twice weekly): 1

• Hemoglobin
• Platelet count
• Liver transaminases (AST, ALT)
• Creatinine
• Uric acid

Urine Analysis:

• Repeated assessments for proteinuria if not already present 1
• Quantification if positive 1

Fetal Monitoring:

Initial Assessment at Diagnosis: 1

• Fetal biometry (ultrasound)
• Amniotic fluid assessment
• Umbilical artery Doppler

Ongoing Monitoring:

• Every 2 weeks if initial assessment normal 1, 3
• More frequent if fetal growth restriction present 1, 3
• Electronic fetal heart monitoring 1

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Slide 15: MCQ #5 (Hard Level)

A 31-year-old G2P1 at 32 weeks with preeclampsia (BP 152/98 mmHg, proteinuria 2+ on dipstick) is being managed as an outpatient on labetalol. She calls reporting a severe headache that started 2 hours ago and is not relieved by acetaminophen. Her home BP is 156/94 mmHg. What should you advise?

A) Increase labetalol dose and follow up in clinic tomorrow
B) Take an extra dose of labetalol and recheck BP in 4 hours
C) Come to the emergency department immediately for evaluation
D) Add nifedipine to labetalol and follow up in 2 days
E) This is normal in pregnancy; continue current management

Answer: C 1, 2

Rationale: Non-remitting headache in a patient with preeclampsia is a maternal warning sign requiring immediate evaluation 1. This could indicate impending eclampsia or other serious complications. The BP is not severely elevated, but the symptom mandates urgent assessment 1. All women with preeclampsia can become emergencies rapidly 1.

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Slide 16: Preeclampsia-Specific Management

Magnesium Sulfate for Seizure Prophylaxis:

Indications: 1, 2

• Women with preeclampsia who have:
  • Proteinuria AND severe hypertension (≥160/110 mmHg)
  • Hypertension with neurological signs or symptoms
• Treatment of eclamptic seizures 4

Dosing (Low Resource Settings): 1

• Loading dose: 4 g IV or 10 g IM
• Maintenance: 5 g IM every 4 hours OR 1 g/h infusion
• Continue until delivery and for at least 24 hours postpartum

Critical Drug Interaction:

• NEVER give magnesium sulfate with calcium channel blockers (severe hypotension risk) 2, 4

What NOT to Do:

Plasma Volume Expansion:

• NOT recommended routinely in preeclampsia 1

Attempting to Classify Severity:

• Do not attempt to diagnose "mild" vs "severe" preeclampsia clinically 1
• All cases may become emergencies rapidly 1

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Slide 17: Timing of Delivery

Gestational Hypertension (without preeclampsia):

• Delivery can be delayed until 39+6 weeks if: 2, 3
  • BP remains controlled
  • Fetal monitoring is reassuring
  • Preeclampsia has not developed
• Optimal timing appears to be 38-39 weeks based on retrospective data (needs RCT confirmation) 1, 3

Preeclampsia at Term:

• Recommend delivery 2

Preeclampsia with Adverse Conditions:

• Immediate delivery indicated for: 2
  • Visual disturbances
  • Coagulation abnormalities
  • Fetal distress
  • Severe hypertension unresponsive to treatment
  • Eclampsia

Preterm Preeclampsia:

• Balance maternal and fetal risks 1
• Consider corticosteroids for fetal lung maturity if <34 weeks 1
• Delivery decision based on severity and gestational age 1

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Slide 18: MCQ #6 (Hard Level)

A 26-year-old G1P0 at 36 weeks with gestational hypertension (BP 146/92 mmHg on methyldopa 500 mg TID) presents with BP 172/114 mmHg and new-onset seizure. After stabilizing the airway and positioning her in left lateral decubitus, what are the next TWO most important interventions?

A) Administer magnesium sulfate 4 g IV loading dose
B) Give immediate-release nifedipine 10 mg PO
C) Start IV labetalol bolus
D) Prepare for immediate delivery
E) Obtain CT head

Best Answer: A and C 1, 2, 4

Rationale: This is eclampsia (seizure in setting of hypertensive disorder). Magnesium sulfate is first-line for eclamptic seizures 4. The BP ≥160/110 mmHg requires urgent treatment with IV labetalol or oral nifedipine 1, 2. However, you cannot give nifedipine with magnesium sulfate due to severe hypotension risk 2, 4, so IV labetalol is the better choice here. Delivery is important but stabilizing the mother first is priority 4.

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Slide 19: Postpartum Management

Blood Pressure Patterns:

• BP typically rises over first 5 postpartum days 2
• Women may become hypertensive again after initial normalization 2
• Continue monitoring closely 2

Medication Adjustments:

Switch from Methyldopa:

• MUST switch to alternative agent postpartum 2
• Risk of postnatal depression 2
• Options: labetalol, nifedipine 2

Breastfeeding Considerations:

• Methyldopa appears in breast milk 5
• Caution advised with all antihypertensives in nursing mothers 5

Resolution Timeline:

• Gestational hypertension typically resolves within 42 days postpartum 1, 3
• If persists beyond 42 days, reclassify as chronic hypertension 1

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Slide 20: Long-Term Cardiovascular Risk - The Critical Counseling Point

Women with PIH Have Dramatically Increased Lifetime CV Risk:

Chronic Hypertension:

• Relative risk 2.3-11 times higher after PIH 6

Stroke:

• Twofold increased risk after preeclampsia/eclampsia 6

Ischemic Heart Disease:

• More than doubled relative risk 2

Type 2 Diabetes:

• 1.8 times increased likelihood 6

Chronic Kidney Disease:

• Tenfold greater risk 6

Cardiovascular Death:

• 2.1 times higher relative risk overall 6
• 4-7 times higher if preterm birth associated with gestational HTN or pre-existing HTN 6

Other Complications:

• Higher frequency of arrhythmias 6
• Increased hospitalization for heart failure 6

Highest Risk Groups: 2

• Early-onset preeclampsia
• Stillbirth
• Fetal growth retardation

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Slide 21: Long-Term Follow-Up Recommendations

Essential Counseling:

Annual Medical Review Lifelong: 2

• Cardiovascular risk assessment
• BP monitoring
• Screening for diabetes
• Lipid profile
• Renal function assessment

Lifestyle Modifications: 2

• Weight management
• Regular physical activity
• Healthy diet
• Smoking cessation

Control of Metabolic Factors: 2

• Early diagnosis and treatment of chronic hypertension
• Diabetes screening and management
• Lipid management

Recurrence Risk:

Subsequent Pregnancies:

• Women with PIH in first pregnancy are at increased risk in subsequent pregnancies 2
• Earlier onset in first pregnancy = greater recurrence risk 2

Postpartum Period:

• Great opportunity to intervene on lifestyle, obesity, and provide early diagnosis/treatment 6

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Slide 22: MCQ #7 (Hard Level)

A 33-year-old woman had severe preeclampsia at 29 weeks in her first pregnancy 2 years ago, requiring emergency cesarean delivery. She is now planning her second pregnancy and asks about prevention strategies. What is the MOST evidence-based recommendation?

A) Start calcium supplementation 2 g/day now
B) Begin low-dose aspirin 75-100 mg at bedtime once pregnant, before 16 weeks
C) Plan for prophylactic antihypertensive therapy starting at 12 weeks gestation
D) Recommend fish oil supplementation throughout pregnancy
E) Advise against future pregnancy due to high recurrence risk

Answer: B 1

Rationale: Low-dose aspirin (75-100 mg/day) is used prophylactically in women with history of early-onset preeclampsia (<28 weeks) 1. It should be started pre-pregnancy or from diagnosis of pregnancy, but before 16 weeks gestation, administered at bedtime, and continued until delivery 1. Calcium supplementation has inconsistent evidence 1. Fish oil has no proven benefit 1. Prophylactic antihypertensives are not standard. While recurrence risk is increased, pregnancy is not contraindicated 2.

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Slide 23: Clinical Pearls and Common Pitfalls

Critical Pitfalls to Avoid:

1. Drug Interactions:

• NEVER combine nifedipine with magnesium sulfate 2, 4
• NEVER combine labetalol with calcium channel blockers 2
• NEVER use ACE inhibitors or ARBs in pregnancy 1, 2

2. Underestimating Gestational Hypertension:

• 25% progress to preeclampsia - not a benign condition 1, 3
• Highest risk if diagnosed <34 weeks 1

3. Attempting to Classify Preeclampsia Severity:

• All preeclampsia can become emergencies rapidly 1
• Don't be falsely reassured by "mild" features 1

4. Forgetting Postpartum Risks:

• BP rises in first 5 days postpartum 2
• Switch from methyldopa (depression risk) 2
• Continue monitoring closely 2

5. Inadequate Long-Term Counseling:

• Lifetime CV risk is dramatically increased 2, 6
• Annual follow-up is essential 2

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Slide 24: Management Algorithm Summary

Step 1: Classify the Disorder

• Chronic HTN vs Gestational HTN vs Preeclampsia vs Superimposed 1, 2

Step 2: Assess Severity

• BP ≥160/110 mmHg = EMERGENCY 1, 2
• BP 140-159/90-109 mmHg = Assess for features requiring treatment 1, 2

Step 3: Determine Treatment Strategy

If BP ≥160/110 mmHg:

• Hospitalize immediately 1, 2
• IV labetalol OR oral immediate-release nifedipine 2
• NOT both together 2
• If preeclampsia with neurological symptoms: add magnesium sulfate 1, 2

If BP 140-159/90-109 mmHg:

• Treat if: gestational HTN, preeclampsia, chronic HTN with superimposed gestational HTN, or any HTN with organ damage/symptoms 1, 2
• First-line: methyldopa, labetalol, or long-acting nifedipine 2
• Target DBP 85 mmHg, SBP 110-140 mmHg 1, 2

If BP 140-149/90-95 mmHg without features:

• Consider non-pharmacological management initially 1, 2
• Close monitoring for progression 3

Step 4: Monitor Appropriately

• Maternal: BP, symptoms, labs twice weekly 1
• Fetal: Ultrasound every 2 weeks if normal 1, 3

Step 5: Plan Delivery

• Gestational HTN: 38-39 weeks if controlled 1, 3
• Preeclampsia at term: deliver 2
• Preeclampsia with adverse features: immediate delivery 2

Step 6: Postpartum and Long-Term

• Switch from methyldopa 2
• Counsel on lifetime CV risk 2, 6
• Arrange annual follow-up 2

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Slide 25: Take-Home Messages

🎯 The Five Most Critical Points:

1. BP ≥160/110 mmHg is a hypertensive EMERGENCY requiring treatment within 15 minutes to prevent maternal stroke 1, 2

2. The three safe first-line agents are methyldopa, labetalol, and long-acting nifedipine - NEVER use ACE inhibitors or ARBs 1, 2

3. Drug interactions can be lethal: NO nifedipine with magnesium sulfate, NO labetalol with calcium channel blockers 2, 4

4. Gestational hypertension is NOT benign - 25% progress to preeclampsia, especially if diagnosed before 34 weeks 1, 3

5. Women with PIH have 2-11 times increased risk of chronic hypertension and doubled risk of stroke - they need annual cardiovascular follow-up for LIFE 2, 6

🔑 The Golden Rule:

All preeclampsia can become an emergency rapidly - never underestimate any hypertensive disorder in pregnancy 1

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Slide 26: Final MCQ #8 (Hard Level)

A 30-year-old G2P1 at 35 weeks with preeclampsia (BP 158/102 mmHg, proteinuria 3+) is admitted. She is started on IV magnesium sulfate for seizure prophylaxis. Two hours later, her BP is 168/110 mmHg. She has no symptoms. What is the MOST appropriate next step?

A) Increase magnesium sulfate infusion rate
B) Add oral immediate-release nifedipine 10 mg
C) Start IV labetalol bolus
D) Prepare for emergency cesarean delivery
E) Continue current management and recheck BP in 1 hour

Answer: C 1, 2

Rationale: BP ≥160/110 mmHg requires urgent treatment 1, 2. She is already on magnesium sulfate, so nifedipine is contraindicated due to severe hypotension risk when combined with magnesium 2, 4. IV labetalol is the appropriate choice 1, 2. Waiting 1 hour is inappropriate for severe hypertension (stroke risk) 1, 2. Emergency delivery is not indicated without other adverse features 2.

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End of Presentation

Remember: PIH management is about preventing maternal stroke, recognizing progression to preeclampsia, using safe medications correctly, and counseling about lifelong cardiovascular risk.