Gestational Hypertension  Peggy Foster, RN, MSN Sandy Warner, RNC- OB, MSN
INCIDENCE and IMPACT <ul><li>Complicates 6-10% of all Pregnancies in U.S. </li></ul><ul><ul><li>3-8 % of Healthy Primipara...
SYMPTOMS—3 Classic <ul><li>High Blood Pressure </li></ul><ul><li>Proteinuria </li></ul><ul><li>Edema </li></ul>
OTHER ASSOCIATED SYMPTOMS <ul><li>Neurological symptoms (Cerebral or Visual Disturbances): </li></ul><ul><ul><ul><li>Hyper...
Classification of Hypertensive States of Pregnancy <ul><li>Gestational hypertension </li></ul><ul><ul><li>development of m...
Classification continued <ul><li>Chronic HTN </li></ul><ul><ul><li>HTN occurring before pregnancy or B/P > 140/90 or great...
Description <ul><li>Preeclampsia—Pts with ↑ BP with Proteinuria, edema, or both </li></ul><ul><ul><li>Further classified a...
Other considerations—Timewise <ul><li>Gestational Hypertension usually occurs in the 3 rd  Trimester </li></ul><ul><li>Pre...
HYPERTENSIVE DISORDERS OF PREGNANCY— Sibai, 2002 Severe Disease   Absent Absent Hepatic Dysfunction  Severe Disease   Abse...
RISK FACTORS <ul><li>Pre-existing hypertension (high blood pressure) </li></ul><ul><li>Kidney disease </li></ul><ul><li>Di...
Other Risk Factors <ul><li>Obesity </li></ul><ul><li>Preeclampsia in Previous Pregnancy </li></ul><ul><li>Poor Outcome in ...
CAUSE AND POSSIBLE CAUSES <ul><li>The Etiology is unknown (Sibai, 2005) </li></ul><ul><li>Originally called Toxemia, becau...
CAUSE AND POSSIBLE CAUSES <ul><li>The recent completion of Human Genome project may lead to Dx by Microarray analysis (Fou...
PATHOPHYSIOLOGY <ul><li>Vasospasm and endothelial damage first described in 1918 </li></ul><ul><li>Vasospasm causes  ↑  BP...
Pathophysiology con’t <ul><li>Also a change in sensitivity to vasopressors (angiotension and norepinephrine) </li></ul><ul...
COMPLICATIONS <ul><li>Cardio-Vascular </li></ul><ul><ul><li>Stroke or Cerebral hemorrhage </li></ul></ul><ul><li>Renal ins...
COMPLICATIONS cont’d <ul><li>Neurologic </li></ul><ul><ul><li>Visual disturbances—blurring of vision, spots in visual fiel...
Uteroplacental complications <ul><li>IUGR </li></ul><ul><li>Oligohydramnios </li></ul><ul><li>Fetal Hypoxia </li></ul><ul>...
HELLP SYNDROME <ul><li>H—Hemolysis </li></ul><ul><li>EL—Elevated liver enzymes </li></ul><ul><li>LP—Low Platelets </li></u...
EXAMS AND TESTS <ul><li>24 Hour urine for Protein and Creatinine Clearance </li></ul><ul><li>Alkaline Phosphatase --Normal...
Blood Component Therapy Platelet count 50,000 or > 50 mL Platelets 1 unit  ↑  count 50,000 Platelet concentration Replace ...
Lab Values in DIC <ul><li>Platelets  ↓   (150,000) </li></ul><ul><li>Fibrinogen  ↓   </li></ul><ul><li>Protime  Prolonged ...
TREATMENT <ul><li>CURE:  DELIVERY </li></ul><ul><li>Mode of delivery is patient-specific and depends on maternal condition...
MAGNESIUM SULFATE CONSIDERATIONS <ul><li>Let patient know treatment effects and possible sensations:  flushing, sluggish t...
Magnesium Sulfate considerations <ul><li>Anticipate Cesarean Delivery—Make sure consents signed/All personnel informed </l...
TREATMENT <ul><li>Treat BP—challenging </li></ul><ul><ul><li>Pt may be Volume depleted, volume adequate, or volume overloa...
OTHER CONSIDERATIONS <ul><li>Watch for changes in Fetal Status—since is a chronic condition affecting placenta—often assoc...
Home care for preeclampsia <ul><li>Fetal Movement assessment 2 x/day </li></ul><ul><li>Bi weekly NST </li></ul><ul><li>Mod...
Nursing care for Preeclampsia <ul><li>Lateral bedrest </li></ul><ul><li>Daily lab work </li></ul><ul><li>Daily weight </li...
PREVENTION— Research--no benefit to date <ul><li>↑  Protein Diet </li></ul><ul><li>↑  Calcium </li></ul><ul><li>↑  Magnesi...
OTHER POSSIBLE TREATMENT <ul><li>Outside U.S. -- instead of Magnesium Sulfate, other centers use: </li></ul><ul><ul><li>Be...
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H:\Gestational Hypertension Capp Moms Mess 2[1]

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  • Terminology is inconsistent
  • Edema not as significant below waist now.
  • These categories develop during pregnancy. Multisystem syndrome.
  • These two are related to preexisting conditions. Primary pathology is elevated B/P
  • How often do office wait 6 hours before sending pt in to triage? Make sure accurate size b/p cuff is used
  • Many theories as to the cause
  • Placental role explains why delivery is the cure and why multiple gestation more prone to preeclampsia ie greater placental tissue.
  • New screening test: protein/creatine ratio. Done with urine. If results are &lt;.16 then there will be &lt;300 mg protein in 24 hr urine
  • many institutions have massive bld transfusion protocol so all these components are given vs just PRBCs
  • Mack truck, with bolus, anti-emetic to prevent emesis
  • Can not give with myasthenia gravis. Excreted by kidneys so be aware of renal function Magnesium continues until 24 hours after delivery
  • B/P can be labile. Need to use consistent size cuff. Pt should be on side when b/p taken
  • Preeclamptic nose – periorbital edema – spreads out nose
  • Are there other kids at home? Does she have help in the house? Pt education about reasons to call the doctor.
  • No visitation from kids, financial difficulties, child care issues, loss of control
  • H:\Gestational Hypertension Capp Moms Mess 2[1]

    1. 1. Gestational Hypertension Peggy Foster, RN, MSN Sandy Warner, RNC- OB, MSN
    2. 2. INCIDENCE and IMPACT <ul><li>Complicates 6-10% of all Pregnancies in U.S. </li></ul><ul><ul><li>3-8 % of Healthy Primiparas </li></ul></ul><ul><ul><li>18% of Multiparas with prior Hx </li></ul></ul><ul><li>1: 2,000-2,500 Pregnancies </li></ul><ul><li>Mortality estimated 3-5% of those with seizures </li></ul><ul><li>The Preeclampsia Foundation (2007) estimates the annual cost of Preeclampsia in the United States is $7 Billion </li></ul>
    3. 3. SYMPTOMS—3 Classic <ul><li>High Blood Pressure </li></ul><ul><li>Proteinuria </li></ul><ul><li>Edema </li></ul>
    4. 4. OTHER ASSOCIATED SYMPTOMS <ul><li>Neurological symptoms (Cerebral or Visual Disturbances): </li></ul><ul><ul><ul><li>Hyper-reflexia—Brisk reflexes (+/- Clonus) </li></ul></ul></ul><ul><ul><ul><li>Headaches </li></ul></ul></ul><ul><ul><ul><li>Blurring of vision—Double Vision </li></ul></ul></ul><ul><ul><ul><li>Scotoma </li></ul></ul></ul><ul><ul><li>Epigastric or RUQ pain </li></ul></ul><ul><ul><li>Pulmonary edema or cyanosis </li></ul></ul><ul><ul><li>Impaired liver function of unclear etiology </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul>
    5. 5. Classification of Hypertensive States of Pregnancy <ul><li>Gestational hypertension </li></ul><ul><ul><li>development of mild HTN during pregnancy </li></ul></ul><ul><ul><ul><li>Previous normal B/P, no proteinuria and labs WNL </li></ul></ul></ul><ul><li>Preeclampsia </li></ul><ul><ul><li>Development of HTN and proteinuria after 20 wks pregnancy </li></ul></ul><ul><ul><ul><li>Previous normal B/P </li></ul></ul></ul><ul><ul><ul><li>With molar pg, can develop before 20 wks </li></ul></ul></ul><ul><ul><li>Eclampsia </li></ul></ul><ul><ul><ul><li>Seizures in preeclamptic pt </li></ul></ul></ul>
    6. 6. Classification continued <ul><li>Chronic HTN </li></ul><ul><ul><li>HTN occurring before pregnancy or B/P > 140/90 or greater before 20 wks on 2 occasions, 6 hrs apart </li></ul></ul><ul><li>Preeclampsia superimposed on chronic HTN </li></ul><ul><ul><li>Development of preeclampsia or eclampsia </li></ul></ul><ul><ul><ul><li>In pt with chronic HTN </li></ul></ul></ul><ul><ul><li>National High Blood Pressure Education Program Working Group (2000) </li></ul></ul>
    7. 7. Description <ul><li>Preeclampsia—Pts with ↑ BP with Proteinuria, edema, or both </li></ul><ul><ul><li>Further classified as Mild or Severe to reflect the extent of end-organ damage </li></ul></ul><ul><ul><li>Severe Preeclampsia Criteria with 1 or more of: </li></ul></ul><ul><ul><ul><ul><li>BP ≥ 160 mm Hg systolic of ≥ 110 diastolic on 2 occasions 6 hours apart with the patient at bedrest </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Proteinuria > 5 gms in 24 hours or 3+ to 4+ on qualitative assessment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oliguria ≤ 400 ml in 24 hours </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cerebral or visual disturbances </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Epigastric or RUQ pain, N&V </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pulmonary edema or cyanosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Impaired liver function of unclear etiology </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thrombocytopenia </li></ul></ul></ul></ul><ul><ul><li>Eclampsia—those with ↑ BP, seizures, +/- Coma </li></ul></ul><ul><ul><li>NOTE: Eclampsia is a consequence of severe pre-eclampsia—however it is not always preceded by ↑ BP, significant proteinuria or edema </li></ul></ul>
    8. 8. Other considerations—Timewise <ul><li>Gestational Hypertension usually occurs in the 3 rd Trimester </li></ul><ul><li>Preeclampsia occurs ≥ 20 weeks gestation </li></ul><ul><li>Chronic Hypertension when ↑ BP is present <20 weeks &/or persists > 42 weeks PP </li></ul>
    9. 9. HYPERTENSIVE DISORDERS OF PREGNANCY— Sibai, 2002 Severe Disease Absent Absent Hepatic Dysfunction Severe Disease Absent Absent Thrombocytopenia Severe Disease Absent Absent Hemoconcentration Usually present Absent Absent Proteinuria Mild or severe Mild Mild or severe Degree of Hypertension ≥ 20 weeks Usually in 3rd Trimester < 20 weeks Time of Onset of Hypertension PREECLAMPSIA GESTATIONAL HYPERTENSION CHRONIC HYPERTENSION CLINICAL FINDINGS
    10. 10. RISK FACTORS <ul><li>Pre-existing hypertension (high blood pressure) </li></ul><ul><li>Kidney disease </li></ul><ul><li>Diabetes </li></ul><ul><li>Mother's age < 20 or >40 </li></ul><ul><li>Multiple Gestation (twins, triplets) </li></ul><ul><li>Molar Pregnancy </li></ul><ul><li>1 st Pregnancy (or 1 st pregnancy with a given Partner) (Note: Lower risk if had Ab with that partner) </li></ul><ul><li>Genetic History (Daughters of Preeclamptic Mothers, and also Men born to Preeclamptic mothers who then father children) (Lachmeijer, 2002 and Esplin, 2001 and Skjaerven, 2005) </li></ul><ul><ul><li>Over 70 different genes associated (Entrez, 2007) </li></ul></ul>
    11. 11. Other Risk Factors <ul><li>Obesity </li></ul><ul><li>Preeclampsia in Previous Pregnancy </li></ul><ul><li>Poor Outcome in Previous Pregnancy </li></ul><ul><li>Pre-existing Medical or Genetic Conditions </li></ul><ul><li>IDDM </li></ul><ul><li>Thrombophilias (Anti-phospholipid/Clotting Disorders </li></ul><ul><li>Factor 5 Leiden </li></ul>
    12. 12. CAUSE AND POSSIBLE CAUSES <ul><li>The Etiology is unknown (Sibai, 2005) </li></ul><ul><li>Originally called Toxemia, because thought that there was a “Toxin” which caused Preeclampsia </li></ul><ul><li>Emerging consensus suggests that inadequate trophoblast invasion fails to remodel the uterine spiral arteries. This shallow implantation compromises placental blood flow--leading to placental ischemia and necrosis—Microscopic debris from the necrotized placenta may circulate in mother’s blood stream—leading to endothelial dysfunction, ↓ ing perfusion to maternal organs—resulting in vasoconstriction and micro-thrombi evidenced by severe end-organ pathology (Khong,1986; Smarason,1993; Roberts,1989, Levine & Karumanchi, 2005) </li></ul>
    13. 13. CAUSE AND POSSIBLE CAUSES <ul><li>The recent completion of Human Genome project may lead to Dx by Microarray analysis (Founds, et al. JOGNN, Mar/April, 2008) </li></ul>
    14. 14. PATHOPHYSIOLOGY <ul><li>Vasospasm and endothelial damage first described in 1918 </li></ul><ul><li>Vasospasm causes ↑ BP—restriction of blood flow associated with endothelial cell damage which stimulates platelet and fibrinogen utilization </li></ul><ul><li>Researchers unsure if vasospasm causes vessel damage or vise versa </li></ul>
    15. 15. Pathophysiology con’t <ul><li>Also a change in sensitivity to vasopressors (angiotension and norepinephrine) </li></ul><ul><ul><li>Linked to 2 prostaglandins (prostacylin > thromboxane) </li></ul></ul><ul><ul><ul><li>Both produced by placenta </li></ul></ul></ul><ul><ul><ul><li>Placenta has ineffective trophoblastic invasion, resulting in decrease placental blood supply to fetus. This decreased blood supply then produces chemical factors which enter the maternal circulation and affect the entire vasculature of the mom. </li></ul></ul></ul>
    16. 16. COMPLICATIONS <ul><li>Cardio-Vascular </li></ul><ul><ul><li>Stroke or Cerebral hemorrhage </li></ul></ul><ul><li>Renal insufficiency or failure </li></ul><ul><ul><li>↓ GFR, ↓ Uric acid clearance, and Na retention </li></ul></ul><ul><ul><li>Glomerular damage results in ↑ Proteinuria </li></ul></ul><ul><li>Hepatic damage caused by vasospasm and ischemia may lead to Liver rupture, hemorrhage, and necrosis </li></ul><ul><ul><li>ALT—formerly known as SGPT—released when liver is damaged </li></ul></ul><ul><ul><li>AST—formerly known as SGOT—released when liver and heart muscle and kidneys are damaged </li></ul></ul><ul><ul><li>Symptoms RUQ pain, Nausea/Vomiting </li></ul></ul>
    17. 17. COMPLICATIONS cont’d <ul><li>Neurologic </li></ul><ul><ul><li>Visual disturbances—blurring of vision, spots in visual fields, temporary blindness—probably caused by vaso-spasm of retinal artery, can also have retinal detachment </li></ul></ul><ul><ul><li>Seizures—which may result in coma or death </li></ul></ul><ul><li>Hematologic—HELLP </li></ul><ul><li>Respiratory Failure—related to Pulmonary Edema </li></ul><ul><li>Maternal and/or fetal death </li></ul>
    18. 18. Uteroplacental complications <ul><li>IUGR </li></ul><ul><li>Oligohydramnios </li></ul><ul><li>Fetal Hypoxia </li></ul><ul><li>Category II or III tracing </li></ul><ul><li>Placental Abruption </li></ul><ul><li>Increased, absent or reverse doppler flow studies </li></ul><ul><li>Low BPP score < 6 </li></ul><ul><li>Fetal death </li></ul>
    19. 19. HELLP SYNDROME <ul><li>H—Hemolysis </li></ul><ul><li>EL—Elevated liver enzymes </li></ul><ul><li>LP—Low Platelets </li></ul><ul><li>Occurs 15-20% patients with Severe Pre-eclampsia (Sibai, 1993) </li></ul><ul><li>Pathophysiology—Vasospasms cause endothelial damage to liver—leads to platelet aggregation, adherence and fibrin deposits—results in hemorrhage, rupture of hepatic vessels and necrosis—may lead to hepatic infarction and rupture </li></ul><ul><li>Sx’s liver rupture—sudden RUQ and upper abdominal pain, shoulder pain, nausea and vomiting </li></ul><ul><li>A ruptured liver requires immediate surgical intervention, but may still result in ~ 30 % mortality </li></ul>
    20. 20. EXAMS AND TESTS <ul><li>24 Hour urine for Protein and Creatinine Clearance </li></ul><ul><li>Alkaline Phosphatase --Normal U/L (30 to 120) </li></ul><ul><li>LDH Lactate Dehydrogenase U/L (100-225) </li></ul><ul><li>AST (Aspartate aminotransferase) (SGOT) U/L (5 to 45) </li></ul><ul><li>ALT (Alanine aminotransferase) (SGPT) U/L (5 to 45) </li></ul><ul><li>Albumin g/L (38-55) </li></ul><ul><li>Uric Acid (less than 5) </li></ul><ul><li>CBC </li></ul><ul><li>Clotting Studies </li></ul><ul><ul><li>Platelets (> 150,000) </li></ul></ul><ul><ul><li>Prothrombin Time Seconds (11 to 13.5) </li></ul></ul><ul><ul><li>Partial Thromboplastin time (25-39 secs) </li></ul></ul><ul><ul><li>Fibrinogen (150-300 mg/dL) </li></ul></ul>
    21. 21. Blood Component Therapy Platelet count 50,000 or > 50 mL Platelets 1 unit ↑ count 50,000 Platelet concentration Replace clotting factors Fibrinogen > 100mg/dL 15-20 mL Clotting factors 1 unit ↑ Fibrinogen 10 mg/dL Cryoprecipitate Replace clotting factors Fibrinogen > 100mg/dL 180-200 mL Clotting factors 1 unit ↑ Fibrinogen 10 mg/dL FFP Hct 30% 200-275 mL RBC 1 unit ↑ Hct 3 % Packed RBC’s Goal Volume Content Component
    22. 22. Lab Values in DIC <ul><li>Platelets ↓ (150,000) </li></ul><ul><li>Fibrinogen ↓ </li></ul><ul><li>Protime Prolonged </li></ul><ul><li>PTT Prolonged </li></ul><ul><li>Anti-thrombin III ↓ </li></ul><ul><li>FDP (Fibrin Degradation Products or (FSP’s—Fibrin Split Products) Greater than 40 </li></ul><ul><li>D-Dimer ↑ </li></ul>
    23. 23. TREATMENT <ul><li>CURE: DELIVERY </li></ul><ul><li>Mode of delivery is patient-specific and depends on maternal condition and fetal status </li></ul><ul><li>Steroids to ↑ fetal lung maturity </li></ul><ul><li>Seizure Prophylaxis: </li></ul><ul><ul><li>Magnesium Sulfate 4-6 gm loading dose (over 15-30 minutes) </li></ul></ul><ul><ul><li>Maintenance—continuous infusion 1-3 gm/hour </li></ul></ul>
    24. 24. MAGNESIUM SULFATE CONSIDERATIONS <ul><li>Let patient know treatment effects and possible sensations: flushing, sluggish thoughts, etc </li></ul><ul><li>Irritating to Vein—use large vein </li></ul><ul><li>Metabolized in Kidney, so must verify adequate Urinary output (≥ 30 ml/hour) Patient may need Foley Catheter </li></ul><ul><li>Therapeutic range 4-8 mg/dL </li></ul><ul><ul><li>Loss of DTR’s 9-12 mg/dL </li></ul></ul><ul><ul><li>Respiratory arrest > 15 mg/dL </li></ul></ul><ul><ul><li>Cardiac arrest >25-30 mg/dL </li></ul></ul><ul><li>Calcium Gluconate is Antidote </li></ul><ul><ul><li>10 mL of 10% solution given IV slowly over 1-3 minutes until signs of overdose are reversed </li></ul></ul>
    25. 25. Magnesium Sulfate considerations <ul><li>Anticipate Cesarean Delivery—Make sure consents signed/All personnel informed </li></ul><ul><li>Relaxes smooth muscle </li></ul><ul><li> Verify Respirations are > 12 </li></ul><ul><li> Relaxes uterus and patients often need Oxytocin supplementation for labor </li></ul><ul><li> Relaxes smooth muscle in Vessels and may ↓ BP—but is given to ↓ CNS Irritability </li></ul><ul><li> Relaxes digestive system—after delivery may see constipation </li></ul><ul><li>Babies may be lethargic with decreased suck and slowed GI motility </li></ul>
    26. 26. TREATMENT <ul><li>Treat BP—challenging </li></ul><ul><ul><li>Pt may be Volume depleted, volume adequate, or volume overloaded. . .Usually not give Diuretics </li></ul></ul><ul><ul><li>Consider too the Placenta is used to working with ↑ pressures—if decrease BP too much may see Late decelerations </li></ul></ul><ul><li>Antihypertensive Agents </li></ul><ul><ul><li>Apresoline (Hydralazine) </li></ul></ul><ul><ul><li>Labetolol </li></ul></ul><ul><ul><li>Calcium channel blocker (Nifedipine) </li></ul></ul><ul><ul><li>Not ACE inhibitors—associated with fetal anomalies and immune system dysfunction </li></ul></ul><ul><li>Correct Blood Discrepancies </li></ul><ul><ul><li>Platelets </li></ul></ul><ul><ul><li>FFP </li></ul></ul><ul><ul><li>Whole Blood </li></ul></ul>
    27. 27. OTHER CONSIDERATIONS <ul><li>Watch for changes in Fetal Status—since is a chronic condition affecting placenta—often associated with Late decelerations and Metabolic acidosis </li></ul><ul><li>Watch patient for Pulmonary Edema </li></ul><ul><li>Oxygenation </li></ul><ul><li>ACCURATE Intake and Output </li></ul><ul><li>NPO—may need C/S </li></ul><ul><li>Minimize stimulation to patient and sensorium </li></ul><ul><ul><li>Limited visitors </li></ul></ul><ul><ul><li>Dimmed lights/sounds/ odors </li></ul></ul><ul><ul><li>Seizure observations and precautions </li></ul></ul>
    28. 28. Home care for preeclampsia <ul><li>Fetal Movement assessment 2 x/day </li></ul><ul><li>Bi weekly NST </li></ul><ul><li>Modified bedrest </li></ul><ul><li>Daily monitoring of blood pressure, weight, urine protein </li></ul><ul><li>Consider anti-hypertensive med (Aldomet, Labetalol) </li></ul><ul><li>Anticipatory guidance/pt education </li></ul>
    29. 29. Nursing care for Preeclampsia <ul><li>Lateral bedrest </li></ul><ul><li>Daily lab work </li></ul><ul><li>Daily weight </li></ul><ul><li>I and O </li></ul><ul><li>Assess for headache, visual changes, epigastric pain, reflexes, edema, lung auscultation </li></ul><ul><li>Vitals q 4 hours </li></ul><ul><li>Psychosocial needs </li></ul>
    30. 30. PREVENTION— Research--no benefit to date <ul><li>↑ Protein Diet </li></ul><ul><li>↑ Calcium </li></ul><ul><li>↑ Magnesium </li></ul><ul><li>Fish and evening Primrose oil </li></ul><ul><li>Antihypertensive drugs ( with Diuretics) </li></ul><ul><li>Aspirin Therapy—had ↑ rates of Abruptio Placenta </li></ul><ul><li>↓ Sodium Diet </li></ul><ul><li>↑ Heparin </li></ul><ul><li>↑ Vitamins E and C </li></ul><ul><li>Folic acid—still being researched </li></ul>
    31. 31. OTHER POSSIBLE TREATMENT <ul><li>Outside U.S. -- instead of Magnesium Sulfate, other centers use: </li></ul><ul><ul><li>Benzodiazepines (i.e. Librium, Xanax, Valium, Halcion, Restoril, Ativan) </li></ul></ul><ul><ul><li>Phenytoin (Dilantin) </li></ul></ul>

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