{"id":37088,"date":"2026-06-25T11:48:08","date_gmt":"2026-06-25T06:18:08","guid":{"rendered":"https:\/\/atsixty.com\/?p=37088"},"modified":"2026-06-25T11:49:08","modified_gmt":"2026-06-25T06:19:08","slug":"hypertensive-disorders-of-pregnancy","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/obg\/hypertensive-disorders-of-pregnancy\/","title":{"rendered":"Hypertensive Disorders of Pregnancy"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Hypertensive Disorders of Pregnancy<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#obs02 *,#obs02 *::before,#obs02 *::after{box-sizing:border-box;margin:0;padding:0}\n#obs02{\n  --ob:#4B3A6E;\n  --ob-light:#5F4D85;\n  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font-weight=\"bold\">Preeclampsia &mdash; Any ONE Severe Feature Changes Management<\/text>\n      <rect x=\"10\" y=\"26\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"20\" y=\"43\" fill=\"#B83232\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">BP &ge;160 systolic or &ge;110 diastolic<\/text>\n      <rect x=\"285\" y=\"26\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"295\" y=\"43\" fill=\"#B83232\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Platelets &lt;100,000\/mm&sup3;<\/text>\n      <rect x=\"10\" y=\"58\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"20\" y=\"75\" fill=\"#B83232\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Severe persistent headache \/ visual sx<\/text>\n      <rect x=\"285\" y=\"58\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"295\" y=\"75\" fill=\"#B83232\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Impaired liver function \/ RUQ pain<\/text>\n      <rect x=\"10\" y=\"90\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"20\" y=\"107\" fill=\"#B83232\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Renal insufficiency (rising creatinine)<\/text>\n      <rect x=\"285\" y=\"90\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"295\" y=\"107\" fill=\"#B83232\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Pulmonary oedema<\/text>\n      <rect x=\"10\" y=\"125\" width=\"540\" height=\"28\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"280\" y=\"143\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">&rarr; MgSO&#8324; + BP control + plan delivery after stabilisation (not prolonged expectant care)<\/text>\n      <text x=\"14\" y=\"172\" fill=\"#4A3D63\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-style=\"italic\">Proteinuria alone, without any of the above, does not by itself make the case \"severe.\"<\/text>\n      <text x=\"14\" y=\"186\" fill=\"#4A3D63\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-style=\"italic\">MgSO&#8324; is started empirically once severe features are present &mdash; not deferred for neuroimaging.<\/text>\n    <\/svg>\n  <\/figure>\n<\/div>\n\n<div id=\"obs02\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Obstetrics Series &middot; Round 02<\/div>\n    <div class=\"mr-title\">\n      Hypertensive Disorders<br><em>of Pregnancy<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; PIH, preeclampsia, eclampsia &amp; the escalation protocol &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"obs02-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"obs02-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"obs02-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"obs02-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"obs02-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"obs02-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"obs02-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"obs02-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"obs02-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"obs02-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"obs02-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"obs02-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"obs02-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"obs02-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #obs02 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'obs02';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Hypertensive Disorders &mdash; Diagnosis',\n      stem:    'A primigravida at <strong>32 weeks<\/strong>, previously normotensive, now has BP <strong>142\/92 mmHg<\/strong> on two readings 4 hours apart, with confirmed <strong>2+ proteinuria<\/strong> on dipstick. There is no headache or visual symptoms, and platelet count and liver enzymes are normal. What is the correct diagnosis and classification?',\n      correct: 'This meets criteria for preeclampsia (new-onset hypertension after 20 weeks plus proteinuria) without severe features at this time, given the absence of severe-range BP, symptoms, or abnormal labs',\n      opts: [\n        'This is gestational hypertension only, since the BP values do not meet the threshold for severe hypertension, and proteinuria alone without other organ involvement does not qualify for a diagnosis of preeclampsia',\n        'This meets criteria for preeclampsia (new-onset hypertension after 20 weeks plus proteinuria) without severe features at this time, given the absence of severe-range BP, symptoms, or abnormal labs',\n        'This already qualifies as severe preeclampsia, since any degree of proteinuria occurring alongside new hypertension after 20 weeks automatically classifies the case as severe disease regardless of BP level or organ function tests',\n        'This should be classified as chronic hypertension with superimposed preeclampsia, since blood pressure elevation at 32 weeks in a primigravida is presumed to reflect pre-existing, previously undiagnosed chronic hypertension'\n      ],\n      exp:     'New-onset hypertension (&ge;140\/90) after 20 weeks <strong>plus proteinuria<\/strong> meets the standard diagnostic criteria for <strong>preeclampsia<\/strong> &mdash; the diagnosis does not require severe-range BP. Calling this \"gestational hypertension only\" ignores the confirmed proteinuria, which is precisely what distinguishes preeclampsia from isolated gestational hypertension. <br><br>It is <strong>not yet severe<\/strong>, however &mdash; severe disease requires specific additional criteria (BP &ge;160\/110, thrombocytopenia, hepatic or renal impairment, pulmonary oedema, or severe symptoms), none of which are present here. <strong>Any degree of proteinuria automatically meaning \"severe\"<\/strong> is a significant overcall; proteinuria amount itself is not part of the standard severity criteria at all. <br><br>\"Chronic hypertension with superimposed preeclampsia\" requires hypertension predating 20 weeks or pre-pregnancy &mdash; she is explicitly described as <strong>previously normotensive<\/strong>, so labelling this as pre-existing chronic disease contradicts the history given rather than reflecting it.',\n      imgId:   null\n    },\n\n    {\n      id:      2,\n      tag:     'Hypertensive Disorders &mdash; Severe Features',\n      stem:    'A woman at <strong>34 weeks<\/strong> with known preeclampsia now develops BP <strong>168\/112 mmHg<\/strong>, a severe headache unrelieved by analgesia, and a platelet count of <strong>90,000\/mm&sup3;<\/strong> (newly low; previously normal). What is the correct next step?',\n      correct: 'This is preeclampsia with severe features; start magnesium sulfate for seizure prophylaxis, control BP with antihypertensives, and plan delivery after brief maternal stabilisation rather than continued expectant management, regardless of gestational age',\n      opts: [\n        'Continue expectant management with twice-weekly monitoring, since 34 weeks is sufficiently preterm that prolonging pregnancy to improve neonatal outcomes outweighs the risk posed by these findings',\n        'This is preeclampsia with severe features; start magnesium sulfate for seizure prophylaxis, control BP with antihypertensives, and plan delivery after brief maternal stabilisation rather than continued expectant management, regardless of gestational age',\n        'Start magnesium sulfate alone without addressing the blood pressure, since seizure prophylaxis takes priority over hypertensive control here and antihypertensive therapy can be deferred until after delivery',\n        'Delay magnesium sulfate until neuroimaging has excluded other causes of the headache, since starting empiric seizure prophylaxis without first ruling out an alternative neurological diagnosis would not be justified'\n      ],\n      exp:     'BP &ge;160\/110 plus new thrombocytopenia and a severe, treatment-resistant headache together meet criteria for <strong>preeclampsia with severe features<\/strong>. The standard response is <strong>magnesium sulfate plus antihypertensive control concurrently<\/strong>, followed by delivery once the mother is stabilised &mdash; not a prolonged trial of expectant monitoring on the assumption that 34 weeks is \"too early\" to act. Once severe features appear, the maternal\/fetal risk of continuing generally outweighs the marginal benefit of further fetal maturation. <br><br>Giving <strong>MgSO&#8324; without treating the BP<\/strong> leaves a dangerously high pressure (168\/112) untreated &mdash; this level itself carries meaningful stroke risk and needs prompt antihypertensive therapy alongside seizure prophylaxis, not after delivery. <br><br><strong>Waiting for neuroimaging<\/strong> before starting MgSO&#8324; introduces a dangerous delay &mdash; in the setting of severe preeclampsia with headache, seizure prophylaxis is started empirically; ruling out alternative causes is not a prerequisite for initiating treatment that is already indicated on clinical grounds.',\n      imgId:   'obs02-img1'\n    },\n\n    {\n      id:      3,\n      tag:     'Eclampsia Management',\n      stem:    'A woman at <strong>36 weeks<\/strong> has a witnessed generalised tonic-clonic seizure, followed by post-ictal drowsiness; BP is <strong>170\/110 mmHg<\/strong>. After securing the airway and ensuring safety during the seizure, what is the correct management priority?',\n      correct: 'Give magnesium sulfate (loading dose followed by maintenance) for seizure control and prevention of recurrence, control blood pressure with antihypertensives, and proceed toward delivery once the mother is stabilised, since delivery &mdash; not seizure control alone &mdash; is the definitive treatment for eclampsia',\n      opts: [\n        'Give intravenous diazepam or phenytoin as first-line agents for eclamptic seizure control, reserving magnesium sulfate only for cases where these standard anticonvulsants fail to prevent recurrent seizures',\n        'Give magnesium sulfate (loading dose followed by maintenance) for seizure control and prevention of recurrence, control blood pressure with antihypertensives, and proceed toward delivery once the mother is stabilised, since delivery &mdash; not seizure control alone &mdash; is the definitive treatment for eclampsia',\n        'Once the seizure has terminated and the patient is stabilised on magnesium sulfate, continue managing the pregnancy expectantly to allow further fetal maturation, since the seizure event itself does not change the plan of care established before it occurred',\n        'Proceed to immediate cesarean delivery before initiating magnesium sulfate, since rapid delivery takes priority over seizure prophylaxis and giving magnesium sulfate first would unnecessarily delay the more definitive treatment'\n      ],\n      exp:     '<strong>Magnesium sulfate<\/strong> is the first-line agent for both treating and preventing recurrent eclamptic seizures &mdash; it has been shown to be superior to phenytoin and benzodiazepines specifically for this indication; those agents are not the standard first-line choice with MgSO&#8324; held in reserve. <br><br>An eclamptic seizure is itself a sign that the disease has reached its most severe form &mdash; <strong>delivery is the definitive treatment<\/strong>, and \"continuing to manage expectantly\" once the seizure is controlled fundamentally misreads what has just happened: the seizure event changes the plan, it doesn\\'t leave the prior plan unchanged. <br><br>Equally, rushing to <strong>cesarean delivery before maternal stabilisation<\/strong> is dangerous &mdash; operating on a patient with uncontrolled BP and without seizure prophylaxis on board risks further seizures or haemorrhagic stroke intraoperatively. The sequence is stabilise first (MgSO&#8324; plus BP control), then move to delivery &mdash; not the reverse.',\n      imgId:   null\n    },\n\n    {\n      id:      4,\n      tag:     'HELLP Syndrome',\n      stem:    'A woman at <strong>33 weeks<\/strong> with preeclampsia develops right upper quadrant pain and nausea. Labs show evidence of haemolysis (schistocytes, elevated LDH), liver enzymes (AST\/ALT) at <strong>three times normal<\/strong>, and a platelet count of <strong>80,000\/mm&sup3;<\/strong>. What is the correct diagnosis and management approach?',\n      correct: 'This is HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets), a severe variant of preeclampsia; management is maternal stabilisation (BP control, MgSO4, correction of coagulopathy as needed) followed by delivery without prolonged delay, given the risk of rapid deterioration including hepatic rupture and DIC',\n      opts: [\n        'This presentation is more consistent with acute fatty liver of pregnancy than HELLP syndrome, since right upper quadrant pain and deranged liver function in pregnancy are specific to fatty liver and exclude a diagnosis of HELLP',\n        'This is HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets), a severe variant of preeclampsia; management is maternal stabilisation (BP control, MgSO4, correction of coagulopathy as needed) followed by delivery without prolonged delay, given the risk of rapid deterioration including hepatic rupture and DIC',\n        'HELLP syndrome can be managed expectantly with close monitoring well beyond 34 weeks as long as the platelet count remains above 50,000\/mm&sup3;, since that threshold is considered the safe cut-off below which delivery becomes urgent',\n        'Platelet transfusion is mandatory before delivery in all cases of HELLP syndrome with thrombocytopenia, regardless of bleeding risk or planned mode of delivery, since uncorrected thrombocytopenia is itself an absolute contraindication to proceeding'\n      ],\n      exp:     'The combination of <strong>haemolysis (schistocytes, elevated LDH), elevated liver enzymes, and thrombocytopenia<\/strong> is the defining triad of <strong>HELLP syndrome<\/strong>, a severe variant of preeclampsia. While acute fatty liver of pregnancy can present with overlapping features, this specific lab pattern &mdash; particularly the haemolysis markers alongside thrombocytopenia &mdash; fits HELLP, not a presentation that should be reflexively relabelled as fatty liver. <br><br>There is <strong>no safe platelet threshold<\/strong> (such as \"above 50,000\") that justifies prolonged expectant management in HELLP &mdash; the syndrome carries a real risk of rapid maternal deterioration, including hepatic rupture and DIC, and the standard approach is stabilisation followed by <strong>prompt delivery<\/strong>, generally without extended delay regardless of gestational age once the diagnosis is made. <br><br><strong>Platelet transfusion is not mandatory in every case<\/strong> &mdash; it is reserved for specific situations such as active bleeding, very low counts, or planned cesarean delivery at particular thresholds, not applied automatically to every HELLP patient with any degree of thrombocytopenia.',\n      imgId:   null\n    },\n\n    {\n      id:      5,\n      tag:     'ICU Referral &amp; Escalation Protocol',\n      stem:    'A woman with severe preeclampsia &mdash; BP <strong>170\/115<\/strong>, oliguria, rising creatinine, and early signs of pulmonary oedema &mdash; is managed on the labor ward, which lacks ICU-level monitoring. The team continues ward-based management for several hours without contacting the ICU\/anaesthesia team, despite the unit\\'s own documented protocol mandating ICU referral once two or more severe organ-dysfunction criteria are met. What is the most accurate statement about the medico-legal implications of this delay?',\n      correct: 'Failure to escalate to ICU-level care once the unit\\'s own documented threshold criteria are met is a deviation from the institution\\'s established standard of care, and creates significant medico-legal exposure independent of whether the patient ultimately survives without further complication',\n      opts: [\n        'Since the final outcome, not the timing of escalation, determines liability, this delay carries no specific medico-legal weight as long as the patient does not suffer a major adverse event before eventual ICU transfer',\n        'Failure to escalate to ICU-level care once the unit\\'s own documented threshold criteria are met is a deviation from the institution\\'s established standard of care, and creates significant medico-legal exposure independent of whether the patient ultimately survives without further complication',\n        'Internal hospital protocols for ICU referral are advisory guidelines without independent legal standing, so failing to follow them carries the same medico-legal weight as any informal clinical preference and does not specifically heighten liability in this case',\n        'Obstetric teams are not required to consult intensive care specialists for organ dysfunction occurring secondary to pregnancy-related hypertensive disease, so the absence of ICU referral here reflects an appropriate division of clinical responsibility rather than any deviation from expected care'\n      ],\n      exp:     'Once a unit has a <strong>documented protocol<\/strong> specifying objective criteria for ICU referral, and those criteria are met, failing to escalate is treated as a deviation from that unit\\'s own established standard of care &mdash; this carries independent medico-legal weight, regardless of whether the patient happens to recover without further incident. Outcome alone does not determine liability here; the <strong>protocol deviation itself<\/strong> is the recognised exposure, because the existence of clear, met criteria that were ignored is precisely the kind of evidence used to establish that care fell below what the institution itself defines as acceptable. <br><br>Calling the protocol merely <strong>\"advisory\"<\/strong> with no independent legal standing misstates how documented institutional protocols function once established &mdash; they generally define the relevant standard of care for that unit, not a take-it-or-leave-it suggestion. <br><br>And framing the lack of ICU referral as an <strong>\"appropriate division of responsibility\"<\/strong> ignores that severe preeclampsia with multi-organ dysfunction (oliguria, rising creatinine, pulmonary oedema) is exactly the picture that multidisciplinary obstetric\/ICU referral protocols exist to capture &mdash; this is not a case sitting outside expected referral norms.',\n      imgId:   null\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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The ICU on-call team would not need to be called twice.'],\n      [4, 'Strong round \\u2014 one threshold or escalation point to revisit.'],\n      [3, 'Solid base \\u2014 the debrief will sharpen the criteria.'],\n      [2, 'Halfway there \\u2014 review the missed cases carefully.'],\n      [0, 'Hypertensive disorders reward close re-reading \\u2014 the severity thresholds are unforgiving.']\n    ];\n    gid('verdict').textContent = verdicts[4][1];\n    for (vi = 0; vi < verdicts.length; vi++) {\n      if (c >= verdicts[vi][0]) {\n        gid('verdict').innerHTML = verdicts[vi][1];\n        break;\n      }\n    }\n\n    gid('ct-c').textContent = '\\u2705 ' + c + ' Correct';\n    gid('ct-w').textContent = '\\u274C ' + w + ' Wrong';\n    gid('ct-s').textContent = '\\u23ED ' + s + ' Skipped';\n\n    sc = gid('score');\n    sc.style.display = 'block';\n    sc.scrollIntoView({ behavior: 'smooth', block: 'center' });\n  }\n\n  function tryInit() {\n    var sentinel = document.getElementById(NS + '-sentinel');\n    var submit   = document.getElementById(NS + '-submit');\n    var retry    = document.getElementById(NS + '-retry');\n    if (!sentinel || !submit || !retry) {\n      setTimeout(tryInit, 80);\n      return;\n    }\n    submit.addEventListener('click', showScore);\n    retry.addEventListener('click', function () {\n      build();\n      window.scrollTo(0, 0);\n    });\n    var bar = document.getElementById(NS + '-progress');\n    if (bar && window.IntersectionObserver) {\n      new IntersectionObserver(function (entries) {\n        bar.className = entries[0].isIntersecting ? 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