Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 19-12: Preeclampsia-Eclampsia + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Preeclampsia Blood pressure of ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic after 20 weeks gestation Proteinuria of ≥ 0.3 g in 24 h Preeclampsia with severe features (one or more of below) Blood pressure of ≥ 160 mm Hg systolic or ≥ 110 mm Hg diastolic Progressive kidney injury Oliguria of < 500 mL in 24 h Thrombocytopenia Hemolysis elevated liver enzymes low platelets (HELLP) Pulmonary edema Vision changes or headache When hypertension is present with severe features of preeclampsia, seizure prophylaxis could be beneficial Eclampsia Seizures in a patient with evidence of preeclampsia +++ General Considerations ++ Cause is unknown, but it is likely a multifactorial, two-stage process The first stage: probable disturbance in placental implantation involving the spiral arteries very early in gestation; the abnormal placental perfusion that results leads to the formation of noxious free radicals The second stage: excessive inflammation causing endothelial damage, vasospasm, and finally clinical signs and symptoms An immunologic component has been proposed, citing the increased incidence in primigravidas This entire process is likely enhanced by environmental factors, genetic predisposition, and preexisting maternal disease Can occur any time after 20 weeks' gestation and up to 6 weeks postpartum The only cure is delivery of the fetus and placenta Uncontrolled eclampsia is a significant cause of maternal death Preeclampsia progresses to eclampsia in 5% of women +++ Demographics ++ Occurs in 7% of pregnant women in the United States Higher incidence in primiparas Other risk factors Multifetal gestations Preeclampsia in a previous pregnancy Chronic hypertension Pregestational diabetes Gestational diabetes Thrombophilia Kidney disease Systemic lupus erythematosus Pre-pregnancy BMI above 30 Antiphospholipid antibody syndrome Maternal age 35 years or older Assisted reproductive technology Obstructive sleep apnea + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ See Table 19–3 Preeclampsia without severe features Patients usually have few complaints Diastolic blood pressure < 110 mm Hg Edema may be present Platelet count > 100,000/mcL Antepartum fetal testing is reassuring CNS irritability is minimal Epigastric pain is not present Liver enzymes are not elevated Preeclampsia with severe features Patients may complain of headache and changes in vision Blood pressure often ≥ 160/110 mm Hg Thrombocytopenia (platelet counts < 100,000/mcL) may be present and progress to disseminated intravascular coagulation Severe epigastric pain may be present from hepatic subcapsular hemorrhage with significant stretch or rupture of the liver capsule HELLP syndrome is a form of severe preeclampsia Severity can be assessed with reference to the six sites where disease has its effects CNS Kidneys Liver Hematologic system Vascular system Fetal placental unit ++Table Graphic Jump LocationTable 19–3.Indicators of mild, moderate, and severe preeclampsia-eclampsia.View Table||Download (.pdf) Table 19–3. Indicators of mild, moderate, and severe preeclampsia-eclampsia. Site Indicator Mild to Moderate Severe Central nervous system Symptoms and signs Hyperreflexia Seizures, blurred vision, scotomas, headache, clonus, irritability Kidney Proteinuria Urinary output > 0.3 g/24 h > 30 mL/h > 0.3 g/24 h < 30 mL/h Liver AST, ALT, LD Normal liver enzymes Elevated liver enzymes, epigastric pain, ruptured liver Hematologic Platelets Hemoglobin Normal Normal < 100,000/mcL Low, normal, or elevated Vascular Blood pressure Retina < 160/110 mm Hg Arteriolar spasm > 160/110 mm Hg Retinal hemorrhages Fetal-placental unit Growth restriction Oligohydramnios Fetal distress Absent Absent Absent Present Present Present ALT, alanine aminotransferase; AST, aspartate aminotransferase; LD, lactate dehydrogenase. +++ Differential Diagnosis ++ Chronic hypertension Chronic kidney disease or proteinuria due to other cause Primary seizure disorder Immune or thrombotic thrombocytopenic purpura Gallbladder and pancreatic disease Hemolytic-uremic syndrome + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ See Table 19–3 Platelet count is over 100,000/mcL in preeclampsia without severe features disease Thrombocytopenia seen in severe disease Abnormal findings in the HELLP syndrome Hyperuricemia is uncommon in pregnancy, except in gout, kidney disease, or preeclampsia-eclampsia + Treatment Download Section PDF Listen +++ +++ Medications ++ If fetal lung immaturity is present, Betamethasone, 12 mg intramuscularly every 24 hours for two doses Dexamethasone, 6 mg intramuscularly every 12 hours for four doses Magnesium sulfate Used for seizure prophylaxis in patients with severe preeclampsia Dose is given intravenously, 4- to 6-g load followed by 2–3 g/h maintenance Infusion should be continued for 24 hours postpartum Antihypertensive therapy is used if systolic value ≥ 160 mm Hg or diastolic value ≥ 110 mm Hg; target is 140–150/90–100 mm Hg Hydralazine, 5–10 mg intravenously every 20 min Labetalol, 10–20 mg intravenously every 20 min can be used to control blood pressure The 2017 ACOG guidelines for treatment of emergency hypertension include using immediate-release oral nifedipine (not sublingual), particularly for patients who do not have intravenous access Oxytocin may be used to induce or augment labor Use of diuretics, dietary changes, and vitamin-mineral supplements such as calcium, or vitamin C or E have not been confirmed to be effective in clinical studies +++ Surgery ++ Cesarean section is reserved for the usual fetal indications or when rapid delivery is needed Regional anesthesia or analgesia is acceptable +++ Therapeutic Procedures ++ Nonstress fetal monitoring or a biophysical profile should be obtained serially to confirm fetal well-being Daily fetal kick counts can be recorded by the mother Blood pressure, proteinuria, and fetal monitoring must be checked regularly in hospitalized patients 24-h urine collection for total protein and creatinine clearance on admission and as indicated Blood cell count, platelet count, and electrolyte panel, including liver enzymes should be checked regularly in hospitalized patients, with frequency determined by severity Patients receiving magnesium infusions are monitored for signs of toxicity such as loss of deep tendon reflexes or respiratory depression; calcium gluconate (1 g intravenously over 2 minutes) can be used for reversal Urinary output is checked hourly in severe disease or eclampsia If the fetus is < 34 weeks gestation, corticosteroids can be administered to the mother Betamethasone, 12 mg intramuscularly every 24 h for two doses or Dexamethasone, 6 mg intramuscularly every 12 h for four doses Delivery in a woman clearly suffering from eclampsia or severe preeclampsia should not be delayed for fetal lung maturation or administration of corticosteroids +++ PREECLAMPSIA ++ Disease of any severity at 36 weeks or later is managed by delivery Epigastric pain, severe range blood pressures, thrombocytopenia, and visual disturbances are strong indications for delivery +++ ECLAMPSIA ++ Patients having seizures are placed on their side to increase placental blood flow and avoid aspiration Maternal and fetal status determine the method of delivery + Outcome Download Section PDF Listen +++ +++ Prevention ++ Low-dose aspirin (81 mg orally daily), initiated between 12 and 28 weeks' gestation for women at increased risk for preeclampsia +++ When to Refer ++ New onset of hypertension and proteinuria in a pregnant patient > 20 weeks gestation New onset of seizure activity in a pregnant patient +++ When to Admit ++ Symptoms of preeclampsia with severe features in a pregnant patient with elevated blood pressure above baseline Evaluation for preeclampsia when severe features of the disease are suspected Evaluation for preeclampsia in a patient with an unstable home environment Evidence of eclampsia + References Download Section PDF Listen +++ + +American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 202: Gestational hypertension and preeclampsia. Obstet Gynecol. 2019 Jan;133(1):e1–25. [PubMed: 30575675] + +American College of Obstetrics and Gynecologists. Committee Opinion No. 692: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2017 Apr;129(4):e90–5. [PubMed: 28333820] + +American College of Obstetricians and Gynecologists. Practice Advisory on low-dose aspirin and prevention of preeclampsia, 2016. https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Low-Dose-Aspirin-and-Prevention-of-Preeclampsia-Updated-Recommendations + +Mol BW et al. Pre-eclampsia. Lancet. 2016 Mar 5;387(10022):999–1011. [PubMed: 26342729]