Preeclampsia-Eclampsia

Key Features

Essentials of Diagnosis

• Gestational hypertension

  • Blood pressure of ≥ 140/90 mm Hg systolic or ≥ 90 mm Hg diastolic after 20 weeks' gestation

  • May be present in the absence of proteinuria

• Preeclampsia

  • Defined as newly elevated blood pressure and proteinuria during pregnancy

  • Blood pressure of ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic after 20 weeks' gestation

  • Proteinuria of ≥ 0.3 g in 24 h

    • Although proteinuria is usually associated with preeclampsia, hypertension with the presence of severe features suggests seizure prophylaxis could be beneficial

• 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

• 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

• 5% of women with preeclampsia progress to eclampsia

Demographics

• Occurs in 7% of pregnant women in the United States

• Higher incidence in primiparas

• Other risk factors

  • Multiple gestations

  • Chronic hypertension

  • Diabetes mellitus

  • Kidney disease

  • Collagen-vascular and autoimmune disease

  • Gestational trophoblastic disease

Clinical Findings

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 (100 × 10⁹/L)

  • Antepartum fetal testing is reassuring

  • CNS irritability is minimal

  • Epigastric pain is not present

  • Liver enzymes are not elevated

  • Proteinuria is present with urine protein ≥ 0.3/24 hours

• Preeclampsia with severe features

  • Patients may complain of headache and changes in vision

  • Blood pressure often ≥ 160/110 mm Hg

  • Proteinuria may not always be present

  • Thrombocytopenia (platelet counts < 100,000/mcL [100 × 10⁹/L]) 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 ...