DESCRIPTION

• Hypertension in pregnancy:
  • 1% of all pregnancies
  • 16% of maternal deaths
• Gestational hypertension (GH)
  • Hypertension associated with pregnancy
  • Resolves with delivery
  • 6–7% of all pregnancies
• Preeclampsia
  • GH PLUS proteinuria
  • 2.2–6.3% of all pregnancies
• Eclampsia
  • Preeclampsia with seizure
• Postpartum preeclampsia
  • Occurs within 6 wk of delivery
  • Usually no history of hypertension
  • Occurs in 5% patients
  • Most women are African American
• HELLP syndrome
  • May occur in women with preeclampsia or eclampsia
  • Hemolysis
  • Elevated liver function tests
  • Low platelets
• Superimposed preeclampsia
  • Preeclampsia in the setting of chronic hypertension
  • Complicates pregnancy in up to 25% of women with chronic hypertension
  • Risk factors:
    • African American
    • Antihypertensive medication use
• Chronic hypertension
  • Systolic BP (SBP) > 140 or diastolic BP (DBP) > 90
  • Measured twice prior to 20 wk gestation or lasting > 12 wk after delivery

ETIOLOGY

• Preeclampsia
  • Incomplete placental implantation and underperfusion
  • Leads to decreased angiogenic growth factor and increased maternal placental debris in circulation
• Eclampsia
  • 1/3 of patients with eclampsia did not have hypertension prior to seizure
• Risk factors:
  • Extremes of reproductive age
  • Primagravida
  • Multiple gestations
  • Molar pregnancy, hydatidiform mole
  • Smoking
  • Increased body mass index
  • Diabetes, collagen vascular diseases
  • Pre-existing hypertension or renal disease
  • History of preeclampsia with prior pregnancies (7.5–10% increased risk)
  • Independent risk factors for eclampsia
    • Nulliparity
    • Maternal age
    • GH

[Outline]

• DESCRIPTION
• ETIOLOGY

• GH
  • Normotensive prior to 20 wk gestation
  • SBP > 140 or DBP > 90 on 2 separate measurements
  • Severe: SBP > 160 and DBP > 110
• Preeclampsia
  • GH and proteinuria
  • 300 mg protein on 24 hr urine
  • 1+ protein on urinalysis
  • Mild:
    • SBP < 160 mm Hg or
    • DBP < 110 mm Hg
    • Normal platelets
    • Normal liver function tests
    • No cerebral symptoms
  • Severe:
    • SBP > 160 or DBP > 110
    • 5 g protein on 24 hr urine
    • 3+ proteinuria on 2 occasions
    • Oliguria
    • Thrombocytopenia
    • Right upper quadrant pain
    • Impaired liver function
    • Cerebral symptoms
    • Intrauterine growth restriction
    • Vision changes
    • Pulmonary edema
• HELLP Syndrome
  • Hemolysis
  • Elevated liver enzyme
  • Low platelets
  • May present with:
    • Pulmonary edema
    • Renal failure
    • Liver failure
    • Sepsis
    • Pulmonary disease
    • Stroke

SIGNS AND SYMPTOMS

History

• History of preeclampsia
• Parity
• Weight gain
• Leg swelling
• Abdominal pain
• Nausea/vomiting
• Shortness of breath
• Headache
• Visual changes
• Jaundice
• Stroke symptoms

Physical Exam

• Check serial BP
• Palpate abdomen carefully, especially RUQ
• Assess extremities for edema
• Perform neurologic exam:
  • Deep tendon reflexes
  • Mental status changes
  • Visual acuity

ESSENTIAL WORKUP

• Serial BP measurements
• Urinalysis
• CBC, LFTs, BUN/creatinine, uric acid
• US
• Fetal monitoring
• Head CT depending on severity of presentation

DIAGNOSIS TESTS & INTERPRETATION

Lab

• Urinalysis:
  • Protein > 1+ correlates to 30 mg/dL
  • > 1+ requires 24 hr urine collection
  • Urine sediment for RBC, WBC, casts
• CBC
• LFTs
• BUN/creatinine
• Uric acid
• LDH
• D-dimer
• Fibrinogen levels
• Coagulation studies

Imaging

• US:
  • Gestational age
  • Fetal viability/distress
  • Oligohydramnios
• Fetal monitoring, nonstress test
• Head CT: Rule out mass or hemorrhage

Diagnostic Procedures/Surgery

• Lumbar puncture: Rule out infection or subarachnoid hemorrhage
• Urine toxicology: Rule out substance abuse:
  • Cocaine
  • Methamphetamine

DIFFERENTIAL DIAGNOSIS

• Essential hypertension
• Renal or collagen vascular disease
• Hydatidiform mole, hydrops fetalis
• Drug abuse
• Epilepsy
• Encephalitis
• Meningitis
• Encephalopathy
• Brain tumor
• Intracranial hemorrhage

[Outline]

• INFORMATION
• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• ABCs
• Oxygen
• Place patient in left lateral decubitus position

INITIAL STABILIZATION/THERAPY

• ABCs
• 100% oxygen
• Left lateral decubitus position (reduces pressure on inferior vena cava, enhancing cardiac return/output)
• Maternal cardiopulmonary monitoring
• Magnesium sulfate (MgSO₄) for seizures

ED TREATMENT/PROCEDURES

• Make arrangements for emergent C-section
• MgSO₄for seizure treatment and prophylaxis
• Hydralazine or labetalol for BP control
  • Goal is to lower BP by 25% initially and then to < 160/100 over subsequent hours
• Mg toxicity:
  • Hypotension
  • Loss of patellar reflex
  • Respiratory depression
  • Decreased urine output
  • Elevated creatinine
  • Calcium gluconate to reverse
• Intubate for airway protection/hypoxia or if seizures refractory to interventions
• Tocographic and fetal monitoring
• OB consult:
  • All cases along GH–preeclampsia–eclampsia spectrum
  • Expectant management if < 30 wk gestation
  • Delivery > 30 wk
  • Emergent delivery for severe symptoms: Induction vs. C-section

MEDICATION

First Line

• MgSO₄: 10 g IM or 4 g IV; followed by 1–2 g/hr IV infusion:
  • MgSO₄ bolus should not exceed 1 g/min
  • Serum Mg goal: 4–7 mEq/L
• Hydralazine: 5–20 mg IV
• Labetalol: 10 mg IV initially, then 5–10 mg increments for desired effect

Second Line

• Valium: 5–10 mg IV if no response to MgSO₄
• Fosphenytoin: 15–20 mg phenytoin equivalents (PE) IV × 1 (max. 150 mg PE/min IV)
• Phenytoin: 15–18 mg/kg IV, not to exceed 25–50 mg/min, for persistent seizure activity
• Calcium gluconate: 1 g IV

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Preeclampsia
• Eclampsia
• HELLP syndrome
• ICU, labor and delivery, OR

Discharge Criteria

• Isolated hypertension with workup negative for preeclampsia
• Asymptomatic
• Close obstetric follow-up assured

FOLLOW-UP RECOMMENDATIONS

• Follow-up with OB as above
• Return to ED:
  • Headache
  • Abdominal pain
  • Leg swelling
  • Decreased urination
  • Shortness of breath

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Delivery is the definitive treatment for preeclampsia and eclampsia
• BP of 130/80 mm Hg in a pregnant woman requires investigation
• Postpartum presentation: Consider preeclampsia/eclampsia in patient up to 30 days postpartum presenting with:
  • Edema
  • Shortness of breath
  • Headache
  • Seizure
• Airway considerations in preeclamptic or eclamptic patients:
  • Reduced internal diameter of airways due to engorgement
  • Airway edema may be present
  • Use smaller-diameter endotracheal tube
  • Use fiberoptic guidance if available
  • High risk for aspiration

ICD9

• 642.40 Mild or unspecified pre-eclampsia, unspecified as to episode of care
• 642.60 Eclampsia complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care
• 642.64 Eclampsia, postpartum condition or complication

ICD10

• O14.90 Unspecified pre-eclampsia, unspecified trimester
• O15.2 Eclampsia in the puerperium
• O15.9 Eclampsia, unspecified as to time period

[Outline]

• ICD9
• ICD10

• Deak TM, Moskovitz JB. Hypertension and pregnancy. Emerg Med Clin N Am. 2012;30:903–917.
• Leeman L, Fontaine P. Hypertensive disorders of pregnancy. Am Fam Physician. 2008;78:93–100.
• Podymow T, August P. Antihypertensive drugs in pregnancy. Semin Nephrol. 2011;31:70–85.
• Sibai BM. Etilogy and management of postpartum hypertension-preeclampsia. Am J Obstet Gynecol. 2012;206:470–475.
• Yancey LM, Withers E, Bakes K, et al. Postpartum preeclampsia: Emergency department presentation and management. J Emerg Med. 2011;40;380–384.
• Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age. Am J Med. 2009;122:890–895.

See Also (Topic, Algorithm, Electronic Media Element)

• HELLP Syndrome
• Hydatidiform Mole
• Seizure, Adult

Adam Z. Barkin