Preeclampsia/Eclampsia

[Section Outline]

Description
Etiology

Author:

BonnieKaplan

Description

Hypertension in pregnancy:
- 10% of all pregnancies
- 7.4% of maternal deaths
- Major contributor to prematurity
Gestational hypertension (GH):
- Hypertension associated with pregnancy after 20 wk gestation
- Resolves with delivery
- 6-17% of all pregnancies
Preeclampsia:
- GH PLUS proteinuria OR GH PLUS end-organ damage:
  - Thrombocytopenia: Plt <100,000/microL
  - Renal insufficiency: Cr >1.1 mg/dL
  - Impaired liver function: LFTs >2× normal levels
  - Pulmonary edema
  - Cerebral or visual symptoms
- 4.6% 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 under perfusion
- Leads to decreased angiogenic growth factor and increased maternal placental debris in circulation
- Causes increased dysfunction in maternal vascular system
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, especially in second trimester (7.5-10% increased risk)
- Independent risk factors for eclampsia:
  - Nulliparity
  - Maternal age
  - GH

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms
Essential Workup
Diagnostic Tests & Interpretation
Differential Diagnosis

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 OR GH + end-organ damage
- 300 mg protein on 24 hr urine
- 1+ protein on urinalysis
- Mild:
  - SBP ≥140 and <160 mm Hg
  - DBP ≥90 and <110 mm Hg
  - 2 BP readings at least 4 hr apart
  - 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:
    - <100,000/microL
  - Serum creatinine:
    - >1.1 mg/dL or doubling of baseline Cr
  - Right upper-quadrant pain
  - Impaired liver function:
    - >2× normal
  - Cerebral symptoms
  - 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

ALERT
In the ED, should not wait 4 hr for repeated elevated BP measurements if high clinical suspicion

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
Chest pain or shortness of breath

Physical Exam

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

Essential Workup

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

Diagnostic 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
TTP
HUS

Treatment ⬆ ⬇

[Section Outline]

Prehospital
Initial Stabilization/Therapy
ED Treatment/Procedures
Medication

Prehospital

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
MgSO₄ for 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 <34 wk gestation
- Delivery >36 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

Follow-Up ⬆ ⬇

[Section Outline]

Disposition
Follow-up Recommendations

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
- Chest pain

Pearls and Pitfalls ⬆ ⬇

Delivery is the definitive treatment for preeclampsia and eclampsia
BP of 130/80 mm Hg in a pregnant woman requires investigation and immediate OB consultation
Postpartum presentation: Consider preeclampsia/eclampsia in patient up to 6 weeks 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

Additional Reading ⬆ ⬇

American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy . Obstet Gynecol. 2013;122:1122-1131. Available at http://www.acog.org/Clinical-Guidance-and -Publications/Task-Force-and -Work-Group-Reports/Hypertension-in-Pregnancy.
BroekhuijsenK, van BaarenGJ, van PampusMG, et al. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): An open-label, rand omised controlled trial . Lancet. 2015;385:2492-2501.
Centers for Disease Control and Prevention. Pregnancy mortality surveillance system . Available at http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html.
DeakTM, MoskovitzJB. Hypertension and pregnancy . Emerg Med Clin North Am. 2012;30:903-917.
LeemanL, FontaineP. Hypertensive disorders of pregnancy . Am Fam Physician. 2008;78:93-100.
LisonkovaS, SabrY, MayerC, et al. Maternal morbidity associated with early-onset and late-onset preeclampsia . Obstet Gynecol. 2014;124:771-781.
PodymowT, AugustP. Antihypertensive drugs in pregnancy . Semin Nephrol. 2011;31:70-85.
SibaiBM. Etiology and management of postpartum hypertension-preeclampsia . Am J Obstet Gynecol. 2012;206:470-475.
YanceyLM, WithersE, BakesK, et al. Postpartum preeclampsia: Emergency department presentation and management . J Emerg Med. 2011;40:380-384.
YoderSR, ThornburgLL, BisognanoJD. Hypertension in pregnancy and women of childbearing age . Am J Med. 2009;122:890-895.

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆

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
642.50 Severe pre-eclampsia, unspecified as to episode of care
642.41 Mild or unspecified pre-eclampsia, delivered, with or without mention of antepartum condition
642.42 Mild or unspecified pre-eclampsia, delivered, with mention of postpartum complication
642.43 Mild or unspecified pre-eclampsia, antepartum condition or complication
642.44 Mild or unspecified pre-eclampsia, postpartum condition or complication
642.4 Mild or unspecified pre-eclampsia
642.51 Severe pre-eclampsia, delivered, with or without mention of antepartum condition
642.52 Severe pre-eclampsia, delivered, with mention of postpartum complication
642.53 Severe pre-eclampsia, antepartum condition or complication
642.54 Severe pre-eclampsia, postpartum condition or complication
642.5 Severe pre-eclampsia
642.61 Eclampsia, delivered, with or without mention of antepartum condition
642.62 Eclampsia, delivered, with mention of postpartum complication
642.63 Eclampsia, antepartum condition or complication
642.6 Eclampsia complicating pregnancy, childbirth or the puerperium

ICD10

O14.90 Unspecified pre-eclampsia, unspecified trimester
O15.2 Eclampsia in the puerperium
O15.9 Eclampsia, unspecified as to time period
O14.20 HELLP syndrome (HELLP), unspecified trimester
O14.00 Mild to moderate pre-eclampsia, unspecified trimester
O14.02 Mild to moderate pre-eclampsia, second trimester
O14.03 Mild to moderate pre-eclampsia, third trimester
O14.0 Mild to moderate pre-eclampsia
O14.10 Severe pre-eclampsia, unspecified trimester
O14.12 Severe pre-eclampsia, second trimester
O14.13 Severe pre-eclampsia, third trimester
O14.1 Severe pre-eclampsia
O14.22 HELLP syndrome (HELLP), second trimester
O14.23 HELLP syndrome (HELLP), third trimester
O14.2 HELLP syndrome
O14.92 Unspecified pre-eclampsia, second trimester
O14.93 Unspecified pre-eclampsia, third trimester
O14.9 Unspecified pre-eclampsia
O14 Pre-eclampsia
O15.00 Eclampsia in pregnancy, unspecified trimester
O15.02 Eclampsia in pregnancy, second trimester
O15.03 Eclampsia in pregnancy, third trimester
O15.0 Eclampsia in pregnancy
O15.1 Eclampsia in labor

SNOMED

398254007 Pre-eclampsia (disorder)
15938005 Eclampsia (disorder)
303063000 Eclampsia in puerperium
95605009 hemolysis-elevated liver enzymes-low platelet count syndrome (disorder)
41114007 Mild pre-eclampsia (disorder)
46764007 Severe pre-eclampsia (disorder)

section name header

Basics ⬇

Diagnosis ⬆ ⬇

ALERT

History

Physical Exam

Lab

Imaging

Diagnostic Procedures/Surgery

Treatment ⬆ ⬇

First Line

Second Line

Follow-Up ⬆ ⬇

Admission Criteria

Discharge Criteria

Pearls and Pitfalls ⬆ ⬇

Additional Reading ⬆ ⬇

Codes ⬆