Preeclampsia: Difference between revisions
Patricklin (talk | contribs) No edit summary |
|||
| (47 intermediate revisions by 8 users not shown) | |||
| Line 1: | Line 1: | ||
== Background == | ==Background== | ||
*New-onset hypertensive disorder related to pregnancy, resulting in significant maternal morbidity and mortality worldwide | |||
*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum | |||
**May occur sooner with gestational trophoblastic disease | |||
**Only 10% of cases occur prior to 34wk | |||
*Pathogenesis: Abnormalities in placental arterial vasculature, including spiral arteries, in early pregnancy can lead to relative hypoperfusion of placenta; subsequent release of growth factors lead to maternal endothelial dysfunction causing systemic hypertension | |||
==Work-Up== | ===Risk Factors=== | ||
*Past history of preeclampsia | |||
*First pregnancy | |||
*Family history of preeclampsia | |||
*Preexisting medical conditions: | |||
**Pregestational [[diabetes]] | |||
**Blood pressure ≥130/80 mm Hg at the first prenatal visit | |||
**Antiphospholipid antibodies | |||
**Body mass index ≥26.1 | |||
**Chronic kidney disease | |||
**Twin pregnancies | |||
**Advanced maternal age | |||
==Clinical Features== | |||
*[[Headache]], new-onset | |||
*Edema | |||
*RUQ or epigastric pain | |||
*[[Elevated BP]] | |||
*With increasing severity; [[pulmonary edema]], [[visual changes]], and [[altered mental status]] can develop | |||
==Differential Diagnosis== | |||
{{Postpartum emergencies DDX}} | |||
{{Hypertension DDX}} | |||
==Evaluation== | |||
===Work-Up=== | |||
Note that all lab findings must not be explained by an pre-existing condition in order to be relevant for diagnosis of preeclampsia | |||
*CBC | *CBC | ||
**[[Thrombocytopenia]] suggests severe disease | **[[Thrombocytopenia]] suggests severe disease | ||
*Chemistry | *Chemistry | ||
**Elevated | **Elevated creatinine suggests severe disease | ||
* | *[[LFTs]] | ||
**AST/ALT elevation suggests severe disease | **AST/ALT elevation suggests severe disease | ||
*[[Urinalysis]] | |||
**[[Proteinuria]] (see diagnostic criteria) | |||
*Baseline Mg level | |||
*LDH | *LDH | ||
**Elevation suggests microangiopathic hemolysis | **Elevation suggests microangiopathic hemolysis | ||
*Uric acid level | *Uric acid level | ||
**Often elevated in preeclampsia | **Often elevated in preeclampsia but is not counted as a severe feature | ||
In 2013, ACOG has decided to remove proteinuria from the definition of preeclampsia | ==ACOG Diagnostic Criteria== | ||
*''In 2013, ACOG has decided to remove proteinuria from the definition of severity of preeclampsia but it is still part of the diagnosis''<ref>Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.</ref> | |||
*See ACOG practice bulletin 222, Gestational Hypertension and Preeclampsia, for recommendations on diagnosis<ref>Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics & Gynecology 135(6):p e237-e260, June 2020. | DOI:10.1097/AOG.0000000000003891</ref> | |||
*'''Diagnosis is based on blood pressure and proteinuria, OR based on blood pressure and presence of end-organ dysfunction (severe features) without proteinuria | |||
**Although most patients will have proteinuria, lack of it does not preclude diagnosis | |||
**Presence of "severe features" (see below) signify end organ dysfunction | |||
*Preeclampsia superimposed upon chronic hypertension: Similar criteria to preeclampsia, with acutely worsening blood pressure superimposed upon baseline, along with proteinuria and/or end-organ dysfunction | |||
=== | ===[[hypertension|Blood Pressure]]=== | ||
*Hypertension: Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs | |||
* | *Severe range hypertension: Systolic ≥160 mmHg or diastolic ≥110 mmHg acutely requiring emergent blood pressure decreases | ||
* | |||
=== | ===[[Proteinuria]]=== | ||
*Proteinuria ≥300mg in a 24-hour urine collection | |||
*Spot (one-time) protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3 | |||
*2+ on urine dipstick (not preferred; use if no quantitative measurement is unavailable) | |||
=== | ===Severe Features=== | ||
* | *Systolic BP ≥160 or diastolic BP ≥110, 2 occasions, 4 hours apart, while on bed rest (unless antihypertension meds were started before this time) | ||
* | *[[Thrombocytopenia]] platelets <100,000/mL | ||
*Progressive renal insufficiency (creatinine >1.1mg/dL or doubling of creatinine concentration in absence of renal disease) | |||
* | **Reduced urine output < 30 cc/hr may indicate severe disease | ||
**Liver | *Elevated [[Liver function tests]] (2x normal concentration), severe persistent [[RUQ pain|RUQ]]/[[epigastric pain]] unresponsive to medications and no alternative diagnosis | ||
* | *[[Pulmonary edema]] | ||
* | *New onset headache resistant to medications, or [[visual disturbance]] (scotomata, blurry vision, loss of vision) | ||
*Note that massive proteinuria is not currently a criteria for severe feature | |||
== | ==Management== | ||
===BP Control=== | |||
*For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg | |||
*Either labetalol or hydralazine can be used for initial control. Maximize the dose of each drug before adding on additional therapy. | |||
===Urgent BP Control=== | |||
*[[Labetalol]] | |||
**Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg | |||
**Option 2: Constant IV infusion of 1-2mg/min | |||
*[[Hydralazine]] | |||
**Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg | |||
**Option 2: Constant infusion 0.5-10mg/hr | |||
*[[Nifedipine]] | |||
**Option 1: 10-20mg PO, repeat in 30 minutes PRN; then 10-20mg q 2-6 hours | |||
===Oral Antihypertension=== | |||
These meds can be used safely to control hypertension of pregnancy | |||
*[[Labetalol]] | |||
**Option 1: 200-2400mg/d in two to three divided doses | |||
*[[Nifedipine|Nifedipine ER]] | |||
**Option 1: 30-120mg/d | |||
*[[Methyldopa]] | |||
**Option 1: 0.5-3 g/d in two to three divided doses | |||
*Thiazide diuretics - used as second line agent | |||
*ACE Inhibitor/ARB - CONTRAINDICATED IN PREGNANCY DUE TO TERATOGENICITY | |||
== | ===Delivery Timing=== | ||
* | *Preeclampsia without severe features, delivery at 37 weeks | ||
** | *Preeclampsia with severe features | ||
** | **Before fetal viability, delivery after maternal stabilization, expectant management is not recommended | ||
* | **Viable fetus at 33 6/7 weeks or less may delay delivery for 48 hours of corticosteroids if maternal and fetal conditions remain stable with any of the following: | ||
** | ***PPROM | ||
** | ***Labor | ||
* | ***Low platelet count <100,000mL | ||
** | ***Persistent abnormal LFT(2x normal concentration) | ||
*** | ***IUGR<5% | ||
**** | ***Severe oligohydramnios (AFI<5cm) | ||
**** | ***Reversed end diastolic flow on umbilical artery Doppler studies | ||
*** | ***New onset renal dysfunction or increasing renal dysfunction. | ||
**** | *Do not delay delivery after initial maternal stabilization regardless of gestational age for women with PreE with severe features complicated by any of the following: | ||
**Uncontrollable severe hypertension | |||
**[[Eclampsia]] | |||
**[[Pulmonary edema]] | |||
**[[Placental abruption]] | |||
**Disseminated intravascular coagulation | |||
**Evidence of nonreassuring fetal status | |||
**Intrapartum fetal demise | |||
===Prevention=== | |||
*The USPSTF recommends the use of low-dose aspirin (81mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ([[Evidence Based Recommendation Levels| B recommendation]])<ref>http://annals.org/article.aspx?articleid=1902275</ref> | |||
*Per ACOG Task Force: For women with prior preeclampsia that led to delivery before 34 weeks of gestation or occurring in more than one pregnancy, offer daily low-dose aspirin (81mg or less) late in the first trimester. | |||
* | |||
*[[Magnesium]]: Load 4- | ==[[Seizure]] Prophylaxis== | ||
**Observe for loss of reflexes, respiratory depression | *[[Magnesium]] | ||
**Option 1: Load 4-6 grams 10% magnesium sulfate in 100ml solution IV over 20 minutes, then continuous infusion of Magnesium sulfate maintenance 1-2 grams/hour | |||
**Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump | |||
*Despite [[pregnancy risk drug|category D]] label, can be safely used for <48h to allow administration of betamethasone prior to preterm delivery | |||
*Contraindications: [[pulmonary edema]], [[renal failure]], [[myasthenia gravis]] | |||
*Observe for loss of reflexes, respiratory depression | |||
==Disposition== | ==Disposition== | ||
*Consult | *Consult with OB/GYN regarding discharge versus admission | ||
**Some cases of mild preeclampsia may be candidates for outpatient therapy | |||
***Close follow up and return precautions is key | |||
***Repeat lab tests 1-2x per week (platelet count, creatinine, AST) | |||
==See Also== | ==See Also== | ||
*[[ | *[[Postpartum Emergencies]] | ||
*[[Eclampsia]] | *[[Eclampsia]] | ||
== | ==External Links== | ||
[http://lifeinthefastlane.com/ccc/pre-eclampsia-and-eclampsia/ LITFL: Pre-eclampsia and Eclampsia] | |||
==References== | |||
<references/> | <references/> | ||
[[Category: | |||
[[Category:OBGYN]] | |||
Latest revision as of 04:44, 5 December 2023
Background
- New-onset hypertensive disorder related to pregnancy, resulting in significant maternal morbidity and mortality worldwide
- Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
- May occur sooner with gestational trophoblastic disease
- Only 10% of cases occur prior to 34wk
- Pathogenesis: Abnormalities in placental arterial vasculature, including spiral arteries, in early pregnancy can lead to relative hypoperfusion of placenta; subsequent release of growth factors lead to maternal endothelial dysfunction causing systemic hypertension
Risk Factors
- Past history of preeclampsia
- First pregnancy
- Family history of preeclampsia
- Preexisting medical conditions:
- Pregestational diabetes
- Blood pressure ≥130/80 mm Hg at the first prenatal visit
- Antiphospholipid antibodies
- Body mass index ≥26.1
- Chronic kidney disease
- Twin pregnancies
- Advanced maternal age
Clinical Features
- Headache, new-onset
- Edema
- RUQ or epigastric pain
- Elevated BP
- With increasing severity; pulmonary edema, visual changes, and altered mental status can develop
Differential Diagnosis
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Evaluation
Work-Up
Note that all lab findings must not be explained by an pre-existing condition in order to be relevant for diagnosis of preeclampsia
- CBC
- Thrombocytopenia suggests severe disease
- Chemistry
- Elevated creatinine suggests severe disease
- LFTs
- AST/ALT elevation suggests severe disease
- Urinalysis
- Proteinuria (see diagnostic criteria)
- Baseline Mg level
- LDH
- Elevation suggests microangiopathic hemolysis
- Uric acid level
- Often elevated in preeclampsia but is not counted as a severe feature
ACOG Diagnostic Criteria
- In 2013, ACOG has decided to remove proteinuria from the definition of severity of preeclampsia but it is still part of the diagnosis[1]
- See ACOG practice bulletin 222, Gestational Hypertension and Preeclampsia, for recommendations on diagnosis[2]
- Diagnosis is based on blood pressure and proteinuria, OR based on blood pressure and presence of end-organ dysfunction (severe features) without proteinuria
- Although most patients will have proteinuria, lack of it does not preclude diagnosis
- Presence of "severe features" (see below) signify end organ dysfunction
- Preeclampsia superimposed upon chronic hypertension: Similar criteria to preeclampsia, with acutely worsening blood pressure superimposed upon baseline, along with proteinuria and/or end-organ dysfunction
Blood Pressure
- Hypertension: Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs
- Severe range hypertension: Systolic ≥160 mmHg or diastolic ≥110 mmHg acutely requiring emergent blood pressure decreases
Proteinuria
- Proteinuria ≥300mg in a 24-hour urine collection
- Spot (one-time) protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3
- 2+ on urine dipstick (not preferred; use if no quantitative measurement is unavailable)
Severe Features
- Systolic BP ≥160 or diastolic BP ≥110, 2 occasions, 4 hours apart, while on bed rest (unless antihypertension meds were started before this time)
- Thrombocytopenia platelets <100,000/mL
- Progressive renal insufficiency (creatinine >1.1mg/dL or doubling of creatinine concentration in absence of renal disease)
- Reduced urine output < 30 cc/hr may indicate severe disease
- Elevated Liver function tests (2x normal concentration), severe persistent RUQ/epigastric pain unresponsive to medications and no alternative diagnosis
- Pulmonary edema
- New onset headache resistant to medications, or visual disturbance (scotomata, blurry vision, loss of vision)
- Note that massive proteinuria is not currently a criteria for severe feature
Management
BP Control
- For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg
- Either labetalol or hydralazine can be used for initial control. Maximize the dose of each drug before adding on additional therapy.
Urgent BP Control
- Labetalol
- Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg
- Option 2: Constant IV infusion of 1-2mg/min
- Hydralazine
- Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg
- Option 2: Constant infusion 0.5-10mg/hr
- Nifedipine
- Option 1: 10-20mg PO, repeat in 30 minutes PRN; then 10-20mg q 2-6 hours
Oral Antihypertension
These meds can be used safely to control hypertension of pregnancy
- Labetalol
- Option 1: 200-2400mg/d in two to three divided doses
- Nifedipine ER
- Option 1: 30-120mg/d
- Methyldopa
- Option 1: 0.5-3 g/d in two to three divided doses
- Thiazide diuretics - used as second line agent
- ACE Inhibitor/ARB - CONTRAINDICATED IN PREGNANCY DUE TO TERATOGENICITY
Delivery Timing
- Preeclampsia without severe features, delivery at 37 weeks
- Preeclampsia with severe features
- Before fetal viability, delivery after maternal stabilization, expectant management is not recommended
- Viable fetus at 33 6/7 weeks or less may delay delivery for 48 hours of corticosteroids if maternal and fetal conditions remain stable with any of the following:
- PPROM
- Labor
- Low platelet count <100,000mL
- Persistent abnormal LFT(2x normal concentration)
- IUGR<5%
- Severe oligohydramnios (AFI<5cm)
- Reversed end diastolic flow on umbilical artery Doppler studies
- New onset renal dysfunction or increasing renal dysfunction.
- Do not delay delivery after initial maternal stabilization regardless of gestational age for women with PreE with severe features complicated by any of the following:
- Uncontrollable severe hypertension
- Eclampsia
- Pulmonary edema
- Placental abruption
- Disseminated intravascular coagulation
- Evidence of nonreassuring fetal status
- Intrapartum fetal demise
Prevention
- The USPSTF recommends the use of low-dose aspirin (81mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ( B recommendation)[3]
- Per ACOG Task Force: For women with prior preeclampsia that led to delivery before 34 weeks of gestation or occurring in more than one pregnancy, offer daily low-dose aspirin (81mg or less) late in the first trimester.
Seizure Prophylaxis
- Magnesium
- Option 1: Load 4-6 grams 10% magnesium sulfate in 100ml solution IV over 20 minutes, then continuous infusion of Magnesium sulfate maintenance 1-2 grams/hour
- Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump
- Despite category D label, can be safely used for <48h to allow administration of betamethasone prior to preterm delivery
- Contraindications: pulmonary edema, renal failure, myasthenia gravis
- Observe for loss of reflexes, respiratory depression
Disposition
- Consult with OB/GYN regarding discharge versus admission
- Some cases of mild preeclampsia may be candidates for outpatient therapy
- Close follow up and return precautions is key
- Repeat lab tests 1-2x per week (platelet count, creatinine, AST)
- Some cases of mild preeclampsia may be candidates for outpatient therapy
See Also
External Links
LITFL: Pre-eclampsia and Eclampsia
References
- ↑ Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
- ↑ Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics & Gynecology 135(6):p e237-e260, June 2020. | DOI:10.1097/AOG.0000000000003891
- ↑ http://annals.org/article.aspx?articleid=1902275