Preeclampsia: Difference between revisions

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==Background==
==Background==
*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
**May occur sooner w/ gestational trophoblastic disease
**May occur sooner with gestational trophoblastic disease
*Defined as SBP>140 or DBP>90 in previously normotensive pt AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
*Defined as SBP>140 or DBP>90 in previously normotensive pt AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
*Only 10% of cases occur prior to 34wk
*Only 10% of cases occur prior to 34wk
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*Family history of preeclampsia  
*Family history of preeclampsia  
*Preexisting medical conditions:
*Preexisting medical conditions:
**Pregestational diabetes  
**Pregestational [[diabetes]]
**Blood pressure ≥130/80 mm Hg at the first prenatal visit  
**Blood pressure ≥130/80 mm Hg at the first prenatal visit  
**Antiphospholipid antibodies  
**Antiphospholipid antibodies  
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==Clinical Features==
==Clinical Features==
*Edema
*Edema
*Elevated BP
*[[Elevated BP]]
*With increasing severity pulm edema, visual changes, and AMS can develop
*With increasing severity pulmonary edema, visual changes, and [[AMS]] can develop


==Differential Diagnosis==
==Differential Diagnosis==
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***Lack of proteinuria is not rule-out!
***Lack of proteinuria is not rule-out!


In 2013, ACOG has decided to remove proteinuria from the definition of preeclampsia
''In 2013, ACOG has decided to remove proteinuria from the definition of preeclampsia''


===ACOG Diagnostic Criteria<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>===
===ACOG Diagnostic Criteria<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>===
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**Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease  
**Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease  
**Liver transaminases at least twice the normal concentrations  
**Liver transaminases at least twice the normal concentrations  
**Pulmonary edema  
**[[Pulmonary edema]]
**Cerebral or visual symptoms
**Cerebral or visual symptoms


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==Disposition==
==Disposition==
*Consult w/ OB/GYN regarding d/c versus admission
*Consult with OB/GYN regarding discharge versus admission
**Some cases of mild preeclampsia may be candidates for outpatient therapy
**Some cases of mild preeclampsia may be candidates for outpatient therapy
***Close follow up and return precautions is key
***Close follow up and return precautions is key

Revision as of 15:12, 17 December 2015

Background

  • Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
    • May occur sooner with gestational trophoblastic disease
  • Defined as SBP>140 or DBP>90 in previously normotensive pt AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
  • Only 10% of cases occur prior to 34wk

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

  • Edema
  • Elevated BP
  • With increasing severity pulmonary edema, visual changes, and AMS can develop

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Hypertension

Diagnosis

Work-Up

  • CBC
  • Chemistry
    • Elevated Cr suggests severe disease
  • Baseline Mg level
  • LFT
    • AST/ALT elevation suggests severe disease
  • LDH
    • Elevation suggests microangiopathic hemolysis
  • Uric acid level
    • Often elevated in preeclampsia
  • UA
    • Proteinuria

Diagnosis

  • Mild preeclampsia:
    • SBP > 140 or DBP > 90
    • Proteinuria > 0.3 g/24 hrs or > 1+ on urine dipstick
  • Severe preeclampsia suggested by any of the following:
    • SBP >160 or DBP>110
    • Neurologic sequelae
    • Pulmonary edema
    • GI involvement
      • Epigastric or RUQ pain
      • LFT abnormalities (> 2x normal)
    • Thrombocytopenia < 100,000 plt/mm^3
    • Impaired fetal growth
    • Oliguria (<500 mL in 24hr)
    • Proteinuria of 5 gm in 24hr OR 3+ on two random urine samples collected 4hr apart
      • Lack of proteinuria is not rule-out!

In 2013, ACOG has decided to remove proteinuria from the definition of preeclampsia

ACOG Diagnostic Criteria[1]

Elevated Blood Pressure

  • Elevated blood pressure after 20 weeks of gestation in a previously normotensive patient, defined as EITHER:
    • SBP ≥160 mmHg or diastolic ≥110 mmHg on repeat blood pressure checks over several minutes, OR
    • SBP ≥140 mmHg or diastolic ≥90 mmHg on two occasions at least four hours apart

Proteinuria Criteria

  • Elevated blood pressure (see above), AND
  • Proteinuria:
    • Dipstick 1+ (if a quantitative measurement is unavailable), OR
    • Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3

Non-Proteinuria Criteria

  • Elevated blood pressure (see above), AND
  • Any one of the following:
    • Platelet count <100,000/microliter
    • Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease
    • Liver transaminases at least twice the normal concentrations
    • Pulmonary edema
    • Cerebral or visual symptoms

Management

  • Only definitive treatment is delivery
    • Mild preeclampsia - induction or C-section if > 37 wks; consider close monitoring if 34-37 wks
    • Severe Preeclampsia - induction or C-section independent of gestational age

BP Control

  • Lower to Sys 130-150, dia 80-100
    • Labetalol
      • Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
      • Option 2: Initial 20mg; then IV infusion of 1-2mg/min
    • Nicardipine
      • Initial rate of 5mg/hr and increase by 2.5mg/hr q5min to effect
    • Hydralazine
      • Should not be considered first line therapy[2]
      • 5mg IV over 1-2min; repeat bolus of 5-10mg q20min PRN to total of 30mg

Prevention

  • The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ( B recommendation)[3]
  • Magnesium: For seizure prevention, load 4g IV over 15min followed by 1-2g per hr in coordination with admission by OBGYN
    • 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)

See Also

External Links

LITFL: Pre-eclampsia and Eclampsia

References

  1. ↑ Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
  2. ↑ Leone M and Einav S. Severe preeclampsia: What's new in intensive care? Intensive Care Med. 2015; 41:1343-1346.
  3. ↑ http://annals.org/article.aspx?articleid=1902275
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