Preeclampsia: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
''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''<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 | ===ACOG Diagnostic Criteria=== | ||
====Elevated Blood Pressure==== | ====Elevated Blood Pressure==== | ||
*Elevated blood pressure after 20 weeks of gestation in a previously normotensive patient, defined as '''EITHER''': | *Elevated blood pressure after 20 weeks of gestation in a previously normotensive patient, defined as '''EITHER''': | ||
Revision as of 12:15, 18 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
- 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
Diagnosis
Work-Up
- CBC
- Thrombocytopenia suggests severe disease
- 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
In 2013, ACOG has decided to remove proteinuria from the definition of preeclampsia[1]
ACOG Diagnostic Criteria
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
- Labetalol
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)
- 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.
- ↑ Leone M and Einav S. Severe preeclampsia: What's new in intensive care? Intensive Care Med. 2015; 41:1343-1346.
- ↑ http://annals.org/article.aspx?articleid=1902275