Preeclampsia: Difference between revisions
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==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
*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
**May occur sooner with gestational trophoblastic disease
**May occur sooner with gestational trophoblastic disease
*Defined as SBP>140 or DBP>90 in previously normotensive patient 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
*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===
===Risk Factors===
*Past history of preeclampsia  
*Past history of preeclampsia  
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==Clinical Features==
==Clinical Features==
*[[Headache]], new-onset
*Edema
*Edema
*RUQ or epigastric pain
*[[Elevated BP]]
*[[Elevated BP]]
*With increasing severity pulmonary edema, visual changes, and [[altered mental status]] can develop
*With increasing severity; [[pulmonary edema]], [[visual changes]], and [[altered mental status]] can develop


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Work-Up===
===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 creatinine suggests severe disease
**Elevated creatinine suggests severe disease
*[[LFTs]]
**AST/ALT elevation suggests severe disease
*[[Urinalysis]]
**[[Proteinuria]] (see diagnostic criteria)
*Baseline Mg level
*Baseline Mg level
*LFT
**AST/ALT elevation suggests severe disease
*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
*[[Urinalysis]]
**Proteinuria


==ACOG Diagnostic Criteria==
==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>
*''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>
*'''Diagnosis is either based on blood pressure AND proteinuria or the presence of Severe Symptoms'''
*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>
===Blood Pressure===
*'''Diagnosis is based on blood pressure and proteinuria, OR based on blood pressure and presence of end-organ dysfunction (severe features) without proteinuria
*Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs
**Although most patients will have proteinuria, lack of it does not preclude diagnosis
*Systolic ≥160 mmHg or diastolic ≥110 mmHg acutely requiring emergent blood pressure decreases
**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


===Proteinuria===
===[[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
*Proteinuria ≥300mg in a 24-hour urine collection
*Spot protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3
*Spot (one-time) protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3
*1+ on urine dipstick (if no quantitative measurement is unavailable)
*2+ on urine dipstick (not preferred; use if no quantitative measurement is unavailable)


===Severe Symptoms===
===Severe Features===
In the absence of proteinuria, new onset hypertension with any 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)
*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
*[[Thrombocytopenia]] platelets <100,000/mL
*Elevated LFTS (2x normal concentration), severe persistent RUQ/epigastric pain unresponsive to medications and no alternative diagnosis
*Progressive renal insufficiency (creatinine >1.1mg/dL or doubling of creatinine concentration in absence of renal disease)
*Progressive renal insufficiency (creatinine >1.1mg/dL or doubling of creatinine concentration in absence of renal disease)
*Pulmonary edema
**Reduced urine output < 30 cc/hr may indicate severe disease
*New onset cerebral or visual disturbance
*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==
==Management==
===BP Control===
===BP Control===
*For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg
*For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg
*Either labetol or hydralazine can be used for initial control.  Maximize the dose of each drug before adding on additional therapy.
*Either labetalol or hydralazine can be used for initial control.  Maximize the dose of each drug before adding on additional therapy.
===Urgent BP Control===
===Urgent BP Control===
*[[Labetalol]]
*[[Labetalol]]
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*[[Nifedipine|Nifedipine ER]]
*[[Nifedipine|Nifedipine ER]]
**Option 1: 30-120mg/d  
**Option 1: 30-120mg/d  
*[[Methydopa]]
*[[Methyldopa]]
**Option 1: 0.5-3 g/d in two to three divided doses
**Option 1: 0.5-3 g/d in two to three divided doses
*Thiazide diuretics - used as second line agent
*Thiazide diuretics - used as second line agent
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===Delivery Timing===
===Delivery Timing===
*Pre Eclampsia without severe features, delivery at 37 weeks
*Preeclampsia without severe features, delivery at 37 weeks
*Pre Eclampsia with severe features
*Preeclampsia with severe features
**Before fetal viability, delivery after maternal stabilization, expectant management is not recommended
**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:  
**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:  
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*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:
*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
**Uncontrollable severe hypertension
**Eclampsia
**[[Eclampsia]]
**Pulmonary edema
**[[Pulmonary edema]]
**Abruption placentae
**[[Placental abruption]]
**Disseminated intravascular coagulation
**Disseminated intravascular coagulation
**Evidence of nonreassuring fetal status
**Evidence of nonreassuring fetal status
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*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>
*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.
*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==
==[[Seizure]] Prophylaxis==
*Magnesium
*[[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 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
**Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump
Contraindications: pulmonary edema, renal failure, myasthenia gravis
*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
*Observe for loss of reflexes, respiratory depression


==Disposition==
==Disposition==

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

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Hypertension

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
  • Chemistry
    • Elevated creatinine suggests severe disease
  • LFTs
    • AST/ALT elevation suggests severe disease
  • Urinalysis
  • 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:

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)

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. ↑ Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics & Gynecology 135(6):p e237-e260, June 2020. | DOI:10.1097/AOG.0000000000003891
  3. ↑ http://annals.org/article.aspx?articleid=1902275
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