Preeclampsia: Difference between revisions
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==Background==
==Background==
*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
*Hypertensive disorder of pregnancy characterized by '''new-onset hypertension + proteinuria or end-organ dysfunction''' after '''20 weeks gestation'''
**May occur sooner with gestational trophoblastic disease
*Affects 2-8% of pregnancies worldwide
*Defined as SBP>140 or DBP>90 in previously normotensive patient AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
*Leading cause of maternal and fetal morbidity and mortality
*Only 10% of cases occur prior to 34wk
*Risk factors:
===Risk Factors===
**Nulliparity, prior preeclampsia, chronic [[hypertension]]
*Past history of preeclampsia
**Multiple gestation, advanced maternal age (>35), obesity
*First pregnancy
**Autoimmune disease ([[SLE]], antiphospholipid syndrome)
*Family history of preeclampsia  
**Pregestational [[diabetes]], [[chronic kidney disease]]
*Preexisting medical conditions:
**Family history of preeclampsia
**Pregestational [[diabetes]]
*Pathophysiology: abnormal placental development → endothelial dysfunction → systemic vasospasm and organ damage
**Blood pressure ≥130/80 mm Hg at the first prenatal visit
*Spectrum includes: preeclampsia, [[eclampsia]] (seizures), [[HELLP syndrome]]
**Antiphospholipid antibodies
 
**Body mass index ≥26.1  
===Diagnostic Criteria (ACOG)===
**Chronic kidney disease
*Blood pressure ≥140/90 mmHg on two occasions at least 4 hours apart (or ≥160/110 once) after 20 weeks in previously normotensive patient
**Twin pregnancies
*PLUS one or more:
**Advanced maternal age
**Proteinuria (≥300 mg/24h, protein/creatinine ratio ≥0.3, or dipstick ≥2+)
**OR end-organ dysfunction (even without proteinuria):
***Platelets <100,000
***Creatinine >1.1 mg/dL (or doubling of baseline)
***Liver transaminases >2x normal
***Pulmonary edema
***Cerebral or visual symptoms


==Clinical Features==
==Clinical Features==
*Edema
===Preeclampsia Without Severe Features===
*[[Elevated BP]]
*BP 140-159/90-109 mmHg
*With increasing severity pulmonary edema, visual changes, and [[altered mental status]] can develop
*Proteinuria
*May be asymptomatic or have mild edema
 
===Preeclampsia With Severe Features (Any One)===
*BP ≥160/110 mmHg (confirmed within minutes to facilitate timely treatment)
*Thrombocytopenia (<100,000)
*Impaired liver function (transaminases >2x normal, severe RUQ/epigastric pain)
*Renal insufficiency (creatinine >1.1 mg/dL)
*Pulmonary edema
*New-onset headache unresponsive to medication
*Visual disturbances (scotomata, blurred vision, photopsia)
 
===HELLP Syndrome===
*Hemolysis, Elevated Liver enzymes, Low Platelets
*Variant of severe preeclampsia; may occur without significant hypertension
*Risk of hepatic rupture, [[DIC]], [[placental abruption]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Postpartum emergencies DDX}}
*Chronic [[hypertension]] (pre-existing before 20 weeks)
 
*Gestational hypertension (no proteinuria or end-organ damage)
{{Hypertension DDX}}
*[[HELLP syndrome]]
*[[Thrombotic thrombocytopenic purpura]] (TTP) / [[hemolytic uremic syndrome]] (HUS)
*Acute fatty liver of pregnancy
*[[SLE]] nephritis flare
*[[Pheochromocytoma]]


==Evaluation==
==Evaluation==
===Work-Up===
*Blood pressure: manual measurement, correct cuff size, patient seated
*CBC
*CBC with platelet count
**[[Thrombocytopenia]] suggests severe disease
*BMP: creatinine, uric acid (elevated in preeclampsia)
*Chemistry
*LFTs: AST/ALT (hepatic involvement)
**Elevated creatinine suggests severe disease
*LDH, haptoglobin, peripheral smear (evaluate for hemolysis / HELLP)
*Baseline Mg level
*Coagulation studies: PT/INR, fibrinogen, D-dimer (if concern for DIC)
*[[LFTs]]
*Urinalysis and urine protein/creatinine ratio
**AST/ALT elevation suggests severe disease
*Fetal monitoring: continuous fetal heart rate monitoring, BPP/NST
*LDH
*Bedside US: fetal assessment, amniotic fluid index
**Elevation suggests microangiopathic hemolysis
*Uric acid level
**Often elevated in preeclampsia
*[[Urinalysis]]
**Proteinuria
 
==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>
*'''Diagnosis is either based on blood pressure AND proteinuria or the presence of Severe Symptoms'''
===Blood Pressure===
*Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs
*Systolic ≥160 mmHg or diastolic ≥110 mmHg acutely requiring emergent blood pressure decreases
 
===Proteinuria===
*Proteinuria ≥300mg in a 24-hour urine collection
*Spot protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3
*1+ on urine dipstick (if no quantitative measurement is unavailable)
 
===Severe Symptoms===
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)
*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)
**Reduced urine output < 30 cc/hr may indicate severe disease
*Pulmonary edema
*New onset cerebral or visual disturbance (scotomata, blurry vision, loss of vision)


==Management==
==Management==
===BP Control===
===Severe Hypertension (BP ≥160/110) — Treat Within 30-60 Minutes===
*For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg
*First-line:
*Either labetol or hydralazine can be used for initial control.  Maximize the dose of each drug before adding on additional therapy.
**IV labetalol: 20 mg IV bolus, then 40 mg, then 80 mg q10min (max 300 mg)
===Urgent BP Control===
**IV hydralazine: 5-10 mg IV q20min (max 30 mg)
*[[Labetalol]]
**PO nifedipine (immediate release): 10-20 mg PO q20-30min (max 50 mg)
**Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg
*Goal: BP 140-150/90-100 mmHg (avoid precipitous drops — risk of fetal distress)
**Option 2: Constant IV infusion of 1-2mg/min
*Avoid: ACE inhibitors, ARBs (teratogenic), nitroprusside (cyanide risk to fetus)
*[[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
*[[Methydopa]]
**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===
*Pre Eclampsia without severe features, delivery at 37 weeks
*Pre Eclampsia 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
**Abruption placentae
**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.
===Seizure Prophylaxis===
*Magnesium sulfate for ALL patients with severe features<ref>Altman D, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. ''Lancet''. 2002;359(9321):1877-1890. PMID 12057549</ref>
**Loading dose: 4-6g IV over 15-20 minutes
**Maintenance: 1-2g/hr IV continuous infusion
**Continue for 24-48 hours postpartum
*Monitor for Mg toxicity:
**Loss of DTRs (first sign — check q1-2h)
**Respiratory depression (hold if RR <12)
**Therapeutic level: 4-7 mg/dL
**Antidote: calcium gluconate 1g IV over 3 minutes


==[[Seizure]] Prophylaxis==
===Definitive Treatment===
*Magnesium
*Delivery is the only cure
**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
*≥37 weeks: delivery recommended regardless of severity
**Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump
*<37 weeks without severe features: expectant management with close monitoring
Contraindications: pulmonary edema, renal failure, myasthenia gravis
*<37 weeks with severe features: delivery after stabilization (give antenatal corticosteroids if 24-34 weeks)
*Mode of delivery: vaginal preferred unless obstetric indication for cesarean


Observe for loss of reflexes, respiratory depression
===Postpartum Preeclampsia===
*Can occur up to 6 weeks postpartum (even without antepartum diagnosis)
*Same treatment principles: antihypertensives, magnesium if severe
*Common cause of postpartum [[headache]] and [[seizures]]


==Disposition==
==Disposition==
*Consult with OB/GYN regarding discharge versus admission
*Preeclampsia without severe features: admit to L&D for monitoring; may manage expectantly if <37 weeks
**Some cases of mild preeclampsia may be candidates for outpatient therapy
*Preeclampsia with severe features: admit to L&D; plan for delivery after maternal stabilization
***Close follow up and return precautions is key
*OB consultation for all suspected cases
***Repeat lab tests 1-2x per week (platelet count, creatinine, AST)
*Postpartum: close BP monitoring for 72 hours minimum


==See Also==
==See Also==
*[[Postpartum Emergencies]]
*[[Eclampsia]]
*[[Eclampsia]]
*[[HELLP syndrome]]
*[[Hypertension in pregnancy]]
*[[Placental abruption]]
*[[Postpartum emergencies]]


==External Links==
[http://lifeinthefastlane.com/ccc/pre-eclampsia-and-eclampsia/ LITFL: Pre-eclampsia and Eclampsia]
==References==
==References==
<references/>
<references/>
*ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia. ''Obstet Gynecol''. 2020;135(6):e237-e260. PMID 32443079
*Chappell LC, et al. Pre-eclampsia. ''Lancet''. 2021;398(10297):341-354. PMID 34051884
*Sibai BM. Diagnosis, prevention, and management of eclampsia. ''Obstet Gynecol''. 2005;105(2):402-410. PMID 15684172


[[Category:OBGYN]]
[[Category:OBGYN]]
[[Category:Critical Care]]

Latest revision as of 09:28, 22 March 2026

Background

  • Hypertensive disorder of pregnancy characterized by new-onset hypertension + proteinuria or end-organ dysfunction after 20 weeks gestation
  • Affects 2-8% of pregnancies worldwide
  • Leading cause of maternal and fetal morbidity and mortality
  • Risk factors:
    • Nulliparity, prior preeclampsia, chronic hypertension
    • Multiple gestation, advanced maternal age (>35), obesity
    • Autoimmune disease (SLE, antiphospholipid syndrome)
    • Pregestational diabetes, chronic kidney disease
    • Family history of preeclampsia
  • Pathophysiology: abnormal placental development → endothelial dysfunction → systemic vasospasm and organ damage
  • Spectrum includes: preeclampsia, eclampsia (seizures), HELLP syndrome

Diagnostic Criteria (ACOG)

  • Blood pressure ≥140/90 mmHg on two occasions at least 4 hours apart (or ≥160/110 once) after 20 weeks in previously normotensive patient
  • PLUS one or more:
    • Proteinuria (≥300 mg/24h, protein/creatinine ratio ≥0.3, or dipstick ≥2+)
    • OR end-organ dysfunction (even without proteinuria):
      • Platelets <100,000
      • Creatinine >1.1 mg/dL (or doubling of baseline)
      • Liver transaminases >2x normal
      • Pulmonary edema
      • Cerebral or visual symptoms

Clinical Features

Preeclampsia Without Severe Features

  • BP 140-159/90-109 mmHg
  • Proteinuria
  • May be asymptomatic or have mild edema

Preeclampsia With Severe Features (Any One)

  • BP ≥160/110 mmHg (confirmed within minutes to facilitate timely treatment)
  • Thrombocytopenia (<100,000)
  • Impaired liver function (transaminases >2x normal, severe RUQ/epigastric pain)
  • Renal insufficiency (creatinine >1.1 mg/dL)
  • Pulmonary edema
  • New-onset headache unresponsive to medication
  • Visual disturbances (scotomata, blurred vision, photopsia)

HELLP Syndrome

  • Hemolysis, Elevated Liver enzymes, Low Platelets
  • Variant of severe preeclampsia; may occur without significant hypertension
  • Risk of hepatic rupture, DIC, placental abruption

Differential Diagnosis

Evaluation

  • Blood pressure: manual measurement, correct cuff size, patient seated
  • CBC with platelet count
  • BMP: creatinine, uric acid (elevated in preeclampsia)
  • LFTs: AST/ALT (hepatic involvement)
  • LDH, haptoglobin, peripheral smear (evaluate for hemolysis / HELLP)
  • Coagulation studies: PT/INR, fibrinogen, D-dimer (if concern for DIC)
  • Urinalysis and urine protein/creatinine ratio
  • Fetal monitoring: continuous fetal heart rate monitoring, BPP/NST
  • Bedside US: fetal assessment, amniotic fluid index

Management

Severe Hypertension (BP ≥160/110) — Treat Within 30-60 Minutes

  • First-line:
    • IV labetalol: 20 mg IV bolus, then 40 mg, then 80 mg q10min (max 300 mg)
    • IV hydralazine: 5-10 mg IV q20min (max 30 mg)
    • PO nifedipine (immediate release): 10-20 mg PO q20-30min (max 50 mg)
  • Goal: BP 140-150/90-100 mmHg (avoid precipitous drops — risk of fetal distress)
  • Avoid: ACE inhibitors, ARBs (teratogenic), nitroprusside (cyanide risk to fetus)

Seizure Prophylaxis

  • Magnesium sulfate for ALL patients with severe features[1]
    • Loading dose: 4-6g IV over 15-20 minutes
    • Maintenance: 1-2g/hr IV continuous infusion
    • Continue for 24-48 hours postpartum
  • Monitor for Mg toxicity:
    • Loss of DTRs (first sign — check q1-2h)
    • Respiratory depression (hold if RR <12)
    • Therapeutic level: 4-7 mg/dL
    • Antidote: calcium gluconate 1g IV over 3 minutes

Definitive Treatment

  • Delivery is the only cure
  • ≥37 weeks: delivery recommended regardless of severity
  • <37 weeks without severe features: expectant management with close monitoring
  • <37 weeks with severe features: delivery after stabilization (give antenatal corticosteroids if 24-34 weeks)
  • Mode of delivery: vaginal preferred unless obstetric indication for cesarean

Postpartum Preeclampsia

  • Can occur up to 6 weeks postpartum (even without antepartum diagnosis)
  • Same treatment principles: antihypertensives, magnesium if severe
  • Common cause of postpartum headache and seizures

Disposition

  • Preeclampsia without severe features: admit to L&D for monitoring; may manage expectantly if <37 weeks
  • Preeclampsia with severe features: admit to L&D; plan for delivery after maternal stabilization
  • OB consultation for all suspected cases
  • Postpartum: close BP monitoring for 72 hours minimum

See Also

References

  1. ↑ Altman D, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877-1890. PMID 12057549
  • ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2020;135(6):e237-e260. PMID 32443079
  • Chappell LC, et al. Pre-eclampsia. Lancet. 2021;398(10297):341-354. PMID 34051884
  • Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105(2):402-410. PMID 15684172
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