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 w/ gestational trophoblastic disease
*Affects 2-8% of pregnancies worldwide
#Defined as SBP>140 or DBP>90 in previously normotensive pt 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:
**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]]


===Risk Factors===
===Diagnostic Criteria (ACOG)===
*Past history of preeclampsia
*Blood pressure ≥140/90 mmHg on two occasions at least 4 hours apart (or ≥160/110 once) after 20 weeks in previously normotensive patient
*First pregnancy
*PLUS one or more:
*Family history of preeclampsia
**Proteinuria (≥300 mg/24h, protein/creatinine ratio ≥0.3, or dipstick ≥2+)
*Preexisting medical conditions:
**OR end-organ dysfunction (even without proteinuria):
**Pregestational diabetes
***Platelets <100,000
**Blood pressure ≥130/80 mm Hg at the first prenatal visit
***Creatinine >1.1 mg/dL (or doubling of baseline)
**Antiphospholipid antibodies
***Liver transaminases >2x normal
**Body mass index ≥26.1  
***Pulmonary edema
**Chronic kidney disease
***Cerebral or visual symptoms
**Twin pregnancies
**Advanced maternal age


==Work-Up==
==Clinical Features==
*CBC
===Preeclampsia Without Severe Features===
**[[Thrombocytopenia]] suggests severe disease
*BP 140-159/90-109 mmHg
*Chemistry
*Proteinuria
**Elevated Cr suggests severe disease
*May be asymptomatic or have mild edema
*LFT
**AST/ALT elevation suggests severe disease
*LDH
**Elevation suggests microangiopathic hemolysis
*Uric acid level
**Often elevated in preeclampsia
*UA
**Proteinuria


==Diagnosis==
===Preeclampsia With Severe Features (Any One)===
*Mild preeclampsia:
*BP ≥160/110 mmHg (confirmed within minutes to facilitate timely treatment)
**SBP > 140 or DBP > 90
*Thrombocytopenia (<100,000)
**Proteinuria > 0.3 g/24 hrs or > 1+ on urine dipstick
*Impaired liver function (transaminases >2x normal, severe RUQ/epigastric pain)
*Severe preeclampsia suggested by any of the following:
*Renal insufficiency (creatinine >1.1 mg/dL)
**SBP >160 or DBP>110
*Pulmonary edema
**Neurologic sequelae
*New-onset headache unresponsive to medication
***[[Visual disturbances]]
*Visual disturbances (scotomata, blurred vision, photopsia)
***[[Mental status changes]]
***[[Focal neurologic symptoms]]
***Severe headache refractory to analgesia
**[[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
===HELLP Syndrome===
*Hemolysis, Elevated Liver enzymes, Low Platelets
*Variant of severe preeclampsia; may occur without significant hypertension
*Risk of hepatic rupture, [[DIC]], [[placental abruption]]


===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>===
==Differential Diagnosis==
====Elevated Blood Pressure====
*Chronic [[hypertension]] (pre-existing before 20 weeks)
*Elevated blood pressure after 20 weeks of gestation in a previously normotensive patient, defined as '''EITHER''':
*Gestational hypertension (no proteinuria or end-organ damage)
**SBP ≥160 mmHg or diastolic ≥110 mmHg on repeat blood pressure checks over several minutes, '''OR'''
*[[HELLP syndrome]]
**SBP ≥140 mmHg or diastolic ≥90 mmHg on two occasions at least four hours apart
*[[Thrombotic thrombocytopenic purpura]] (TTP) / [[hemolytic uremic syndrome]] (HUS)
*Acute fatty liver of pregnancy
*[[SLE]] nephritis flare
*[[Pheochromocytoma]]


====Proteinuria Criteria====
==Evaluation==
*Elevated blood pressure (see above), '''AND'''
*Blood pressure: manual measurement, correct cuff size, patient seated
*Proteinuria:
*CBC with platelet count
**Dipstick 1+ (if a quantitative measurement is unavailable), '''OR'''
*BMP: creatinine, uric acid (elevated in preeclampsia)
**Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3
*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


====Non-Proteinuria Criteria====
==Management==
*Elevated blood pressure (see above), '''AND'''
===Severe Hypertension (BP ≥160/110) — Treat Within 30-60 Minutes===
*Any one of the following:  
*First-line:
**Platelet count <100,000/microliter
**IV labetalol: 20 mg IV bolus, then 40 mg, then 80 mg q10min (max 300 mg)
**Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease
**IV hydralazine: 5-10 mg IV q20min (max 30 mg)
**Liver transaminases at least twice the normal concentrations
**PO nifedipine (immediate release): 10-20 mg PO q20-30min (max 50 mg)
**Pulmonary edema
*Goal: BP 140-150/90-100 mmHg (avoid precipitous drops — risk of fetal distress)
**Cerebral or visual symptoms
*Avoid: ACE inhibitors, ARBs (teratogenic), nitroprusside (cyanide risk to fetus)


==Differential Diagnosis==
===Seizure Prophylaxis===
{{Postpartum emergencies DDX}}
*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


{{Hypertension DDX}}
===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


==Treatment==
===Postpartum Preeclampsia===
*Only definitive treatment is delivery
*Can occur up to 6 weeks postpartum (even without antepartum diagnosis)
**Mild preeclampsia - induction or C-section if > 37 wks; consider close monitoring if 34-37 wks
*Same treatment principles: antihypertensives, magnesium if severe
**Severe Preeclampsia - induction or C-section independent of gestational age
*Common cause of postpartum [[headache]] and [[seizures]]
===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
**[[Hydralazine]]
***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. ([[Evidence Based Recommendation Levels| B recommendation]])<ref>http://annals.org/article.aspx?articleid=1902275</ref>
 
*[[Magnesium]]: Load 4-6g IV over 15min followed by 2-3g per hr in coordination with admission by OBGYN
**Observe for loss of reflexes, respiratory depression


==Disposition==
==Disposition==
*Consult w/ OB/GYN regarding d/c 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]]


==Source==
==References==
*EBM, Volume 12, Number 8, Aug 2010. Postpartum Emergencies
<references/>
<references/>
[[Category:OB/GYN]]
*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: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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