Preeclampsia: Difference between revisions
(Major update: ACOG diagnostic criteria, severe features definition, labetalol/hydralazine/nifedipine dosing, Mg monitoring, HELLP, postpartum preeclampsia, Magpie Trial, references with PMIDs) |
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==Background== | ==Background== | ||
*Hypertensive disorder of pregnancy characterized by '''new-onset hypertension + proteinuria or end-organ dysfunction''' after '''20 weeks gestation''' | *Hypertensive disorder of pregnancy characterized by '''new-onset hypertension + proteinuria or end-organ dysfunction''' after '''20 weeks gestation''' | ||
*Affects | *Affects 2-8% of pregnancies worldwide | ||
*Leading cause of maternal and fetal morbidity and mortality | *Leading cause of maternal and fetal morbidity and mortality | ||
*Risk factors: | *Risk factors: | ||
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===Diagnostic Criteria (ACOG)=== | ===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: | *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 | ***Platelets <100,000 | ||
***Creatinine >1.1 mg/dL (or doubling of baseline) | ***Creatinine >1.1 mg/dL (or doubling of baseline) | ||
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*BP 140-159/90-109 mmHg | *BP 140-159/90-109 mmHg | ||
*Proteinuria | *Proteinuria | ||
*May be | *May be asymptomatic or have mild edema | ||
===Preeclampsia With Severe Features (Any One)=== | ===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=== | ===HELLP Syndrome=== | ||
* | *Hemolysis, Elevated Liver enzymes, Low Platelets | ||
*Variant of severe preeclampsia; may occur without significant hypertension | *Variant of severe preeclampsia; may occur without significant hypertension | ||
*Risk of hepatic rupture, [[DIC]], [[placental abruption]] | *Risk of hepatic rupture, [[DIC]], [[placental abruption]] | ||
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==Evaluation== | ==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== | ==Management== | ||
===Severe Hypertension (BP ≥160/110) — Treat Within 30-60 Minutes=== | ===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=== | ===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 | **Continue for 24-48 hours postpartum | ||
* | *Monitor for Mg toxicity: | ||
**Loss of DTRs (first sign — check q1-2h) | **Loss of DTRs (first sign — check q1-2h) | ||
**Respiratory depression (hold if RR <12) | **Respiratory depression (hold if RR <12) | ||
**Therapeutic level: 4-7 mg/dL | **Therapeutic level: 4-7 mg/dL | ||
** | **Antidote: calcium gluconate 1g IV over 3 minutes | ||
===Definitive Treatment=== | ===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 | *Mode of delivery: vaginal preferred unless obstetric indication for cesarean | ||
===Postpartum Preeclampsia=== | ===Postpartum Preeclampsia=== | ||
*Can occur | *Can occur up to 6 weeks postpartum (even without antepartum diagnosis) | ||
*Same treatment principles: antihypertensives, magnesium if severe | *Same treatment principles: antihypertensives, magnesium if severe | ||
*Common cause of postpartum [[headache]] and [[seizures]] | *Common cause of postpartum [[headache]] and [[seizures]] | ||
==Disposition== | ==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 | *Postpartum: close BP monitoring for 72 hours minimum | ||
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
- Chronic hypertension (pre-existing before 20 weeks)
- Gestational hypertension (no proteinuria or end-organ damage)
- HELLP syndrome
- Thrombotic thrombocytopenic purpura (TTP) / hemolytic uremic syndrome (HUS)
- Acute fatty liver of pregnancy
- SLE nephritis flare
- Pheochromocytoma
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
- ↑ 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