Preeclampsia

Background

1. Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
   1. May occur sooner w/ gestational trophoblastic disease
2. Defined as SBP>140 or DBP>90 in previously normotensive pt AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
3. Only 10% of cases occur prior to 34wk

Work-Up

• CBC
  • Thrombocytopenia suggests severe disease
• Chemistry
  • Elevated Cr suggests severe disease
• LFT
  • AST/ALT elevation suggests severe disease
• LDH
  • Elevation suggests microangiopathic hemolysis
• Uric acid level
  • Often elevated in preeclampsia
• UA
  • Proteinuria

Diagnosis

• Mild preeclampsia:
  • SBP > 140 or DBP > 90
  • Proteinuria > 0.3 g/24 hrs or > 1+ on urine dipstick
• Severe preeclampsia suggested by any of the following:
  • SBP >160 or DBP>110
  • Neurologic sequelae
    • Visual disturbances
    • 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

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

Treatment

1. Only definitive tx is delivery
   1. Mild preeclampsia - induction or C-section if > 37 wks; consider close monitoring if 34-37 wks
   2. Severe Preeclampsia - induction or C-section independent of GA
2. Some cases of mild preeclampsia may be candidates for outpatient therapy
   1. close follow up and return precautions is key
   2. Repeat lab tests 1-2x per week (platelet count, creatinine, AST)
3. BP Control
   1. Lower to Sys 130-150, dia 80-100
      1. Labetalol
         1. Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
         2. Option 2: Initial 20mg; then IV infusion of 1-2mg/min
      2. Hydralazine
         1. 5mg IV over 1-2min; repeat bolus of 5-10mg q20min PRN to total of 30mg

Prevention

1. 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)

1. Magnesium: Load 4-6g IV over 15min followed by 2-3g per hr in coordination with admission by OBGYN
   1. Observe for loss of reflexes, respiratory depression

Disposition

• Consult w/ OB/GYN regarding d/c versus admission

See Also

• Post-Partum Emergencies
• Eclampsia

Source

• EBM, Volume 12, Number 8, Aug 2010. Postpartum Emergencies