Diferencia entre revisiones de «Preeclampsia»

(Add MedicationDose SMW entries for labetalol, hydralazine, nifedipine, magnesium sulfate; doses verified against ACOG guidelines)
(Major update: ACOG diagnostic criteria, severe features definition, labetalol/hydralazine/nifedipine dosing, Mg monitoring, HELLP, postpartum preeclampsia, Magpie Trial, references with PMIDs)
Línea 1: Línea 1:
==Background==
==Background==
*New-onset hypertensive disorder related to pregnancy, resulting in significant maternal morbidity and mortality worldwide
*Hypertensive disorder of pregnancy characterized by '''new-onset hypertension + proteinuria or end-organ dysfunction''' after '''20 weeks gestation'''
*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
*Affects '''2-8% of pregnancies''' worldwide
**May occur sooner with gestational trophoblastic disease
*Leading cause of maternal and fetal morbidity and mortality
**Only 10% of cases occur prior to 34wk
*Risk factors:
*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
**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


==Clinical Features==
==Clinical Features==
*[[Headache]], new-onset
===Preeclampsia Without Severe Features===
*Edema
*BP 140-159/90-109 mmHg
*RUQ or epigastric pain
*Proteinuria
*[[Elevated BP]]
*May be '''asymptomatic''' or have mild edema
*With increasing severity; [[pulmonary edema]], [[visual changes]], and [[altered mental status]] can develop
 
===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===
*'''H'''emolysis, '''E'''levated '''L'''iver enzymes, '''L'''ow '''P'''latelets
*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
Note that all lab findings must not be explained by an pre-existing condition in order to be relevant for diagnosis of preeclampsia
*'''CBC with platelet count'''
*CBC
*'''BMP''': creatinine, uric acid (elevated in preeclampsia)
**[[Thrombocytopenia]] suggests severe disease
*'''LFTs''': AST/ALT (hepatic involvement)
*Chemistry
*'''LDH, haptoglobin, peripheral smear''' (evaluate for hemolysis / HELLP)
**Elevated creatinine suggests severe disease
*'''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
*[[Urinalysis]]
*'''Bedside US''': fetal assessment, amniotic fluid index
**[[Proteinuria]] (see diagnostic criteria)
*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''<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>
*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>
*'''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
 
===[[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
*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 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===
===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 labetalol 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
*[[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===
===Seizure Prophylaxis===
*Preeclampsia without severe features, delivery at 37 weeks
*'''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>
*Preeclampsia with severe features
**'''Loading dose: 4-6g IV over 15-20 minutes'''
**Before fetal viability, delivery after maternal stabilization, expectant management is not recommended
**'''Maintenance: 1-2g/hr IV continuous infusion'''
**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:  
**Continue for '''24-48 hours postpartum'''
***PPROM
*'''Monitor for Mg toxicity''':
***Labor
**Loss of DTRs (first sign — check q1-2h)
***Low platelet count <100,000mL
**Respiratory depression (hold if RR <12)
***Persistent abnormal LFT(2x normal concentration)
**Therapeutic level: 4-7 mg/dL
***IUGR<5%
**'''Antidote: calcium gluconate 1g IV over 3 minutes'''
***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]]
**[[Placental abruption]]
**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.
===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


==[[Seizure]] Prophylaxis==
===Postpartum Preeclampsia===
*[[Magnesium]]
*Can occur '''up to 6 weeks postpartum''' (even without antepartum diagnosis)
**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
*Same treatment principles: antihypertensives, magnesium if severe
**Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump
*Common cause of postpartum [[headache]] and [[seizures]]
*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


==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
 
 
==Medication Dosing==
===Urgent BP Control===
*{{MedicationDose|drug=Labetalol|dose=10-20 mg IV, then 20-80 mg q20-30min|route=IV|context=Urgent BP control|indication=Preeclampsia|population=Adult|max_dose=300 mg total}}
*{{MedicationDose|drug=Hydralazine|dose=5 mg, then 5-10 mg q20-40min|route=IV/IM|context=Urgent BP control|indication=Preeclampsia|population=Adult|max_dose=30 mg total}}
*{{MedicationDose|drug=Nifedipine|dose=10-20 mg PO, repeat in 30 min PRN|route=PO|context=Urgent BP control|indication=Preeclampsia|population=Adult}}
 
===Seizure Prophylaxis===
*{{MedicationDose|drug=Magnesium sulfate|dose=4-6 g IV load over 20 min, then 1-2 g/hr|route=IV|context=Seizure prophylaxis|indication=Preeclampsia|population=Adult}}


==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]]

Revisión del 19:49 21 mar 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
Obtenido de «https://www.wikem.org/w/index.php?title=Preeclampsia&oldid=388325»