Diferencia entre revisiones de «Preeclampsia»

(Major update: ACOG diagnostic criteria, severe features definition, labetalol/hydralazine/nifedipine dosing, Mg monitoring, HELLP, postpartum preeclampsia, Magpie Trial, references with PMIDs)
(Strip excess bold)
 
Línea 1: Línea 1:
==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 '''2-8% of pregnancies''' worldwide
*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:
Línea 13: Línea 13:


===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
*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+)
**Proteinuria (≥300 mg/24h, protein/creatinine ratio ≥0.3, or dipstick ≥2+)
**'''OR end-organ dysfunction''' (even without proteinuria):
**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)
Línea 27: Línea 27:
*BP 140-159/90-109 mmHg
*BP 140-159/90-109 mmHg
*Proteinuria
*Proteinuria
*May be '''asymptomatic''' or have mild edema
*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)
*BP ≥160/110 mmHg (confirmed within minutes to facilitate timely treatment)
*'''Thrombocytopenia''' (<100,000)
*Thrombocytopenia (<100,000)
*'''Impaired liver function''' (transaminases >2x normal, severe RUQ/epigastric pain)
*Impaired liver function (transaminases >2x normal, severe RUQ/epigastric pain)
*'''Renal insufficiency''' (creatinine >1.1 mg/dL)
*Renal insufficiency (creatinine >1.1 mg/dL)
*'''Pulmonary edema'''
*Pulmonary edema
*'''New-onset headache''' unresponsive to medication
*New-onset headache unresponsive to medication
*'''Visual disturbances''' (scotomata, blurred vision, photopsia)
*Visual disturbances (scotomata, blurred vision, photopsia)


===HELLP Syndrome===
===HELLP Syndrome===
*'''H'''emolysis, '''E'''levated '''L'''iver enzymes, '''L'''ow '''P'''latelets
*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]]
Línea 53: Línea 53:


==Evaluation==
==Evaluation==
*'''Blood pressure''': manual measurement, correct cuff size, patient seated
*Blood pressure: manual measurement, correct cuff size, patient seated
*'''CBC with platelet count'''
*CBC with platelet count
*'''BMP''': creatinine, uric acid (elevated in preeclampsia)
*BMP: creatinine, uric acid (elevated in preeclampsia)
*'''LFTs''': AST/ALT (hepatic involvement)
*LFTs: AST/ALT (hepatic involvement)
*'''LDH, haptoglobin, peripheral smear''' (evaluate for hemolysis / HELLP)
*LDH, haptoglobin, peripheral smear (evaluate for hemolysis / HELLP)
*'''Coagulation studies''': PT/INR, fibrinogen, D-dimer (if concern for DIC)
*Coagulation studies: PT/INR, fibrinogen, D-dimer (if concern for DIC)
*'''Urinalysis and urine protein/creatinine ratio'''
*Urinalysis and urine protein/creatinine ratio
*'''Fetal monitoring''': continuous fetal heart rate monitoring, BPP/NST
*Fetal monitoring: continuous fetal heart rate monitoring, BPP/NST
*'''Bedside US''': fetal assessment, amniotic fluid index
*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''':
*First-line:
**'''IV labetalol''': 20 mg IV bolus, then 40 mg, then 80 mg q10min (max 300 mg)
**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)
**IV hydralazine: 5-10 mg IV q20min (max 30 mg)
**'''PO nifedipine (immediate release)''': 10-20 mg PO q20-30min (max 50 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)
*Goal: BP 140-150/90-100 mmHg (avoid precipitous drops — risk of fetal distress)
*'''Avoid''': ACE inhibitors, ARBs (teratogenic), nitroprusside (cyanide risk to fetus)
*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>
*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'''
**Loading dose: 4-6g IV over 15-20 minutes
**'''Maintenance: 1-2g/hr IV continuous infusion'''
**Maintenance: 1-2g/hr IV continuous infusion
**Continue for '''24-48 hours postpartum'''
**Continue for 24-48 hours postpartum
*'''Monitor for Mg toxicity''':
*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'''
**Antidote: calcium gluconate 1g IV over 3 minutes


===Definitive Treatment===
===Definitive Treatment===
*'''Delivery is the only cure'''
*Delivery is the only cure
*'''≥37 weeks''': delivery recommended regardless of severity
*≥37 weeks: delivery recommended regardless of severity
*'''<37 weeks without severe features''': expectant management with close monitoring
*<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)
*<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 '''up to 6 weeks postpartum''' (even without antepartum diagnosis)
*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 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
*Preeclampsia with severe features: admit to L&D; plan for delivery after maternal stabilization
*'''OB consultation''' for all suspected cases
*OB consultation for all suspected cases
*Postpartum: close BP monitoring for 72 hours minimum
*Postpartum: close BP monitoring for 72 hours minimum



Revisión actual - 09:28 22 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