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

Clinical Findings

• 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!

Work-Up

1. CBC
   1. Thrombocytopenia suggests severe disease
2. Chemistry
   1. Elevated Cr suggests severe disease
3. LFT
   1. AST/ALT elevation suggests severe disease
4. LDH
   1. Elevation suggests microangiopathic hemolysis
5. Uric acid level
   1. Often elevated in preeclampsia
6. UA
   1. Proteinuria

Treatment

1. Only definitive tx is delivery
   1. Mild preeclampsia - induction or C-section if > 37 wks GA, 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
4. Prevent eclampsia
   1. Magnesium: Load 4-6g IV over 15min followed by 2-3g per hr
      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

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