Snapshot A 20-year-old woman at 30 weeks gestation presents to the emergency room with malaise, headache, and nausea. On physical exam, she is alert and oriented. She is noted to have bilateral lower extremity edema. A urine dipstick shows 2+ proteinuria and her blood pressure is 150/96 mmHg. Her other laboratory values are within normal limits. She is discharged home. The next day, she returns with a worsening headache and found with elevated blood pressure again at 163/100 mmHg. She is admitted and started on magnesium sulfate for seizure prophylaxis. Introduction Overview hypertension during pregnancy can be chronic hypertension, gestational hypertension, preeclamspia, or eclampsia some consider HELLP syndrome to be a form of preeclampsia/eclampsia although this is controversial Diagnosis of preeclampsia hypertension (> 140/90 mmHg on 2 separate occasions or 160/110 mmHg) and proteinuria can also be diagnosed without proteinuria if one of the following signs of severe preeclampsia blood pressure > 160/110 mmHg hepatic dysfunction renal insufficiency visual/cerebral disturbances pulmonary edema thrombocytopenia Spectrum of Hypertensive Disorders in PregnancyChronic HypertensionGestational HypertensionPreeclampsiaEclampsiaHELLP SyndromeHistory of hypertension(> 140/90 mmgHg) before pregnancy or before 20 weeks of gestationHypertension persists after deliveryHypertension after 20 weeks of gestationHypertension returns to baseline by 6 weeks post-partumCommon in multiple gestationsHypertension (> 140/90 mmHg on 2 separate occasions, or >160/110 mmHg) plusproteinuriaPreeclampsia plus seizuresHemolysisElevatedLiver enzymesLowPlatelets Epidemiology Incidence 2-6% Risk factors nulliparity multiple gestations hyatidiform mole diabetes chronic hypertension chronic renal disease Etiology Pathogenesis mechanism impaired vasodilation of spiral arteries causes placental ischemia this results in increased vascular tone, increased vasoconstriction, and decreased vasodilation other factors considered to contribute include maternal immunologic intolerance, inflammatory changes, and abnormal placental implantation Presentation Symptoms common symptoms danger signs headache epigastric pain visual changes pulmonary edema oliguria water retention Physical exam inspection hypertension > 140/90 mmHg tonic-clonic seizures hyperreflexia periorbital and extremity edema altered mental status Studies Serum labs proteinuria 1-2+ on dipstick > 300 mg on 24-hour urine protein/creatinine ratio > 0.3 best confirmatory test is a spot urine protein to creatinine ratio thrombocytopenia hemoconcentration Differential Acute fatty liver of pregnancy key distinguishing factor primarily characterized by fulminant liver failure HELLP syndrome key distinguishing factor characterized by hemolysis, elevated liver enzymes, and low platelets Treatment Medical antihypertensive medication indications blood pressure > 160/100 mmHg risk of decreased utero-placental blood flow drugs labetalol methyldopa hydralazine intravenous magnesium sulfate or diazepam indications seizure prophylaxis and treatment magnesium toxicity can occur hyporeflexia presents before bradypnea treatment calcium gluconate Surgical delivery indications the only definitive treatment if mild preeclampsia, can monitor for progression to severe preeclampsia if severe preeclampsia or eclampsia, deliver immediately preeclampsia can still occur postpartum and still should be managed with IV magnesium Complications Maternal cerebral hemorrhage Disseminated intravascular coagulopathy Acute respiratory distress syndrome Abruptio placentae Recurrence of preeclampsia Prognosis Maternal mortality 14% Most resolve after delivery