Updated: 6/7/2019

Preeclampsia and Eclampsia

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Snapshot
  • A 25-year-old woman comes to the clinic at 28 weeks gestation complaining of headaches and abdominal pain.  She states that these symptoms began 5 days ago and have been worsening.  The patient's vitals are notable for a blood pressure of 175/95 mmHg.  On physical exam pain is elicited upon palpation of all 4 quadrants, in particular the right upper quadrant.  A urine dipstick demonstrates 3+ protein.  The patient is admitted to the hospital and started on IV magnesium sulfate and labetalol.  Five hours after this treatment has begun she has a seizure.
Introduction
  • Chronic hypertension (> 140/90 mmHg)
    • history of elevated blood pressure before the pregnancy or before 20 weeks gestation
    • tends to persist after the pregnancy
  • Gestational hypertension (> 140/90 mmHg)
    • no history of hypertension
    • hypertension that develops during pregnancy usually after 20 weeks gestation
    • usually returns to baseline 6 weeks postpartum
    • more common in twin and triplet pregnancies
    • absence of symptoms found in preeclampsia (discussed below)
  • Preeclampsia 
    • classically: hypertension + proteinuria
      • of note gestational hypertension is new onset hypertension after 20 weeks of pregnancy but does NOT have proteinuria or other signs/symptoms of preeclampsia
      • no evidence supporting treatment of mild to moderate gestational hypertension
      • if proteinuria is absent diagnosis can be made if there is hypertension and a new onset of any of the following:
        • thrombocytopenia (less than 100,000/microliter)
        • serum creatinine greater than 1.1 mg/dL or doubling of serum creatinine in the absence of renal disease
        • elevated liver transaminases (double)
        • pulmonary edema
        • cerebral or visual symptoms
  • Eclampsia
    • preeclampsia + seizures
  • HELLP syndrome 
    • form of preeclampsia with
      • Hemolysis, Elevated LFTs, Low Platelets 
    • should be distinguished from gestational thrombocytopenia in which platelets fall but rarely below 80, poses no risk to the mother or fetus, and resolves spontaneously after birth
  • Acute fatty liver of pregnancy
    • pathophysiology
      • defect of long chain 3-hydroxyacyl-coenzyme A dehydrogenase
    • symptoms
      • nausea, vomiting, abdominal pain, jaundice, anorexia
    • lab findings
      • elevated AST/ALT
      • elevated LDH
      • hyperammonemia
      • throbocytopenia
      • elevated BUN and Cr
    • diagnosis
      • lab findings
      • most accurate: liver biopsy
    • treatment
      • delivery of fetus
    • differentiate from HELLP
      • also has renal failure, hypoglycemia, hyperbilirubinemia, coagulopathy in acute fatty liver
  • Risk factors
    • preexisting hypertension
    • nulliparity
    • maternal age of < 20 years, > 35 years
    • diabetes
    • chronic renal disease
    • autoimmune disorders
  • Typically occurs from 20 weeks gestation to 6 weeks postpartum
    • if symptoms occur before 20 weeks think molar pregnancy
  • Pathophysiology
    • placental ischemia secondary to impaired vasodilation of spiral arteries
    • results in ↑ vascular tone
      • ↑ vasoconstrictors
      • ↓ vasodilators
Presentation
  • Symptoms
    • headache
    • blurred vision
    • abdominal pain
    • weight gain (water retention)
  • Physical exam
    • hypertension
      • mild preeclampsia = > 140/90
      • severe preeclampsia = > 160/110
    • edema of face and extremities
    • altered mentation
    • hyperreflexia
Evaluation
  • Urinalysis
    • proteinuria
      • past guidelines were dependent on quantity of protein in the urine
        • mild preeclampsia = > 300 mg/24 hrs
        • severe preeclampsia = > 5 g/24 hrs
      • protein/creatinine ratio > .3 generally sufficient for diagnosing proteinuria as criteria in preeclampsia 
        • the best confirmatory test is a spot urine protein to creatinine ratio
        • this means higher urine protein levels does not equate with more severe preeclampsia with modern guidelines
      • remember proteinuria is NOT mandatory for diagnosis of preeclampsia
  • Serology
    • thrombocytopenia
    • hyperuricemia
    • hemoconcentration

Treatment
  • Delivery 
    • only definitive treatment
    • in severe preeclampsia and eclampsia deliver at any gestation age due to severe risk to mother with continued pregnancy
    • in mild preeclampsia manage conservatively by observing for progression to severe preeclampsia
  • Bed rest
  • Monitoring and treatment of hypertension 
    • most common agents include labetalol, hydralazine, or nifedipine
  • IV magnesium sulfate and diazepam 
    • 1st line prevention/treatment of eclamptic seizures  
    • magnesium toxicity manifests as hyporeflexia and bradypnea 
      • treatment involves stopping magnesium and giving calcium gluconate 
      • hyporeflexia presents before bradypnea - check patient reflexes regularly to avoid respiratory depression
  • Prophylaxis
    • low dose aspirin in high risk patients can reduce pre-eclampsia by 24%
    • decreases TXA2 while maintaining vascular wall prostacyclin
    • decreases ATII
Complications
  • Maternal cerebral hemorrhage
  • DIC and ARDS
  • Abrupto placentae

 

 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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