Updated: 1/21/2020

Preeclampsia and Eclampsia

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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 Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia

HELLP Syndrome  

  • History of hypertension (> 140/90 mmgHg) before pregnancy or before 20 weeks of gestation
  • Hypertension persists after delivery
  • Hypertension after 20 weeks of gestation
  • Hypertension returns to baseline by 6 weeks post-partum
  • Common in multiple gestations
  • Hypertension (> 140/90 mmHg on 2 separate occasions, or >160/110 mmHg) plus proteinuria
  • Preeclampsia plus seizures
  • Hemolysis
  • Elevated Liver enzymes
  • Low Platelets
  • Epidemiology
    • incidence
      • 2-6%
    • risk factors
      • nulliparity  
      • multiple gestations
      • hyatidiform mole
      • diabetes
      • chronic hypertension
      • chronic renal disease
  • 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
  • Prognosis
    • maternal mortality 14%
    • most resolve after delivery
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
Complications
  • Maternal cerebral hemorrhage
  • Disseminated intravascular coagulopathy
  • Acute respiratory distress syndrome
  • Abruptio placentae
  • Recurrence of preeclampsia

 

 

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Questions (7)
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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(M2.OB.14.6) A 20-year-old woman presents to the emergency department with painful abdominal cramping. She states she has missed her menstrual period for 5 months, which her primary care physician attributes to her obesity. She has a history of a seizure disorder treated with valproic acid; however, she has not had a seizure in over 10 years and is no longer taking medications for her condition. She has also been diagnosed with pseudoseizures for which she takes fluoxetine and clonazepam. Her temperature is 98.0°F (36.7°C), blood pressure is 174/104 mmHg, pulse is 88/min, respirations are 19/min, and oxygen saturation is 98% on room air. Neurologic exam is unremarkable. Abdominal exam is notable for a morbidly obese and distended abdomen that is nontender. Laboratory studies are ordered as seen below.

Serum:
hCG: 100,000 mIU/mL

Urine:
Color: Amber
hCG: Positive
Protein: Positive

During the patient's evaluation, she experiences 1 episode of tonic-clonic motions which persist for 5 minutes. Which of the following treatments is most appropriate for this patient?
Review Topic | Tested Concept

QID: 105176
1

Lorazepam

2%

(1/40)

2

Magnesium

10%

(4/40)

3

Phenobarbital

85%

(34/40)

4

Phenytoin

0%

(0/40)

5

Propofol

0%

(0/40)

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(M2.OB.14.121) A 32-year-old G1P0 woman presents to the emergency department at 34 weeks gestation. She complains of vague upper abdominal pain and nausea which has persisted for 2 weeks, as well as persistent headache over the past several days. Her temperature is 99.0°F (37.2°C), blood pressure is 164/89 mmHg, pulse is 88/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 7,800/mm^3 with normal differential
Platelet count: 25,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
AST: 199 U/L
ALT: 254 U/L

Urine:
Color: Yellow
Protein: Positive
Blood: Positive

The patient begins seizing. Which of the following is the most appropriate definitive treatment for this patient?
Review Topic | Tested Concept

QID: 104761
1

Betamethasone

0%

(0/12)

2

Cesarean section

8%

(1/12)

3

Lorazepam

42%

(5/12)

4

Magnesium

33%

(4/12)

5

Platelet transfusion

17%

(2/12)

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(M2.OB.13.5) A 25-year-old pregnant woman at 28 weeks gestation presents with a headache. Her pregnancy has been managed by a nurse practitioner. Her temperature is 99.0°F (37.2°C), blood pressure is 164/104 mmHg, pulse is 100/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for a comfortable appearing woman with a gravid uterus. Laboratory tests are ordered as seen below.

Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,700/mm^3 with normal differential
Platelet count: 100,500/mm^3

Serum:
Na+: 141 mEq/L
Cl-: 101 mEq/L
K+: 4.4 mEq/L
HCO3-: 25 mEq/L
BUN: 21 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.0 mg/dL
AST: 32 U/L
ALT: 30 U/L

Urine:
Color: Amber
Protein: Positive
Blood: Negative

Which of the following is the most likely diagnosis?
Review Topic | Tested Concept

QID: 103368
1

Acute fatty liver disease of pregnancy

3%

(1/34)

2

Eclampsia

0%

(0/34)

3

HELLP syndrome

47%

(16/34)

4

Preeclampsia

6%

(2/34)

5

Severe preeclampsia

41%

(14/34)

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