Preeclampsia: Difference between revisions
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*Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum | *Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum | ||
**May occur sooner with gestational trophoblastic disease | **May occur sooner with gestational trophoblastic disease | ||
*Defined as SBP>140 or DBP>90 in previously normotensive | *Defined as [[hypertension|SBP>140]] or DBP>90 in previously normotensive patient AND [[proteinuria]] >0.3gm in 24h or persistent proteinuria > 1+ on dipstick | ||
*Only 10% of cases occur prior to 34wk | *Only 10% of cases occur prior to 34wk | ||
===Risk Factors=== | ===Risk Factors=== | ||
| Line 20: | Line 20: | ||
*Edema | *Edema | ||
*[[Elevated BP]] | *[[Elevated BP]] | ||
*With increasing severity pulmonary edema, visual changes, and [[ | *With increasing severity; [[pulmonary edema]], [[visual changes]], and [[altered mental status]] can develop | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 27: | Line 27: | ||
{{Hypertension DDX}} | {{Hypertension DDX}} | ||
== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
*CBC | *CBC | ||
**[[Thrombocytopenia]] suggests severe disease | **[[Thrombocytopenia]] suggests severe disease | ||
*Chemistry | *Chemistry | ||
**Elevated | **Elevated creatinine suggests severe disease | ||
*Baseline Mg level | *Baseline Mg level | ||
* | *[[LFTs]] | ||
**AST/ALT elevation suggests severe disease | **AST/ALT elevation suggests severe disease | ||
*LDH | *LDH | ||
| Line 40: | Line 40: | ||
*Uric acid level | *Uric acid level | ||
**Often elevated in preeclampsia | **Often elevated in preeclampsia | ||
* | *[[Urinalysis]] | ||
**Proteinuria | **[[Proteinuria]] | ||
== | ==ACOG Diagnostic Criteria== | ||
''In 2013, ACOG has decided to remove proteinuria from the definition of preeclampsia''<ref>Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.</ref> | *''In 2013, ACOG has decided to remove proteinuria from the definition of severity of preeclampsia but it is still part of the diagnosis''<ref>Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.</ref> | ||
*'''Diagnosis is either based on blood pressure AND proteinuria or the presence of Severe Symptoms''' | |||
===[[hypertension|Blood Pressure]]=== | |||
*Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs | |||
*Systolic ≥160 mmHg or diastolic ≥110 mmHg acutely requiring emergent blood pressure decreases | |||
=== | ===[[Proteinuria]]=== | ||
*Proteinuria ≥300mg in a 24-hour urine collection | |||
* | *Spot protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3 | ||
* | *1+ on urine dipstick (if no quantitative measurement is unavailable) | ||
* | |||
=== | ===Severe Symptoms=== | ||
In the absence of proteinuria, new onset hypertension with any severe features: | |||
*Systolic BP ≥160 or diastolic BP ≥110, 2 occasions, 4 hours apart, while on bed rest (unless antihypertension meds were started before this time) | |||
* | *[[Thrombocytopenia]] platelets <100,000/mL | ||
* | *Elevated [[LFTS]] (2x normal concentration), severe persistent [[RUQ pain|RUQ]]/[[epigastric pain]] unresponsive to medications and no alternative diagnosis | ||
*Progressive renal insufficiency (creatinine >1.1mg/dL or doubling of creatinine concentration in absence of renal disease) | |||
**Reduced urine output < 30 cc/hr may indicate severe disease | |||
*Elevated | *[[Pulmonary edema]] | ||
*New onset cerebral or [[visual disturbance]] (scotomata, blurry vision, loss of vision) | |||
* | |||
** | |||
* | |||
==Management== | ==Management== | ||
===BP Control=== | ===BP Control=== | ||
* | *For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg | ||
**[[Labetalol]] | *Either labetalol or hydralazine can be used for initial control. Maximize the dose of each drug before adding on additional therapy. | ||
===Urgent BP Control=== | |||
*[[Labetalol]] | |||
**Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg | |||
*** | **Option 2: Constant IV infusion of 1-2mg/min | ||
*[[Hydralazine]] | |||
** | **Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg | ||
*** | **Option 2: Constant infusion 0.5-10mg/hr | ||
*[[Nifedipine]] | |||
**Option 1: 10-20mg PO, repeat in 30 minutes PRN; then 10-20mg q 2-6 hours | |||
===Oral Antihypertension=== | |||
These meds can be used safely to control hypertension of pregnancy | |||
*[[Labetalol]] | |||
**Option 1: 200-2400mg/d in two to three divided doses | |||
*[[Nifedipine|Nifedipine ER]] | |||
**Option 1: 30-120mg/d | |||
*[[Methyldopa]] | |||
**Option 1: 0.5-3 g/d in two to three divided doses | |||
*Thiazide diuretics - used as second line agent | |||
*ACE Inhibitor/ARB - CONTRAINDICATED IN PREGNANCY DUE TO TERATOGENICITY | |||
===Delivery Timing=== | |||
*Preeclampsia without severe features, delivery at 37 weeks | |||
*Preeclampsia with severe features | |||
**Before fetal viability, delivery after maternal stabilization, expectant management is not recommended | |||
**Viable fetus at 33 6/7 weeks or less may delay delivery for 48 hours of corticosteroids if maternal and fetal conditions remain stable with any of the following: | |||
***PPROM | |||
***Labor | |||
***Low platelet count <100,000mL | |||
***Persistent abnormal LFT(2x normal concentration) | |||
***IUGR<5% | |||
***Severe oligohydramnios (AFI<5cm) | |||
***Reversed end diastolic flow on umbilical artery Doppler studies | |||
***New onset renal dysfunction or increasing renal dysfunction. | |||
*Do not delay delivery after initial maternal stabilization regardless of gestational age for women with PreE with severe features complicated by any of the following: | |||
**Uncontrollable severe hypertension | |||
**[[Eclampsia]] | |||
**[[Pulmonary edema]] | |||
**[[Placental abruption]] | |||
**Disseminated intravascular coagulation | |||
**Evidence of nonreassuring fetal status | |||
**Intrapartum fetal demise | |||
===Prevention=== | ===Prevention=== | ||
*The USPSTF recommends the use of low-dose aspirin ( | *The USPSTF recommends the use of low-dose aspirin (81mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ([[Evidence Based Recommendation Levels| B recommendation]])<ref>http://annals.org/article.aspx?articleid=1902275</ref> | ||
*Per ACOG Task Force: For women with prior preeclampsia that led to delivery before 34 weeks of gestation or occurring in more than one pregnancy, offer daily low-dose aspirin (81mg or less) late in the first trimester. | |||
*[[Magnesium]]: | ==[[Seizure]] Prophylaxis== | ||
**Observe for loss of reflexes, respiratory depression | *[[Magnesium]] | ||
**Option 1: Load 4-6 grams 10% magnesium sulfate in 100ml solution IV over 20 minutes, then continuous infusion of Magnesium sulfate maintenance 1-2 grams/hour | |||
**Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump | |||
*Despite [[pregnancy risk drug|category D]] label, can be safely used for <48h to allow administration of betamethasone prior to preterm delivery | |||
*Contraindications: [[pulmonary edema]], [[renal failure]], [[myasthenia gravis]] | |||
*Observe for loss of reflexes, respiratory depression | |||
==Disposition== | ==Disposition== | ||
| Line 103: | Line 138: | ||
<references/> | <references/> | ||
[[Category: | [[Category:OBGYN]] | ||
Revision as of 14:11, 9 October 2020
Background
- Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
- May occur sooner with gestational trophoblastic disease
- Defined as SBP>140 or DBP>90 in previously normotensive patient AND proteinuria >0.3gm in 24h or persistent proteinuria > 1+ on dipstick
- Only 10% of cases occur prior to 34wk
Risk Factors
- Past history of preeclampsia
- First pregnancy
- Family history of preeclampsia
- Preexisting medical conditions:
- Pregestational diabetes
- Blood pressure ≥130/80 mm Hg at the first prenatal visit
- Antiphospholipid antibodies
- Body mass index ≥26.1
- Chronic kidney disease
- Twin pregnancies
- Advanced maternal age
Clinical Features
- Edema
- Elevated BP
- With increasing severity; pulmonary edema, visual changes, and altered mental status can develop
Differential Diagnosis
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Evaluation
Work-Up
- CBC
- Thrombocytopenia suggests severe disease
- Chemistry
- Elevated creatinine suggests severe disease
- Baseline Mg level
- LFTs
- AST/ALT elevation suggests severe disease
- LDH
- Elevation suggests microangiopathic hemolysis
- Uric acid level
- Often elevated in preeclampsia
- Urinalysis
ACOG Diagnostic Criteria
- In 2013, ACOG has decided to remove proteinuria from the definition of severity of preeclampsia but it is still part of the diagnosis[1]
- Diagnosis is either based on blood pressure AND proteinuria or the presence of Severe Symptoms
Blood Pressure
- Systolic ≥140 mmHg or diastolic ≥90 mmHg on 2 occasions at least 4 hours apart, after 20 weeks gestation with previously normal BPs
- Systolic ≥160 mmHg or diastolic ≥110 mmHg acutely requiring emergent blood pressure decreases
Proteinuria
- Proteinuria ≥300mg in a 24-hour urine collection
- Spot protein(mg/dL)/creatinine(mg/dL) ratio ≥0.3
- 1+ on urine dipstick (if no quantitative measurement is unavailable)
Severe Symptoms
In the absence of proteinuria, new onset hypertension with any severe features:
- Systolic BP ≥160 or diastolic BP ≥110, 2 occasions, 4 hours apart, while on bed rest (unless antihypertension meds were started before this time)
- Thrombocytopenia platelets <100,000/mL
- Elevated LFTS (2x normal concentration), severe persistent RUQ/epigastric pain unresponsive to medications and no alternative diagnosis
- Progressive renal insufficiency (creatinine >1.1mg/dL or doubling of creatinine concentration in absence of renal disease)
- Reduced urine output < 30 cc/hr may indicate severe disease
- Pulmonary edema
- New onset cerebral or visual disturbance (scotomata, blurry vision, loss of vision)
Management
BP Control
- For pregnant women with chronic hypertension, BP should be maintained between systolic 120-160mmHg and diastolic 80-105mmHg
- Either labetalol or hydralazine can be used for initial control. Maximize the dose of each drug before adding on additional therapy.
Urgent BP Control
- Labetalol
- Option 1: Initial 10-20mgIV; then doses of 20-80mg IV q20-30min PRN to total of 300mg
- Option 2: Constant IV infusion of 1-2mg/min
- Hydralazine
- Option 1: 5mg IV or IM, then 5-10mg IV q20-40min PRN to total of 30mg
- Option 2: Constant infusion 0.5-10mg/hr
- Nifedipine
- Option 1: 10-20mg PO, repeat in 30 minutes PRN; then 10-20mg q 2-6 hours
Oral Antihypertension
These meds can be used safely to control hypertension of pregnancy
- Labetalol
- Option 1: 200-2400mg/d in two to three divided doses
- Nifedipine ER
- Option 1: 30-120mg/d
- Methyldopa
- Option 1: 0.5-3 g/d in two to three divided doses
- Thiazide diuretics - used as second line agent
- ACE Inhibitor/ARB - CONTRAINDICATED IN PREGNANCY DUE TO TERATOGENICITY
Delivery Timing
- Preeclampsia without severe features, delivery at 37 weeks
- Preeclampsia with severe features
- Before fetal viability, delivery after maternal stabilization, expectant management is not recommended
- Viable fetus at 33 6/7 weeks or less may delay delivery for 48 hours of corticosteroids if maternal and fetal conditions remain stable with any of the following:
- PPROM
- Labor
- Low platelet count <100,000mL
- Persistent abnormal LFT(2x normal concentration)
- IUGR<5%
- Severe oligohydramnios (AFI<5cm)
- Reversed end diastolic flow on umbilical artery Doppler studies
- New onset renal dysfunction or increasing renal dysfunction.
- Do not delay delivery after initial maternal stabilization regardless of gestational age for women with PreE with severe features complicated by any of the following:
- Uncontrollable severe hypertension
- Eclampsia
- Pulmonary edema
- Placental abruption
- Disseminated intravascular coagulation
- Evidence of nonreassuring fetal status
- Intrapartum fetal demise
Prevention
- The USPSTF recommends the use of low-dose aspirin (81mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. ( B recommendation)[2]
- Per ACOG Task Force: For women with prior preeclampsia that led to delivery before 34 weeks of gestation or occurring in more than one pregnancy, offer daily low-dose aspirin (81mg or less) late in the first trimester.
Seizure Prophylaxis
- Magnesium
- Option 1: Load 4-6 grams 10% magnesium sulfate in 100ml solution IV over 20 minutes, then continuous infusion of Magnesium sulfate maintenance 1-2 grams/hour
- Option 2: Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV accessMagnesium sulfate on infusion pump
- Despite category D label, can be safely used for <48h to allow administration of betamethasone prior to preterm delivery
- Contraindications: pulmonary edema, renal failure, myasthenia gravis
- Observe for loss of reflexes, respiratory depression
Disposition
- Consult with OB/GYN regarding discharge versus admission
- Some cases of mild preeclampsia may be candidates for outpatient therapy
- Close follow up and return precautions is key
- Repeat lab tests 1-2x per week (platelet count, creatinine, AST)
- Some cases of mild preeclampsia may be candidates for outpatient therapy
See Also
External Links
LITFL: Pre-eclampsia and Eclampsia
References
- ↑ Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
- ↑ http://annals.org/article.aspx?articleid=1902275