Preeclampsia

Preeclampsia is on a spectrum of pregnancy related illness which includes

eclampsia and HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low
Platelets - debate exists about if this is a separate entity altogether).
Without intervention, it can lead to seizures (eclampsia) and carries a high
mortality for mom and baby.

A pregnancy-related condition occurring anytime after 20 weeks pregnancy

and up to 6 weeks postpartum, it is diagnosed by elevated blood pressure
and and least one associated finding.

Criteria
Pregnancy, 20 weeks gestation up to 6 weeks post partum,
AND Hypertension >140/90 x 2 (at least 4 hours apart) or >160/110 x 2
(minutes apart) in a woman who was previously normotensive
AND any one of the following
Proteinuria, defined as urine dipstick >1+ or >0.3 g in a 24-hour
period
Platelets <100k/mcL
Serum creatinine > 1.1 mg/dL
Liver transaminases at least 2 times normal
Severe right upper quadrant or epigastric pain, not explained by
another diagnosis
Pulmonary edema
Visual symptoms (e.g. blurred vision, flashing lights or sparks,
scotoma)
Cerebral symptoms (e.g. severe persistent headache not
responding to usual doses of analgesics)

Treatment
 Delivering placenta resolves symptoms in 48 hours in most cases
(except postpartum cases)
Magnesium Sulfate IV for seizure prevention:
Loading dose: 4-6 g loading dose
Followed by continuous infusion: 1-2 g/hour for at least 24 hours
BP management until systolic < 150 and diastolic < 100
Labetalol 20 mg IV every 10 min (max 80mg per dose) for a total
of 300mg.
Hydralazine 5 mg IV, repeat in 20 min until goal achieved, max
30mg.
Nicardipine infusion 3-9 mg hour
Nitroglycerin IV if pulmonary edema
Corticosteroids if < 34 weeks gestation and delivery anticipated in next
48 hours.
Betamethasone: Two doses of 12 mg given intramuscularly 24
hours apart OR
Dexamethasone (sodium phosphate): Four doses of 6 mg given
intramuscularly 12 hours apart. A non-sulfite containing
preparation should be used as the sulfite preservative commonly
used in dexamethasone preparations may be directly neurotoxic in
newborns.

Symptoms
Severe headache
Visual changes
Upper abdominal pain
Nausea or vomiting
Shortness of breath
Chest pain
Altered mental status

Risk Factors
 A past history of pre-eclampsia confers a 7-fold risk
First-time pregnancy
Twin pregnancies
Family history in first-degree relative
Advanced maternal age (> 40 years)
Pre-gestational diabetes mellitus
Hypertension
Antiphospholipid antibody
Obesity (BMI>25) (14)
Chronic kidney disease

Complications
Women with preeclampsia have increased risk of:

Congestive heart failure

Disseminated intravascular coagulation
Intracranial hemorrhage
Liver failure or rupture
Placental abruption
Pulmonary edema
Renal failure
Seizure
Stroke
Death
Worldwide 10-15% of maternal death from obstetric cause is due
to preeclampsia/eclampsia [2]
In the U.S., it is one of 4 causes of obstetric deaths (hemorrhage,
cardiovascular conditions, thromboembolism). 1 death / 100,000
births. [12]
Fatality is 6.4 deaths/10,000 [13]

When does it happen and how often?

 After 20 weeks gestation and as late as 6 weeks post partum [1]
3-4% of all pregnancies in the U.S. and 4-5% worldwide [3]
Almost 2 times higher prevalence in first pregnancy [3]
Consider molar pregnancy if they are less than 20 weeks with criteria
[11]

References
1. The American College of Obstetricians and Gynecologists- Task Force
on Hypertension in Pregnancy. Hypertension in pregancy. In : LIbrarY
oF conGress cataLoGInG-In- PubLIcatIon data, 2013. [ACOG]
2. Duley L. The global impact of pre-eclampsia and eclampsia. Semin
Perinatol. 2009;33(3):130-7. [PubMed]
3. Ananth CV, Keyes KM, Wapner RJ. Pre-eclampsia rates in the United
States, 1980-2010: age-period-cohort analysis. BMJ. 2013;347:f6564.
[PubMed]
4. Schutte JM, Steegers EA, Schuitemaker NW, et al. Rise in maternal
mortality in the Netherlands. BJOG. 2010;117(4):399-406. [PubMed]
5. Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal
booking: systematic review of controlled studies. BMJ.
2005;330(7491):565. [PubMed]
6. Roberts JM, Redman CW. Pre-eclampsia: more than pregnancy-
induced hypertension. Lancet. 1993;341(8858):1447-51. [PubMed]
7. Meekins JW, Pijnenborg R, Hanssens M, Mcfadyen IR, Van asshe A. A
study of placental bed spiral arteries and trophoblast invasion in normal
and severe pre-eclamptic pregnancies. Br J Obstet Gynaecol.
1994;101(8):669-74. [PubMed]
8. Bar-lev MR, Maayan-metzger A, Matok I, Heyman Z, Sivan E, Kuint J.
Short-term outcomes in low birth weight infants following antenatal
exposure to betamethasone versus dexamethasone. Obstet Gynecol.
2004;104(3):484-8. [PubMed]
9. Walfisch A, Hallak M, Mazor M. Multiple courses of antenatal steroids:
risks and benefits. Obstet Gynecol. 2001;98(3):491-7. [PubMed]
10. August, P. Management of hypertension in pregnant and postpartum
women. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2018.
[UpToDate]
11. August, P. Preeclampsia: Clinical features and diagnosis. In: UpToDate,
Post, TW (Ed), UpToDate, Waltham, MA, 2018.[UpToDate]
12. Chang J, Elam-evans LD, Berg CJ, et al. Pregnancy-related mortality
surveillance--United States, 1991--1999. MMWR Surveill Summ.
2003;52(2):1-8. [PubMed]
13. Mackay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from
preeclampsia and eclampsia. Obstet Gynecol. 2001;97(4):533-8.
[PubMed]
14. Bartsch E, Medcalf KE, Park AL, Ray JG. Clinical risk factors for pre-
eclampsia determined in early pregnancy: systematic review and meta-
analysis of large cohort studies. BMJ. 2016;353:i1753. [PubMed]