Criteria

  • Pregnancy, 20 weeks gestation up to 6 weeks postpartum,
  • 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 persistent right upper quadrant or epigastric pain, not explained by alternate 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.

Background

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 Pregnancy. In : Library of congress cataloging-In- Publication data, 2013. Download PDF
  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.  Up-To-Date, subscription required
  11. August, P. Preeclampsia: Clinical features and diagnosis. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2018.    Up-To-Date, subscription required
  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

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.