Preeclampsia

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. 

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)
• Chronic kidney disease

Complications 

• Congestive heart failure
• Disseminated intravascular coagulation
• Intracranial hemorrhage
• Liver failure or rupture
• Placental abruption
• Pulmonary edema
• Renal failure
• Seizure
• Stroke
• Death

Mortality

• 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.
  • Fatality is 6.4 deaths / 10,000

Occurrence / Prevalence

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

Further Reading

Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department Date Release: Sep 2021 This course reviews evidence-based recommendations to improve care and outcomes for pregnant and postpartum patients with hemorrhage or severe hypertension. Emergency Medicine Practice and Pediatric Emergency Medicine Practice subscribers receive this content & CME Credit absolutely free!

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. PubMed
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. 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
11. Mackay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol. 2001;97(4):533-8.  PubMed
12. 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

Last Updated on January 25, 2023