Preeclampsia
From IDWiki
Background
Definition
- Gestational hypertension is defined as hypertension developing on or after 20 weeks gestation
- Preeclampsia is gestational hypertension plus one of:
- New proteinuria
- One or more adverse conditions
- CNS: headache, visual disturbance
- Cardiorespiratory: chest pain, dyspnea, O2 sat <97%
- Hematological: increased WBC, decreased platelets, increased INR/PTT
- Renal: increased creatinine or uric acid
- Hepatic: nausea/vomiting, RUQ pain, elevated AST/ALT/LDH/bilirubin, low albumin
- Fetoplacental: IUGR, abnormal FHR, oligohydramnios, abnormal end-diastolic flow
- One or more severe complications
- CNS: eclampsia, neurological deficits, GCS<13, stroke/TIA
- Cardiorespiratory: uncontrolled severe hypertension, O2 sat <90%, intubation, pulmonary edema, inotropes, ACS
- Hematological: platelets <50k, need for any transfusions
- Renal: AKI (Cr>150), new need for dialysis
- Hepatic: INR >2, hepatic hematoma or rupture
- Fetoplacental: abruption, stillbirth, reverse ductus venous A wave
- Severe preeclampsia is preeclampsia with one or more severe complications
Risk factors
- Highest-risk group are those with previous preeclampsia, antiphospholipid syndrome, and preexisting hypertension, renal disease, or diabetes mellitus
- Demographics: maternal age ≥40 years
- Family history: preeclampsia in mother or sister; early-onset cardiovascular disease
- Past medical and obstetrical history
- Previous preeclampsia
- Antiphospholipid syndrome
- Preexisting hypertension, or DBP≥90 at intake
- Preexisting renal disease, or proteinuria at intake
- Preexisting diabetes mellitus
- Lower maternal birthweight and/or preterm delivery
- Heritable thrombophilias
- Increase pre-pregnancy triglycerides
- Non-smoking
- Cocaine and methamphetamine use
- Previous miscarriage at or before 10 weeks with the same partner
- Current pregnancy
- First-trimester
- Multiple pregnancy
- Overweight or obesity
- First ongoing pregnancy
- New partner
- Short duration of sexual relationship with current partner
- Reproductive technologies
- Inter-pregnancy interval ≥10 years
- SBP ≥130 or DBP ≥80 at intake
- Vaginal bleeding in early pregnancy
- Gestational trophoblastic disease
- Abnormal PAPP-A or free β-hCG
- Second or third trimester
- Gestational hypertension
- Abnormal AFP, hCG, inhA, or E3
- Excessive weight gain in pregnancy
- Infection during pregnancy
- Abnormal uterine artyer Doppler
- IUGR
- Investigational laboratory markers
- First-trimester
Clinical Manifestations
- Can present from 20 weeks of gestation to 6 weeks postpartum
- 5% of preeclampsia will progress to eclampsia
Management
- Monitoring
- Monitor BP closely, at least q8h
- Monitor liver enzymes q3-4d
- Seizure prevention
- Give MgSO4 1g IV q1h until blood pressure controlled
- Blood pressure control
- First-line: hydralazine 4-6mg IV slow push q15-30min prn hypertension
- Second-line: nifedipine prn hypertension
Prevention
- Estimate risk based on risk factors (above)
- First-line:
- Exercise
- Folate-containing multivitamin
- If low calcium intake: calcium supplementation
- If at increased risk, add:
- Low-dose aspirin, started between 11 and 14 weeks and continued until 36 weeks
- Possible LMWH if high risk
- L-arginine
- Rest during third trimester