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

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