Preeclampsia

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

• Previous hypertensive disorder in pregnancy
• Family history
• Chronic medical disease
• Abnormal uterine artery Doppler before 24 weeks' gestation

Clinical Manifestations

• Can present from 20 weeks of gestation to 6 weeks postpartum

Prognosis

• 5% of preeclampsia will progress to eclampsia

Prevention

• First-line:
  • Exercise
  • Folate-containing multivitamin
• If low calcium intake: calcium supplementation
• If at increased risk, add:
  • Low dose ASA
  • Possible LMWH if high risk
  • L-arginine
  • Rest during third trimester

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