Preeclampsia: Difference between revisions
From IDWiki
m (Text replacement - "Clinical Presentation" to "Clinical Manifestations") |
(added a bunch of risk factors) |
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− | == |
+ | == Background == |
+ | ===Definition=== |
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− | * Gestational hypertension is defined as hypertension developing on or after 20 weeks gestation |
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− | * Preeclampsia is gestational hypertension plus one of: |
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− | ** New proteinuria |
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− | ** One or more adverse conditions |
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− | *** CNS: headache, visual disturbance |
||
− | *** Cardiorespiratory: chest pain, dyspnea, O2 sat <97% |
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− | *** Hematological: increased WBC, decreased platelets, increased INR/PTT |
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− | *** Renal: increased creatinine or uric acid |
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− | *** Hepatic: nausea/vomiting, RUQ pain, elevated AST/ALT/LDH/bilirubin, low albumin |
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− | *** Fetoplacental: IUGR, abnormal FHR, oligohydramnios, abnormal end-diastolic flow |
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− | ** One or more severe complications |
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− | *** 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 |
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− | *** Fetoplacental: abruption, stillbirth, reverse ductus venous A wave |
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− | * Severe preeclampsia is preeclampsia with one or more severe complications |
||
+ | *Gestational hypertension is defined as hypertension developing on or after 20 weeks gestation |
||
− | == Risk factors == |
||
+ | *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=== |
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− | * Previous hypertensive disorder in pregnancy |
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− | * Family history |
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− | * Chronic medical disease |
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− | * Abnormal uterine artery Doppler before 24 weeks' gestation |
||
+ | *Highest-risk group are those with previous preeclampsia, [[antiphospholipid syndrome]], and preexisting [[hypertension]], renal disease, or [[diabetes mellitus]] |
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− | == Clinical Manifestations == |
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+ | *Demographics: maternal age ≥40 years |
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+ | *Family history: preeclampsia in mother or sister; early-onset cardiovascular disease |
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+ | *Past medical and obstetrical history |
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+ | **Previous preeclampsia |
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+ | **[[Antiphospholipid syndrome]] |
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+ | **Preexisting hypertension, or DBP≥90 at intake |
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+ | **Preexisting renal disease, or proteinuria at intake |
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+ | **Preexisting [[diabetes mellitus]] |
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+ | **Lower maternal birthweight and/or preterm delivery |
||
+ | **Heritable thrombophilias |
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+ | **Increase pre-pregnancy triglycerides |
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+ | **Non-smoking |
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+ | **Cocaine and methamphetamine use |
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+ | **Previous miscarriage at or before 10 weeks with the same partner |
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+ | *Current pregnancy |
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+ | **First-trimester |
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+ | ***Multiple pregnancy |
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+ | ***Overweight or obesity |
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+ | ***First ongoing pregnancy |
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+ | ***New partner |
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+ | ***Short duration of sexual relationship with current partner |
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+ | ***Reproductive technologies |
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+ | ***Inter-pregnancy interval ≥10 years |
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+ | ***SBP ≥130 or DBP ≥80 at intake |
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+ | ***Vaginal bleeding in early pregnancy |
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+ | ***Gestational trophoblastic disease |
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+ | ***Abnormal PAPP-A or free β-hCG |
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+ | **Second or third trimester |
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+ | ***Gestational hypertension |
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+ | ***Abnormal AFP, hCG, inhA, or E<sub>3</sub> |
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+ | ***Excessive weight gain in pregnancy |
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+ | ***Infection during pregnancy |
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+ | ***Abnormal uterine artyer Doppler |
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+ | ***IUGR |
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+ | ***Investigational laboratory markers |
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+ | ==Clinical Manifestations== |
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− | * Can present from 20 weeks of gestation to 6 weeks postpartum |
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+ | *Can present from 20 weeks of gestation to 6 weeks postpartum |
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− | == Prognosis == |
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+ | *5% of preeclampsia will progress to eclampsia |
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+ | ==Management== |
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− | * 5% of preeclampsia will progress to eclampsia |
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+ | |||
+ | *Monitoring |
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+ | **Monitor BP closely, at least q8h |
||
+ | **Monitor liver enzymes q3-4d |
||
+ | *Seizure prevention |
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+ | **Give MgSO4 1g IV q1h until blood pressure controlled |
||
+ | *Blood pressure control |
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+ | **First-line: hydralazine 4-6mg IV slow push q15-30min prn hypertension |
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+ | **Second-line: nifedipine prn hypertension |
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== Prevention == |
== Prevention == |
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+ | *Estimate risk based on risk factors (above) |
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− | * First-line: |
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+ | *First-line: |
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− | ** Exercise |
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+ | **Exercise |
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− | ** Folate-containing multivitamin |
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+ | **Folate-containing multivitamin |
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− | * If low calcium intake: calcium supplementation |
||
+ | *If low calcium intake: calcium supplementation |
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− | * If at increased risk, add: |
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+ | *If at increased risk, add: |
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− | ** Low dose ASA |
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+ | **Low-dose [[aspirin]], started between 11 and 14 weeks and continued until 36 weeks |
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− | ** Possible LMWH if high risk |
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+ | **Possible LMWH if high risk |
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− | ** L-arginine |
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+ | **L-arginine |
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− | ** Rest during third trimester |
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+ | **Rest during third trimester |
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− | |||
− | == 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 |
||
[[Category:Obstetrical medicine]] |
[[Category:Obstetrical medicine]] |
Latest revision as of 21:05, 16 August 2020
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