Preeclampsia is new-onset or worsening of existing hypertension with proteinuria after 20 weeks gestation. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Diagnosis is by measuring blood pressure and urine protein and by tests to evaluate for end-organ damage (eg, pulmonary edema, impaired liver or kidney function). Treatment is usually with IV magnesium sulfate and delivery at term or earlier for maternal or fetal complications. Show
Preeclampsia affects 3 to 7% of pregnant women. Preeclampsia and eclampsia develop after 20 weeks gestation; up to 25% of cases develop postpartum, most often within the first 4 days but sometimes up to 6 weeks postpartum. Untreated preeclampsia is present for a variable time, then can suddenly progress to eclampsia, which occurs in 1/200 patients with preeclampsia. Untreated eclampsia is usually fatal. Etiology of preeclampsia is unknown. High-risk factors include
Moderate-risk factors include
Pathophysiology of preeclampsia and eclampsia is poorly understood. Factors may include poorly developed uterine placental spiral arterioles (which decrease uteroplacental blood flow during late pregnancy), a genetic abnormality, immunologic abnormalities, and placental ischemia or infarction. Lipid peroxidation of cell membranes induced by free radicals may contribute to preeclampsia. Fetal growth restriction Small-for-Gestational-Age (SGA) Infant Infants whose weight is < the 10th percentile for gestational age are classified as small for gestational age. Complications include perinatal asphyxia, meconium aspiration, polycythemia... read more or fetal death Stillbirth Stillbirth is fetal death (fetal demise) at ≥ 20 weeks gestation (> 28 weeks in some definitions). Management is delivery and postpartum care. Maternal and fetal testing is done to determine... read more may result. Diffuse or multifocal vasospasm can result in maternal ischemia, eventually damaging multiple organs, particularly the brain, kidneys, and liver. Factors that may contribute to vasospasm include decreased prostacyclin (an endothelium-derived vasodilator), increased endothelin (an endothelium-derived vasoconstrictor), and increased soluble Flt-1 (a circulating receptor for vascular endothelial growth factor). Women who have preeclampsia are at risk of placental abruption Placental Abruption (Abruptio Placentae) Placental abruption (abruptio placentae) is premature separation of the placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include... read more in the current pregnancy, possibly because both disorders are related to uteroplacental insufficiency. The coagulation system is activated, possibly secondary to endothelial cell dysfunction, leading to platelet activation. Symptoms and Signs of Preeclampsia and EclampsiaPreeclampsia may be asymptomatic or may cause edema or sudden excessive weight gain (> 5 lb/week). Nondependent edema, such as facial or hand swelling (the patient’s ring may no longer fit her finger), is more specific than dependent edema. Petechiae may develop, as may other signs of coagulopathy. Eclampsia manifests as generalized (tonic-clonic) seizures. Preeclampsia with severe features may cause organ damage; these features may include
BP criteria for preeclampsia are one of the following:
In the absence of proteinuria, preeclampsia is also diagnosed if pregnant women meet diagnostic criteria for new-onset hypertension and have new onset of any of the following signs of end-organ damage:
The following points help differentiate among other hypertensive disorders in pregnant women:
If preeclampsia is diagnosed, tests include complete blood count (CBC), platelet count, uric acid, liver tests, blood urea nitrogen (BUN), creatinine, and, if creatinine is abnormal, creatine clearance. The fetus is assessed using a nonstress test or biophysical profile (including assessment of amniotic fluid volume) and tests that estimate fetal weight. Preeclampsia with severe features is differentiated from mild forms by new onset of one or more of the following:
HELLP syndrome is suggested by microangiopathic findings (eg, schistocytes, helmet cells) on peripheral blood smears, elevated liver enzymes, and a low platelet count.
Definitive treatment for preeclampsia is delivery. However, risk of preterm delivery is balanced against gestational age, fetal growth restriction, fetal distress, severity of preeclampsia, and response to other treatments. Usually, immediate delivery after maternal stabilization (eg, controlling seizures, beginning to control blood pressure [BP]) is indicated for the following:
Other treatments aim to optimize maternal health, which usually optimizes fetal health. If delivery can be safely delayed in pregnancies of < 34 weeks, corticosteroids are given for 48 hours to accelerate fetal lung maturity. Some stable patients can be given corticosteroids after 34 weeks and before 36 weeks (late preterm period) if they have not been given corticosteroids earlier in the pregnancy. Most patients are hospitalized. Patients with eclampsia or preeclampsia with severe features are often admitted to a maternal special care unit or an intensive care unit (ICU). Most patients who have preeclampsia without severe features before 37 weeks gestation are hospitalized for evaluation, at least initially. If maternal and fetal status are reassuring, outpatient treatment is possible; it includes modified activity (modified rest), BP measurements, laboratory monitoring, fetal nonstress testing, and physician visits at least once a week. As long as no criteria for preeclampsia with severe features develop, delivery can occur (eg, by induction) at 37 weeks. All hospitalized patients with preeclampsia are evaluated frequently for evidence of seizures, preeclampsia with severe features, and vaginal bleeding; BP, reflexes, and fetal heart status (with nonstress testing or a biophysical profile) are also checked. Platelet count, serum creatinine, and serum liver enzymes are measured frequently until stable, then at least once a week. Outpatients are usually followed by an obstetrician or a maternal-fetal medicine specialist and evaluated at least once a week with the same testing as inpatients. Evaluation is more frequent if preeclampsia with severe features is diagnosed or if gestational age is < 34 weeks. As soon as eclampsia is diagnosed, magnesium sulfate must be given to prevent seizures from recurring. If patients have preeclampsia with severe features, magnesium sulfate may be given to prevent seizures. Magnesium sulfate is given for 12 to 24 hours postpartum. Whether patients who have preeclampsia without severe features always require magnesium sulfate before delivery is controversial. Magnesium sulfate 4 g IV over 20 minutes is given, followed by a constant IV infusion of 2 g/hour. Dose is adjusted based on the patient’s symptoms or on whether renal insufficiency is present. Patients with abnormally high magnesium levels (eg, with magnesium levels > 10 mEq/L or a sudden decrease in reflex reactivity), cardiac dysfunction (eg, with dyspnea or chest pain), or hypoventilation after treatment with magnesium sulfate can be treated with calcium gluconate 1 g IV. IV magnesium sulfate may cause lethargy, hypotonia, and transient respiratory depression in neonates. However, serious neonatal complications are uncommon. If oral intake is prohibited, hospitalized patients are given IV Ringer lactate or 0.9% normal saline solution, beginning at about 125 mL/hour (to maintain hemodynamic status). Persistent oliguria is treated with a carefully monitored fluid challenge. Diuretics are usually not used. Monitoring with a pulmonary artery catheter is rarely necessary and, if needed, is done in consultation with a critical care specialist and in an intensive care unit (ICU). Anuric patients with normovolemia may require renal vasodilators or dialysis. If seizures occur despite magnesium therapy, diazepam or lorazepam can be given IV to stop seizures, and IV hydralazine or labetalol is given in a dose titrated to lower systolic BP to 140 to 155 mm Hg and diastolic BP to 90 to 105 mm Hg. The most efficient method of delivery should be used. If the cervix is favorable and rapid vaginal delivery seems feasible, a dilute IV infusion of oxytocin is given to accelerate labor; if labor is active, the membranes are ruptured. If the cervix is unfavorable and prompt vaginal delivery is unlikely, cesarean delivery can be considered. Preeclampsia and eclampsia, if not resolved before delivery, usually resolve rapidly afterward, within 6 to 12 hours. Patients should be evaluated at least every 1 to 2 weeks postpartum with periodic BP measurement. If BP remains high after 6 weeks postpartum, patients may have chronic hypertension and should be referred to their primary care physician for management. Low-dose aspirin (81 mg/day) is recommended for patients with high-risk factors for preeclampsia (previous pregnancy with preeclampsia, multifetal gestation, renal disorders, autoimmune disorders, type 1 or type 2 diabetes mellitus, chronic hypertension). It is also recommended for those with > 1 moderate-risk factors (first pregnancy, maternal age ≥ 35, body mass index > 30, family history of preeclampsia, sociodemographic characteristics such as African American race or low socioeconomic status, personal history factors such as low-birth-weight or small-for-gestational-age infants, previous adverse pregnancy outcome, or a> 10-year pregnancy interval [ 3 Prevention references Preeclampsia is new-onset or worsening of existing hypertension with proteinuria after 20 weeks gestation. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Diagnosis... read more ]). Aspirin prophylaxis should be started at 12 to 28 weeks of gestation (ideally before 16 weeks) and continued until delivery.
Which condition in a pregnant patient with severe preeclampsia is an indication?Preeclampsia increases your risk of placental abruption. With this condition, the placenta separates from the inner wall of the uterus before delivery. Severe abruption can cause heavy bleeding, which can be life-threatening for both the mother and baby. HELLP syndrome.
Which condition in a pregnant patient with severe preeclampsia is an indication for administering magnesium sulfate?Magnesium sulfate is the medication of choice for the prevention of eclamptic seizures in women with severe preeclampsia and for the treatment of women with eclamptic seizures. One commonly used regimen is a 6-g loading dose of magnesium sulfate followed by a continuous infusion at a rate of 2 g per hour.
Which signs may indicate severe preeclampsia?Further symptoms. severe headaches.. vision problems, such as blurring or seeing flashing lights.. pain just below the ribs.. vomiting.. sudden swelling of the feet, ankles, face and hands.. Which of the following is considered a severe feature of preeclampsia?Severe features of preeclampsia include any of the following findings: Systolic blood pressure of 160mm Hg or higher, or diastolic blood pressure of 110mm Hg or higher on 2 occasions at least 6 hours apart on bed rest.
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