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Pre-eclampsia

Sam Ashoo, MD and Mizuho Morrison, DO
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Tag OB-GYN

Preeclampsia is on a spectrum of pregnancy related illness which includes eclampsia and HELLP syndrome. Without intervention, it can lead to seizures (eclampsia) and carries a high mortality for mom and baby.

Pearls:

  • Remember that preeclampsia can occur up to 6 weeks postpartum.

  • Risk factors include many conditions our patients have: hypertension, diabetes and obesity.

  • Know when to consider the disease and look for the secondary criteria.  The spectrum is vast and asymptomatic or mildly symptomatic patients can rapidly decompensate.

 

CASE:  Sam’s wife gave birth to their 3rd child and mom and baby are discharged home seemingly well.  6 days postpartum, mom begins to experience epigastric pain. They initially attribute it to gastritis from NSAIDs, but the pain becomes increasingly worse and they go to a free-standing ED near their home.  

 

The patient’s blood pressure in triage is 185/110. They initially attribute it to pain, but her blood pressure remains high despite pain control. She has no headache or blurry vision.  She receives a dose of hydralazine and while waiting for her labs to come back, she turns to Sam and asks why the lights are flashing (they are not) and then develops a severe headache.  

 

The labs come back with mildly elevated transaminases. The ED physician speaks with the on call OB-Gyn and they decide to transfer the patient to the Labor & Delivery floor for BP control and continued monitoring.

 

Over the next few hours the patient’s headache becomes increasingly severe and she is rocking back and forth in pain despite multiple doses of IV dilaudid. She is started on a magnesium drip.  Her headache persists for 24 hours and she undergoes CT angiography of the head which is negative.  

 

Over the next several days, the patient’s headache and blood pressure gradually resolve and she goes back to her normal, healthy life.  

 

PREECLAMPSIA

 

EPIDEMIOLOGY

  • Occurs after 20 weeks gestation and up to 6 weeks postpartum (very rare exception: a molar pregnancy can cause preeclampsia earlier than 20 weeks)

  • Affects 3-4% of pregnancies in the U.S. and 4-5% of pregnancies worldwide

  • There is 1 death in every 100,000 births in the U.S. from eclampsia and there are 6.5 deaths in every 10,000 cases of preeclampsia

  • Preeclampsia is 1 of the 4 major causes of obstetric death in the U.S.  (other 3 are hemorrhage, cardiovascular conditions like cardiomyopathies and thromboembolism)

 

RISK FACTORS

  • Prior history of preeclampsia (7x more likely to have it again, and it is more likely to be severe)

  • First pregnancy

  • Family history in first degree relatives

  • History of diabetes

  • Pre-gestational hypertension

  • Anti-phospholipid antibodies

  • Obesity (BMI > 26)

  • Baseline chronic kidney disease

  • Twin pregnancy

  • Age 40 or older

 

PATHOPHYSIOLOGY

  • Not well understood.  The leading theory is that there is reduced placental circulation that causes hypoxia or ischemia within the placenta leading to the release of inflammatory markers resulting in endothelial dysfunction/vasoconstriction/coagulation pathway activation and multisystem organ damage.  

  • Associated pathology:  increased risk of placental abruption, renal failure and intracranial hemorrhage

 

PRESENTATION

  • Hypertension

  • Headache or visual changes

  • Upper abdominal or epigastric pain

  • Nausea or vomiting

  • Shortness of breath or chest pain

  • Altered mental status

 

DIAGNOSIS

  • Primary criteria:

    • BP>140/90 (2 readings 4 hours apart), or

    • BP>160/110 (2 readings a few minutes apart)

  • Secondary criteria:

    • Proteinuria (1+ or higher on a urine dipstick)

    • Platelets < 100,000

    • Creatinine > 1.1

    • Doubling of transaminases

    • Pulmonary edema

    • Blurred vision, flashing lights or scotomas

    • Cerebral pathology including severe persistent headache that does not respond to typical analgesics, altered mental status or signs/symptoms of a stroke

 

  • The spectrum of this illness is vast and can range from mildly elevated blood pressures with proteinuria to full blown seizures with central nervous system collapse, increased intracranial pressure, pulmonary edema, liver failure, DIC and stroke.  

  • HELLP syndrome involves similar pathology, though there is debate in the OB literature whether HELLP syndrome is related to preeclampsia or an entirely different entity.  

    • Hemolysis

    • Elevated Liver enzymes

    • Low Platelets

 

DISPO

  • Severe cases require emergent transfer to the Emergency Department

  • More mild cases like asymptomatic hypertension with mild proteinuria: call the patient’s OB/Gyn for close follow up and possible initiation of antihypertensive medication (usually labetalol or hydralazine)

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