Preeclampsia is a gestational complication presenting as hypertension and organ damage. It is diagnosed with blood pressure monitoring and labs. It is ultimately treated with delivery.

Pathophysiology

• Poorly understood
• Poorly developed uterine placental spiral arterioles
  • Leads to decreased uteroplacental blood flow during pregnancy
• Lipid peroxidation of cell membranes induced by free radicals

Contextual Factors

High Risk

• History of preeclampsia
• Multifetal gestation
• Kidney disorders
• Autoimmune disorders
• Diabetes mellitus
• Chronic hypertension before pregnancy

Moderate Risk

• First pregnancy
• Maternal age >= 30
• BMI > 30
• Family history of preeclampsia
• Socioeconomic hardship

Clinical Manifestation

• Edema
  • Facial or hand swelling
• Excessive weight gain
• Petechiae

Severe Features

• Severe headache
• Visual disturbances
• Confusion
• Hyperreflexia
• Epigastric or right upper quadrant abdominal pain
• Nausea and vomiting
• Dyspnea
• Oliguria
• Stroke

Eclampsia

• Tonic-clonic generalised seizures

Complications

• Fetal growth restriction
• Fetal death
• Maternal ischemia resulting in multiple organ failure
  • Brain
  • Kidneys
  • Liver
• Placental abruption
• HELLP syndrome

Diagnosis

• Must meet two criteria:
  1. New-onset hypertension that starts after 20 weeks gestation
  2. Proteinuria and/ or end-organ damage

Blood Pressure

• Systolic BP >= 140 mmHg and/ or diastolic BP >= 90 mmHg occuring twice 4 hours apart
• Systolic BP >= 160 mmHg and/ or diastolic BP >= 110 mmHg occuring once
  • Considered preeclampsia w/ severe features if occurs twice 4 hours apart

Proteinuria

• 300 mg/ 24 hours or protein/ creatinine ratio >= 0.3

• If no other tests available: dipstick 2+

Preeclampsia Labs After Diagnosis

• CBC
• Platelet count
• Uric acid
• Liver tests
• BUN
• Creatinine
• Fetal nonstress test

Signs of End-Organ Damage (Severe Features)

• Thombocytopenia: platelets < 100000/mcL
• Renal insufficiency: serum creatinine > 1.1 mg/dL
  • Patients without renal disease: serum creatinine 2x baseline
• Impaired liver function: aminotransferases (ALT or AST) > 2x normal
• Symptoms of liver capsule distension: right upper quadrant pain, epigastric pain
• Pulmonary edema
• Central nervous system dysfunction: Visual symptoms, new-onset headache with no relief from acetaminophen, altered mental status

Treatment

• Antihypertensive treatment
• Delivery, if safe or necessary
• Magnesium sulfate as seizure prophylaxis

Antihypertensives

• No hospitalisation needed if maternal and fetal status are fine
  • Outpatient visits with maternal-fetal medicine once a week
• Labetalol is preferred
• Plan for induction at 37 weeks

Delivery

Factors to Consider

• Gestational age
• Fetal growth restriction
• Fetal distress
• Severity of preeclampsia
• Response to antihypertensives

Indications for Delivery

• Gestational age >= 37 weeks
  • Gestational age >= 34 weeks if severe features present
• HELLP syndrome
• Concerns on fetal monitoring
• Eclampsia

Meds to Give with Delivery

• Corticosteroids for 48 hours if gestational age < 34 weeks
  • Accelerates fetal lung maturity
  • Sometimes indicated at gestational age < 36 weeks

Magnesium Sulfate

• Initial 4 g IV over 20 minutes
• Subsequent constant 2 g/hour infusion
• Decrease if magnesium level > 10 mEq/L or hyporeflexia starts
• Continue 24 hours after delivery

Postpartum Care

• 1-2 week follow-ups for BP checks
• Diagnosis of chronic hypertension if persistently hypertensive postpartum