Preeclampsia and Eclampsia

Epidemiology

Definitions

Preeclampsia: new onset of hypertension and proteinuria or hypertension and end-organ dysfunction with/without proteinuria after 20 was of gestation in a previously normotensive female
- Preeclampsia May Also Develop Postpartum in Some Cases
Eclampsia: preeclampsia with seizures (without an alternative neurologic explanation for the seizures)

Demographics

Incidence: occurs in approximately 4.6% of pregnancies worldwide

Risk Factors

Advanced Maternal Age
First Pregnancy (Nulliparity)
History of Pre-Eclampsia/Eclampsia
Family History of Pre-Eclampsia/Eclampsia
Twin Pregnancy
Pre-Existing Medical Conditions
- Antiphospholipid Antibodies (see Antiphospholipid Antibody Syndrome)
- Blood Pressure ≥130/80 mm Hg
- Body Mass Index ≥26.1 (see Obesity)
- Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)
- Pregestational Diabetes Mellitus (see Diabetes Mellitus)

Diagnosis

XXXX

xxx

Clinical Manifestations

General Comments

Timing

Occurs After 20 wks of Pregnancy

Diagnostic Criteria for Preeclampsia (One of the Following) (Obstet Gynecol, 2013) [MEDLINE]

Systolic Blood Pressure ≥140 mm Hg or Diastolic Blood Pressure ≥90 mm Hg on Two Occasions at Least Four Hours Apart After 20 wks of Gestation in a Previously Normotensive Patient
New-Onset Hypertension with the New Onset of Any of the Following (with/without Proteinuria)
- Platelet Count <100k
- Serum Creatinine >1.1 mg/dL or Doubling of the Serum Creatinine in the Absence of Other Renal Disease
- Liver Transaminases at Least 2x the Upper Limit of Normal
- Pulmonary Edema
- Cerebral/Visual Symptoms
  - New-Onset or Persistent Headaches Unresponsive to Usual Doses of Analgesics
  - Blurred Vision
  - Flashing Lights/Sparks
  - Scotomata

Cardiovascular Manifestations

Hypertension (see Hypertension)

Epidemiology
- Hypertension is Present in All Cases
- Hypertension is the Earliest Clinical Finding in Preeclampsia
  - In Contrast, in HELLP Syndrome, Hypertension May Be Minimal or Absent

Gastrointestinal Manifestations

Elevated Liver Function Tests (LFT’s) (see Elevated Liver Function Tests)

Epidemiology
- XXXX

Epigastric Pain

Epidemiology
- Epigastric Pain May Be the Presenting Symptom of Preeclampsia

Nausea/Vomiting (see Nausea and Vomiting)

xEpidemiology
- Nausea/Vomiting May Occur in Some Cases

Right Upper Quadrant (RUQ) Abdominal Pain (see Abdominal Pain)

Physiology
- XXXX

Hematologic Manifestations

Hemoconcentration

Epidemiology
- XXXX

Hemolytic Anemia (see Hemolytic Anemia)

Epidemiology
- XXXX

Thrombocytopenia (see Thrombocytopenia)

Epidemiology
- XXXXX

Neurologic Manifestations

Headache (see Headache)

Epidemiology
- XXXX

Hyperreflexia (see Hyperreflexia)

Epidemiology
- Common

Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident)

Epidemiology
- XXXX

Posterior Reversible Encephalopathy Syndrome (PRES) (see Posterior Reversible Encephalopathy Syndrome)

Epidemiology
- XXX
Clinical
- XXXX

Seizures (see Seizures)

Epidemiology
- XXXX

Visual Symptoms

Clinical
- XXXX

Pulmonary Manifestions

Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome)

Epidemiology
- May Rarely Occur in Association with Preeclampsia
  - Occurs ib Approximately 3% of All Cases
Physiology
- *Patients with Preeclampsia are Usually Hypovolemic
- Pulmonary Edema Most Commonly Occurs in the Early Postpartum Period and is Often Associated with Aggressive Fluid Replacement
- Reduced Albumin Concentration and Myocardial Dysfunction Contribute to Pulmonary Edema Formation
Clinical
- XXXX

Renal Manifestations

Acute Kidney Injury (AKI) (see Acute Kidney Injury)

Epidemiology
- XXXX

Hyperuricemia (see Hyperuricemia)

Epidemiology
- XXXX

Oliguria (see Oliguria)

Epidemiology
- XXXX

Proteinuria (see Proteinuria)

Epidemiology
- Common Feature

Reproductive Manifestations

Abruptio Placentae (see Abruptio Placentae)

Epidemiology
- XXXX

Rheumatologic Manifestations

Peripheral Edema (see Peripheral Edema)

Epidemiology
- XXXX

Other Manifestations

XXXX

xxx

Treatment

Preeclampsia without Severe Features

Preterm Pregnancy <34 wks Gestation

Conservative Management
- Patient Education
- Antihypertensives
- Laboratory Follow-Up
- Assessment of Fetal Growth
- Antenatal Corticosteroids (Betamethasone) to Accelerate Fetal Lung Development (see Betamethasone)

Preterm Pregnancy 34-36 wks Gestation

Optimal Management Is Uncertain, But Conservative Management is Reasonable

Term Pregnancy

Delivery

Preeclampsia with Severe Features

Criteria for Preeclampsia with Severe Features

Central Nervous Dysfunction
- New-Onset Central Nervous System Symptoms
  - Altered Mental Status (see Altered Mental Status)
  - Severe Headache/Headache Unresponsive to Analgesic Therapy
- New-Onset Visual Symptoms
  - Cortical Blindness
  - Photophobia
  - Retinal Vasospasm
  - Scotomata
Hepatic Abnormality
- Severe Persistent RUQ/Epigastric Pain Unresponsive to Analgesia (Not Due to Another Diagnosis) or Transaminases ≥2x Upper Limit of Normal
Severe Hypertension
- Systolic Blood Pressure ≥160 mm Hg or Diastolic Blood Pressure ≥110 mm Hg on Two Occasions at Least 4 hrs Apart While the Patient is on Bedrest: antihypertensive therapy can be initiated on confirmation of severe hypertension without waiting for 4 hrs to elapse
Thrombocytopenia (Platelet Count <100k)
Renal Abnormality with Progressive Renal Failure
- Serum Cr >1.1 mg/dL or Doubling of Serum Cr in Absence of Other Renal Disease
Pulmonary Edema

Therapy

Delivery
- Alternately, Conservative Management Can Be Used for Select Cases ≥24 wks and <34 wks of Gestation

Prognosis

XXXXX

xxxx

References

Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov;122(5):1122-31. doi: 10.1097/01.AOG.0000437382.03963.88 [MEDLINE]