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Preeclampsia and Eclampsia

By Antonette T. Dulay, MD, Attending Physician, Maternal-Fetal Medicine Section, Department of Obstetrics and Gynecology;Senior Physician, Main Line Health System;Axia Women’s Health

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Preeclampsia is new-onset hypertension and proteinuria after 20 wk gestation. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Diagnosis is clinical and by urine protein measurement. Treatment is usually with IV magnesium sulfate and delivery at term.

Preeclampsia affects 3 to 7% of pregnant women. Preeclampsia and eclampsia develop after 20 wk gestation; up to 25% of cases develop postpartum, most often within the first 4 days but sometimes up to 6 wk postpartum.

Untreated preeclampsia usually smolders for a variable time, then suddenly progresses to eclampsia, which occurs in 1/200 patients with preeclampsia. Untreated eclampsia is usually fatal.

Etiology

Etiology of preeclampsia is unknown.

However, risk factors include the following:

Pathophysiology

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 on chromosome 13, immunologic abnormalities, and placental ischemia or infarction. Lipid peroxidation of cell membranes induced by free radicals may contribute to preeclampsia.

Complications

Fetal growth restriction or fetal death 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 abruptio placentae in the current and in future pregnancies, possibly because both disorders are related to uteroplacental insufficiency.

The coagulation system is activated, possibly secondary to endothelial cell dysfunction, leading to platelet activation. The HELLP syndrome (hemolysis, elevated liver function tests, and low platelet count) develops in 10 to 20% of women with severe preeclampsia or eclampsia; this incidence is about 100 times that for all pregnancies (1 to 2/1000). Most pregnant women with HELLP syndrome have hypertension and proteinuria, but some have neither.

Symptoms and Signs

Preeclampsia may be asymptomatic or may cause edema or excessive weight gain. Nondependent edema, such as facial or hand swelling (the patient’s ring may no longer fit her finger), is more specific than dependent edema.

Reflex reactivity may be increased, indicating neuromuscular irritability, which can progress to seizures (eclampsia).

Petechiae may develop, as may other signs of coagulopathy.

Pearls & Pitfalls

  • Check for swelling in the hands (eg, a ring that no longer fits) or face and hyperreflexia, which may be among the more specific findings in preeclampsia.

Preeclampsia with severe features may cause organ damage; these features may include

  • Severe headache

  • Visual disturbances

  • Confusion

  • Epigastric or right upper quadrant abdominal pain (reflecting hepatic ischemia or capsular distention)

  • Nausea and/or vomiting

  • Dyspnea (reflecting pulmonary edema, acute respiratory distress syndrome [ARDS], or cardiac dysfunction secondary to increased afterload)

  • Stroke (rarely)

  • Oliguria (reflecting decreased plasma volume or ischemic acute tubular necrosis)

Diagnosis

  • New-onset hypertension (BP > 140/90 mm Hg) plus new unexplained proteinuria (> 300 mg/24 h after 20 wk or a urine protein/creatinine ratio of ≥ 0.3)

Diagnosis of preeclampsia is suggested by symptoms or presence of hypertension, defined as systolic BP > 140 mm Hg, diastolic BP > 90 mm Hg, or both. Except in emergencies, hypertension should be documented in > 2 measurements taken at least 4 h apart. Urine protein excretion is measured in a 24-h collection.

Proteinuria is defined as > 300 mg/24 h. Alternatively, proteinuria is diagnosed based on a protein/creatinine ratio ≥ 0.3 or a dipstick reading of 1+; the dipstick test is used only if other quantitative methods are not available. Absence of proteinuria on less accurate tests (eg, urine dipstick testing, routine urinalysis) does not rule out preeclampsia.

In the absence of proteinuria, preeclampsia is also diagnosed if pregnant women have new-onset hypertension plus new onset of any of the following:

  • Thrombocytopenia (platelets < 100,000/μL)

  • Renal insufficiency (serum creatinine > 1.1 mg/dL or doubling of serum creatinine in women without renal disease)

  • Impaired liver function (aminotransferases > 2 times normal)

  • Pulmonary edema

  • Cerebral or visual symptoms

The following points help differentiate among hypertensive disorders in pregnant women:

  • Chronic hypertension is identified if hypertension precedes pregnancy, is present at < 20 wk gestation, or persists for > 6 wk (usually > 12 wk) postpartum (even if hypertension is first documented at > 20 wk gestation). Chronic hypertension may be masked during early pregnancy by the physiologic decrease in BP.

  • Gestational hypertension is hypertension without proteinuria or other findings of preeclampsia; it first occurs at > 20 wk gestation in women known not to have hypertension before pregnancy and resolves by 12 wk (usually by 6 wk) postpartum.

  • Preeclampsia is new-onset hypertension (BP > 140/90 mm Hg) plus new unexplained proteinuria (> 300 mg/24 h or urine protein/creatinine ratio ≥ 0.3) after 20 wk or other criteria (see above).

  • Preeclampsia superimposed on chronic hypertension is diagnosed when new unexplained proteinuria develops or proteinuria worsens after 20 wk in a woman known to have hypertension or when BP increases or preeclampsia with severe features develops after 20 wk in a woman known to have hypertension and proteinuria.

Further evaluation

If preeclampsia is diagnosed, tests include urinalysis, CBC, platelet count, uric acid, liver function tests, and measurement of serum electrolytes, BUN, creatinine, and 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.

HELLP syndrome is suggested by microangiopathic findings (eg, schistocytes, helmet cells) on peripheral blood smears, elevated liver enzymes, and a low platelet count.

Preeclampsia with severe features is differentiated from mild by one or more of the following:

  • CNS dysfunction (eg, blurred vision, scotomata, altered mental status, severe headache unrelieved by acetaminophen)

  • Symptoms of liver capsule distention (eg, right upper quadrant or epigastric pain)

  • Nausea and vomiting

  • Serum AST or ALT > 2 times normal

  • Systolic BP > 160 mm Hg or diastolic BP > 110 mm Hg on 2 occasions 4 h apart

  • Platelet count < 100,000/μL

  • Urine output < 500 mL/24 h

  • Pulmonary edema or cyanosis

  • Stroke

  • Progressive renal insufficiency (serum creatinine > 1.1 mg/dL or doubling of serum creatinine in women without renal disease)

Treatment

  • Usually hospitalization and sometimes antihypertensive treatment

  • Delivery, depending on factors such as gestational age and severity of preeclampsia

  • Magnesium sulfate for prevention or treatment of seizures

General approach

Definitive treatment for preeclampsia is delivery. However, risk of early delivery is balanced against gestational age, severity of preeclampsia, and response to other treatments.

Usually, immediate delivery after maternal stabilization (eg, controlling seizures, beginning to control BP) is indicated for the following:

  • Pregnancy of 37 wk

  • Eclampsia

  • Preeclampsia with severe features if pregnancy is ≥ 34 wk

  • Deteriorating renal, pulmonary, cardiac, or hepatic function

  • Nonreassuring results of fetal monitoring or testing

Other treatments aim to optimize maternal health, which usually optimizes fetal health. If delivery can be safely delayed in pregnancies of < 34 wk, corticosteroids are given for 48 h to accelerate fetal lung maturity.

Most patients are hospitalized. Patients with eclampsia or preeclampsia with severe features are often admitted to a maternal special care unit or an ICU.

Mild preeclampsia

If preeclampsia is mild, outpatient treatment is possible; it includes modified activity (modified rest), and BP measurements, laboratory monitoring, fetal nonstress testing, and physician visits 2 to 3 times/wk.

However, most patients with mild preeclampsia require hospitalization, at least initially. As long as no criteria for preeclampsia with severe features are met, delivery can occur (eg, by induction) at 37 wk.

Monitoring

Outpatients are usually evaluated once every 2 or 3 days 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 weekly.

All hospitalized patients are followed by an obstetrician or a maternal-fetal medicine specialist and evaluated as for outpatients (described above); evaluation is more frequent if preeclampsia with severe features is diagnosed or if gestational age is < 34 wk.

Magnesium sulfate

As soon as eclampsia is diagnosed, magnesium sulfate must be given to stop seizures. If patients have preeclampsia with severe features, magnesium sulfate is given to prevent seizures, and it is given for 24 h postpartum. Whether patients with mild preeclampsia always require magnesium sulfate before delivery is controversial.

Magnesium sulfate 4 g IV over 20 min is given, followed by a constant IV infusion of about 1 to 3 g/h, with supplemental doses as necessary. Dose is adjusted based on the patient’s reflexes. 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.

Supportive treatments

If oral intake is prohibited, hospitalized patients are given IV Ringer lactate or 0.9% normal saline solution, beginning at about 125 mL/h (to increase urine output). 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 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.

Delivery method

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, beginning within 6 to 12 h.

Follow-up

Patients should be evaluated every 1 to 2 wk postpartum with periodic BP measurement. If BP remains high after 6 wk postpartum, patients may have chronic hypertension and should be referred to their primary care physician for management.

Key Points

  • Preeclampsia develops after 20 wk gestation; it develops postpartum in 25% of cases.

  • Swelling of the face or hands and hyperreflexia are relatively specific findings for preeclampsia.

  • Preeclampsia is severe if it causes significant organ dysfunction (detected clinically or by testing).

  • HELLP syndrome occurs in 10 to 20% of women who have preeclampsia with severe features or eclampsia.

  • Monitor the mother and fetus closely, usually in a hospital maternal special care unit or ICU.

  • As soon as eclampsia is diagnosed, treat with high doses of magnesium sulfate

  • If preeclampsia with severe features is diagnosed, treat with magnesium sulfate for seizure prophylaxis, and treat for 24 h after delivery; for mild preeclampsia, use of magnesium sulfate is less clear.

  • Delivery is usually indicated when the pregnancy is ≥ 37 wk, but If preeclampsia with severe features is diagnosed, deliver by 34 wk; if HELLP syndrome is diagnosed, deliver immediately.

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