• Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm.
  • Occurs > 20 weeks gestation and up to 6 weeks post partum.
  • Most often onset is close to term, while earlier presentations are more severe.
  • Preeclampsia = new onset hypertension with proteinuria (most often) or organ dysfunction.
  • Preeclampsia with severe features = preeclampsia complicated by severe hypertension or organ dysfunction.
• Eclampsia = preeclampsia with new onset of seizures or coma.
• HELLP Syndrome = severe pre-eclampsia variant defined by hemolysis, elevated liver enzymes and low platelet count.
• Worldwide approximately 4.6% of pregnancies are complicated by preeclampsia.
• Preeclampsia is a leading cause of maternal and fetal mortality and morbidity.
  • Maternal: seizures (eclampsia), stroke, liver dysfunction, pulmonary edema, renal failure, placental abruption.
  • Fetal: stillbirth, preterm or small for gestational age.
• Risk factors: diabetes, hypertension, kidney disease, obesity, prior preeclampsia, nulliparity, multifetal pregnancy, autoimmune disease, maternal age <20 or >35 yrs.
• Presentations: headache, visual disturbances, chest pain, shortness of breath, abdominal pain, nausea/vomiting, or acute edema of face, hands or lower extremities.

Require admission, discharge at obstetrical direction.

Criteria

Preeclampsia

• Previously normotensive women after 20 weeks gestation, now with:
  • Systolic pressure ⩾140 mmHg or diastolic pressure ⩾90 mmHg, and proteinuria
  • Systolic pressure ⩾140 mmHg or diastolic pressure ⩾90 mmHg, and end organ dysfunction
• Superimposed Preeclampsia = new onset/worsening of hypertension, proteinuria or end organ dysfunction in patients with preexisting hypertension and/or proteinuria
• Proteinuria:
  • Urine Dipstick ⩾2+ Protein
  • Confirmation tests (not ED issue):
    • Protein:Creatinine ratio ⩾3omg/mmol
    • Proteinuria ⩾0.3g/d in a 24-hour urine collection
• End organ dysfunction:
  • Thrombocytopenia: Platelet count <100,000/µL
  • Serum creatinine > 97.2 µmol/L or doubling, in the absence of other renal disease.
  • Liver transaminases 2X upper limit of the normal
  • Pulmonary edema
  • CNS:
    • Altered mental status
    • Visual changes
    • Hyperreflexia
    • Clonus
  • FHR abnormality

Preeclampsia with Severe Features

• Preeclampsia with ⩾ 160mmHg Systolic or ⩾110mmHg Diastolic, or if any end organ features are present.

HELLP Syndrome

• Variant of preeclampsia
• NB: hypertension and proteinuria NOT required for diagnosis, although they are present in approximately 85% cases
• Diagnosis requires all of:

1. Hemolysis: LDH ⩾600 IU/L
2. Elevated Liver Enzymes – AST or ALT > 2X upper limit of normal
3. Low Platelets – Platelet count <100,000/µL
4. Hemolysis can also be established by at least two of:

• Peripheral smear with schistocytes and burr cells
• Serum bilirubin ⩾52 µmol/L
• Low serum haptoglobin (<25 mg/dL) or LDH ⩾2 times the upper limit
• Severe anemia without hemorrhage

Eclampsia

• Preeclampsia with generalized tonic-clonic seizures, without other cause (epilepsy or drug use), or coma.

Clinical Findings

• Hypertension
• Persistent or severe headache
• CNS:
  • Altered mental status
  • Visual changes (blurred, scotoma, diplopia, loss of vision, visual field defects)
  • Hyperreflexia
  • Clonus
• GU: RUQ/epigastric pain/tenderness
• Pulmonary: pulmonary edema, O₂ desaturation
• Peripheral edema
• Decreased Fetal movement

Recommended Investigations:

• Urinalysis: protein determination
• Complete blood count + Peripheral blood smear
• Haptoglobin level
• Electrolytes
• BUN, creatinine
• LDH, AST, ALT, bilirubin,
• INR, PTT, (fibrinogen if severe features present)
• Neuroimaging – if focal neurologic signs/symptoms

Assess fetal well-being: maternal perception of fetal movement, establish fetal heart rate (doppler or bedside ultrasound).

1. National, G. A. U. (2019). Hypertension in pregnancy: diagnosis and management.

   
   

2. Milne, F., & Philip, N. (2010). Identification, diagnosis, and management of suspected preeclampsia. In A. Heazell, E. Norwitz, L. Kenny, & P. Baker (Authors), Hypertension in Pregnancy (Cambridge Clinical Guides, pp. 109-124). Cambridge: Cambridge University Press. doi:10.1017/CBO9780511902529.010

   
   

3. Magee, L. A., Helewa, M., Moutquin, J. M., Von Dadelszen, P., & Hypertension Guideline Committee. (2008). Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Journal of Obstetrics and Gynaecology Canada, 30(3 Supplement 1), S1-48.

   
   

4. Rosen’s Emergency Medicine: Acute Complications of Pregnancy, Chapter 178, 2237-2258.

   
   

5. UpToDate: Preeclampsia: Clinical features and diagnosis

   
   

6. UpToDate: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)

   
   

7. ACOG Practice Bulletin Number 202: Gestational Hypertension and Preeclampsia, Obstetrics & Gynecology, 133, no. 1, Jan. 2019.