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Preeclampsia/Eclampsia, Emergency Medicine

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Preeclampsia/Eclampsia, Emergency Medicine

Basics

Description

  • Hypertension in pregnancy:1% of all pregnancies16% of maternal deaths
  • Gestational hypertension (GH)Hypertension associated with pregnancyResolves with delivery6 " “7% of all pregnancies
  • PreeclampsiaGH PLUS proteinuria2.2 " “6.3% of all pregnancies
  • EclampsiaPreeclampsia with seizure
  • Postpartum preeclampsiaOccurs within 6 wk of deliveryUsually no history of hypertensionOccurs in 5% patientsMost women are African American
  • HELLP syndromeMay occur in women with preeclampsia or eclampsiaHemolysisElevated liver function testsLow platelets
  • Superimposed preeclampsiaPreeclampsia in the setting of chronic hypertensionComplicates pregnancy in up to 25% of women with chronic hypertensionRisk factors:African AmericanAntihypertensive medication use
  • Chronic hypertensionSystolic BP (SBP) >140 or diastolic BP (DBP) >90Measured twice prior to 20 wk gestation or lasting >12 wk after delivery
  • 1% of all pregnancies
  • 16% of maternal deaths
  • Hypertension associated with pregnancy
  • Resolves with delivery
  • 6 " “7% of all pregnancies
  • GH PLUS proteinuria
  • 2.2 " “6.3% of all pregnancies
  • Preeclampsia with seizure
  • Occurs within 6 wk of delivery
  • Usually no history of hypertension
  • Occurs in 5% patients
  • Most women are African American
  • May occur in women with preeclampsia or eclampsia
  • Hemolysis
  • Elevated liver function tests
  • Low platelets
  • Preeclampsia in the setting of chronic hypertension
  • Complicates pregnancy in up to 25% of women with chronic hypertension
  • Risk factors:African AmericanAntihypertensive medication use
  • African American
  • Antihypertensive medication use
  • Systolic BP (SBP) >140 or diastolic BP (DBP) >90
  • Measured twice prior to 20 wk gestation or lasting >12 wk after delivery

Etiology

  • PreeclampsiaIncomplete placental implantation and underperfusionLeads to decreased angiogenic growth factor and increased maternal placental debris in circulation
  • Eclampsia1/3 of patients with eclampsia did not have hypertension prior to seizure
  • Risk factors:Extremes of reproductive agePrimagravidaMultiple gestationsMolar pregnancy, hydatidiform moleSmokingIncreased body mass indexDiabetes, collagen vascular diseasesPre-existing hypertension or renal diseaseHistory of preeclampsia with prior pregnancies (7.5 " “10% increased risk)Independent risk factors for eclampsiaNulliparityMaternal ageGH
  • Incomplete placental implantation and underperfusion
  • Leads to decreased angiogenic growth factor and increased maternal placental debris in circulation
  • 1/3 of patients with eclampsia did not have hypertension prior to seizure
  • Extremes of reproductive age
  • Primagravida
  • Multiple gestations
  • Molar pregnancy, hydatidiform mole
  • Smoking
  • Increased body mass index
  • Diabetes, collagen vascular diseases
  • Pre-existing hypertension or renal disease
  • History of preeclampsia with prior pregnancies (7.5 " “10% increased risk)
  • Independent risk factors for eclampsiaNulliparityMaternal ageGH
  • Nulliparity
  • Maternal age
  • GH

Diagnosis

  • GHNormotensive prior to 20 wk gestationSBP >140 or DBP >90 on 2 separate measurementsSevere: SBP >160 and DBP >110
  • PreeclampsiaGH and proteinuria300 mg protein on 24 hr urine1+ protein on urinalysisMild:SBP <160 mm Hg orDBP <110 mm HgNormal plateletsNormal liver function testsNo cerebral symptomsSevere:SBP >160 or DBP >1105 g protein on 24 hr urine3+ proteinuria on 2 occasionsOliguriaThrombocytopeniaRight upper quadrant painImpaired liver functionCerebral symptomsIntrauterine growth restrictionVision changesPulmonary edema
  • HELLP SyndromeHemolysisElevated liver enzymeLow plateletsMay present with:Pulmonary edemaRenal failureLiver failureSepsisPulmonary diseaseStroke
  • Normotensive prior to 20 wk gestation
  • SBP >140 or DBP >90 on 2 separate measurements
  • Severe: SBP >160 and DBP >110
  • GH and proteinuria
  • 300 mg protein on 24 hr urine
  • 1+ protein on urinalysis
  • Mild:SBP <160 mm Hg orDBP <110 mm HgNormal plateletsNormal liver function testsNo cerebral symptoms
  • Severe:SBP >160 or DBP >1105 g protein on 24 hr urine3+ proteinuria on 2 occasionsOliguriaThrombocytopeniaRight upper quadrant painImpaired liver functionCerebral symptomsIntrauterine growth restrictionVision changesPulmonary edema
  • SBP <160 mm Hg or
  • DBP <110 mm Hg
  • Normal platelets
  • Normal liver function tests
  • No cerebral symptoms
  • SBP >160 or DBP >110
  • 5 g protein on 24 hr urine
  • 3+ proteinuria on 2 occasions
  • Oliguria
  • Thrombocytopenia
  • Right upper quadrant pain
  • Impaired liver function
  • Cerebral symptoms
  • Intrauterine growth restriction
  • Vision changes
  • Pulmonary edema
  • Hemolysis
  • Elevated liver enzyme
  • Low platelets
  • May present with:Pulmonary edemaRenal failureLiver failureSepsisPulmonary diseaseStroke
  • Pulmonary edema
  • Renal failure
  • Liver failure
  • Sepsis
  • Pulmonary disease
  • Stroke

Signs and Symptoms

  • History of preeclampsia
  • Parity
  • Weight gain
  • Leg swelling
  • Abdominal pain
  • Nausea/vomiting
  • Shortness of breath
  • Headache
  • Visual changes
  • Jaundice
  • Stroke symptoms
  • Check serial BP
  • Palpate abdomen carefully, especially RUQ
  • Assess extremities for edema
  • Perform neurologic exam:Deep tendon reflexesMental status changesVisual acuity
  • Deep tendon reflexes
  • Mental status changes
  • Visual acuity

Essential Workup

  • Serial BP measurements
  • Urinalysis
  • CBC, LFTs, BUN/creatinine, uric acid
  • US
  • Fetal monitoring
  • Head CT depending on severity of presentation

Diagnosis Tests & Interpretation

  • Urinalysis:Protein >1+ correlates to 30 mg/dL>1+ requires 24 hr urine collectionUrine sediment for RBC, WBC, casts
  • CBC
  • LFTs
  • BUN/creatinine
  • Uric acid
  • LDH
  • d-dimer
  • Fibrinogen levels
  • Coagulation studies
  • Protein >1+ correlates to 30 mg/dL
  • >1+ requires 24 hr urine collection
  • Urine sediment for RBC, WBC, casts
  • US:Gestational ageFetal viability/distressOligohydramnios
  • Fetal monitoring, nonstress test
  • Head CT: Rule out mass or hemorrhage
  • Gestational age
  • Fetal viability/distress
  • Oligohydramnios
  • Lumbar puncture: Rule out infection or subarachnoid hemorrhage
  • Urine toxicology: Rule out substance abuse:CocaineMethamphetamine
  • Cocaine
  • Methamphetamine

Differential Diagnosis

  • Essential hypertension
  • Renal or collagen vascular disease
  • Hydatidiform mole, hydrops fetalis
  • Drug abuse
  • Epilepsy
  • Encephalitis
  • Meningitis
  • Encephalopathy
  • Brain tumor
  • Intracranial hemorrhage

Treatment

Pre-Hospital

  • ABCs
  • Oxygen
  • Place patient in left lateral decubitus position

Initial Stabilization/Therapy

  • ABCs
  • 100% oxygen
  • Left lateral decubitus position (reduces pressure on inferior vena cava, enhancing cardiac return/output)
  • Maternal cardiopulmonary monitoring
  • Magnesium sulfate (MgSO4) for seizures

Ed Treatment/Procedures

  • Make arrangements for emergent C-section
  • MgSO4for seizure treatment and prophylaxis
  • Hydralazine or labetalol for BP controlGoal is to lower BP by 25% initially and then to <160/100 over subsequent hours
  • Mg toxicity:HypotensionLoss of patellar reflexRespiratory depressionDecreased urine outputElevated creatinineCalcium gluconate to reverse
  • Intubate for airway protection/hypoxia or if seizures refractory to interventions
  • Tocographic and fetal monitoring
  • OB consult:All cases along GH " “preeclampsia " “eclampsia spectrumExpectant management if <30 wk gestationDelivery >30 wkEmergent delivery for severe symptoms: Induction vs. C-section
  • Goal is to lower BP by 25% initially and then to <160/100 over subsequent hours
  • Hypotension
  • Loss of patellar reflex
  • Respiratory depression
  • Decreased urine output
  • Elevated creatinine
  • Calcium gluconate to reverse
  • All cases along GH " “preeclampsia " “eclampsia spectrum
  • Expectant management if <30 wk gestation
  • Delivery >30 wk
  • Emergent delivery for severe symptoms: Induction vs. C-section

Medication

  • MgSO4: 10 g IM or 4 g IV; followed by 1 " “2 g/hr IV infusion:MgSO4 bolus should not exceed 1 g/minSerum Mg goal: 4 " “7 mEq/L
  • Hydralazine: 5 " “20 mg IV
  • Labetalol: 10 mg IV initially, then 5 " “10 mg increments for desired effect
  • MgSO4 bolus should not exceed 1 g/min
  • Serum Mg goal: 4 " “7 mEq/L
  • Valium: 5 " “10 mg IV if no response to MgSO4
  • Fosphenytoin: 15 " “20 mg phenytoin equivalents (PE) IV ƒ — 1 (max. 150 mg PE/min IV)
  • Phenytoin: 15 " “18 mg/kg IV, not to exceed 25 " “50 mg/min, for persistent seizure activity
  • Calcium gluconate: 1 g IV

Follow-Up

Disposition

  • Preeclampsia
  • Eclampsia
  • HELLP syndrome
  • ICU, labor and delivery, OR
  • Isolated hypertension with workup negative for preeclampsia
  • Asymptomatic
  • Close obstetric follow-up assured

Follow-Up Recommendations

  • Follow-up with OB as above
  • Return to ED:HeadacheAbdominal painLeg swellingDecreased urinationShortness of breath
  • Headache
  • Abdominal pain
  • Leg swelling
  • Decreased urination
  • Shortness of breath

Pearls and Pitfalls

  • Delivery is the definitive treatment for preeclampsia and eclampsia
  • BP of 130/80 mm Hg in a pregnant woman requires investigation
  • Postpartum presentation: Consider preeclampsia/eclampsia in patient up to 30 days postpartum presenting with:EdemaShortness of breathHeadacheSeizure
  • Airway considerations in preeclamptic or eclamptic patients:Reduced internal diameter of airways due to engorgementAirway edema may be presentUse smaller-diameter endotracheal tubeUse fiberoptic guidance if availableHigh risk for aspiration
  • Edema
  • Shortness of breath
  • Headache
  • Seizure
  • Reduced internal diameter of airways due to engorgement
  • Airway edema may be present
  • Use smaller-diameter endotracheal tube
  • Use fiberoptic guidance if available
  • High risk for aspiration

Additional Reading

  • Deak ‚ TM, Moskovitz ‚ JB. Hypertension and pregnancy. Emerg Med Clin N Am. 2012;30:903 " “917.
  • Leeman ‚ L, Fontaine ‚ P. Hypertensive disorders of pregnancy. Am Fam Physician. 2008;78:93 " “100.
  • Podymow ‚ T, August ‚ P. Antihypertensive drugs in pregnancy. Semin Nephrol. 2011;31:70 " “85.
  • Sibai ‚ BM. Etilogy and management of postpartum hypertension-preeclampsia. Am J Obstet Gynecol. 2012;206:470 " “475.
  • Yancey ‚ LM, Withers ‚ E, Bakes ‚ K, et al. Postpartum preeclampsia: Emergency department presentation and management. J Emerg Med. 2011;40;380 " “384.
  • Yoder ‚ SR, Thornburg ‚ LL, Bisognano ‚ JD. Hypertension in pregnancy and women of childbearing age. Am J Med. 2009;122:890 " “895.

See Also (Topic, Algorithm, Electronic Media Element)

  • HELLP Syndrome
  • Hydatidiform Mole
  • Seizure, Adult

Codes

ICD9

  • 642.40 Mild or unspecified pre-eclampsia, unspecified as to episode of care
  • 642.60 Eclampsia complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care
  • 642.64 Eclampsia, postpartum condition or complication
  • 642.50 Severe pre-eclampsia, unspecified as to episode of care
  • 642.41 Mild or unspecified pre-eclampsia, delivered, with or without mention of antepartum condition
  • 642.42 Mild or unspecified pre-eclampsia, delivered, with mention of postpartum complication
  • 642.43 Mild or unspecified pre-eclampsia, antepartum condition or complication
  • 642.44 Mild or unspecified pre-eclampsia, postpartum condition or complication
  • 642.4 Mild or unspecified pre-eclampsia
  • 642.51 Severe pre-eclampsia, delivered, with or without mention of antepartum condition
  • 642.52 Severe pre-eclampsia, delivered, with mention of postpartum complication
  • 642.53 Severe pre-eclampsia, antepartum condition or complication
  • 642.54 Severe pre-eclampsia, postpartum condition or complication
  • 642.5 Severe pre-eclampsia
  • 642.61 Eclampsia, delivered, with or without mention of antepartum condition
  • 642.62 Eclampsia, delivered, with mention of postpartum complication
  • 642.63 Eclampsia, antepartum condition or complication
  • 642.6 Eclampsia complicating pregnancy, childbirth or the puerperium

ICD10

  • O14.90 Unspecified pre-eclampsia, unspecified trimester
  • O15.2 Eclampsia in the puerperium
  • O15.9 Eclampsia, unspecified as to time period
  • O14.20 HELLP syndrome (HELLP), unspecified trimester
  • O14.00 Mild to moderate pre-eclampsia, unspecified trimester
  • O14.02 Mild to moderate pre-eclampsia, second trimester
  • O14.03 Mild to moderate pre-eclampsia, third trimester
  • O14.0 Mild to moderate pre-eclampsia
  • O14.10 Severe pre-eclampsia, unspecified trimester
  • O14.12 Severe pre-eclampsia, second trimester
  • O14.13 Severe pre-eclampsia, third trimester
  • O14.1 Severe pre-eclampsia
  • O14.22 HELLP syndrome (HELLP), second trimester
  • O14.23 HELLP syndrome (HELLP), third trimester
  • O14.2 HELLP syndrome
  • O14.92 Unspecified pre-eclampsia, second trimester
  • O14.93 Unspecified pre-eclampsia, third trimester
  • O14.9 Unspecified pre-eclampsia
  • O14 Pre-eclampsia
  • O15.00 Eclampsia in pregnancy, unspecified trimester
  • O15.02 Eclampsia in pregnancy, second trimester
  • O15.03 Eclampsia in pregnancy, third trimester
  • O15.0 Eclampsia in pregnancy
  • O15.1 Eclampsia in labor

SNOMED

  • 398254007 Pre-eclampsia (disorder)
  • 15938005 Eclampsia (disorder)
  • 303063000 Eclampsia in puerperium
  • 95605009 hemolysis-elevated liver enzymes-low platelet count syndrome (disorder)
  • 41114007 Mild pre-eclampsia (disorder)
  • 46764007 Severe pre-eclampsia (disorder)