Basics
Description
- Hypertension in pregnancy:
- 1% of all pregnancies
- 16% of maternal deaths
- Gestational hypertension (GH)
- Hypertension associated with pregnancy
- Resolves with delivery
- 6 " “7% of all pregnancies
- Preeclampsia
- GH PLUS proteinuria
- 2.2 " “6.3% of all pregnancies
- Eclampsia
- Preeclampsia with seizure
- Postpartum preeclampsia
- Occurs within 6 wk of delivery
- Usually no history of hypertension
- Occurs in 5% patients
- Most women are African American
- HELLP syndrome
- May occur in women with preeclampsia or eclampsia
- Hemolysis
- Elevated liver function tests
- Low platelets
- Superimposed preeclampsia
- Preeclampsia in the setting of chronic hypertension
- Complicates pregnancy in up to 25% of women with chronic hypertension
- Risk factors:
- African American
- Antihypertensive medication use
- Chronic hypertension
- Systolic BP (SBP) >140 or diastolic BP (DBP) >90
- Measured twice prior to 20 wk gestation or lasting >12 wk after delivery
Etiology
- Preeclampsia
- Incomplete placental implantation and underperfusion
- Leads to decreased angiogenic growth factor and increased maternal placental debris in circulation
- Eclampsia
- 1/3 of patients with eclampsia did not have hypertension prior to seizure
- Risk factors:
- 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 eclampsia
- Nulliparity
- Maternal age
- GH
Diagnosis
- GH
- Normotensive prior to 20 wk gestation
- SBP >140 or DBP >90 on 2 separate measurements
- Severe: SBP >160 and DBP >110
- Preeclampsia
- GH and proteinuria
- 300 mg protein on 24 hr urine
- 1+ protein on urinalysis
- Mild:
- SBP <160 mm Hg or
- DBP <110 mm Hg
- Normal platelets
- Normal liver function tests
- No cerebral symptoms
- Severe:
- 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
- HELLP Syndrome
- Hemolysis
- Elevated liver enzyme
- Low platelets
- May present with:
- Pulmonary edema
- Renal failure
- Liver failure
- Sepsis
- Pulmonary disease
- Stroke
Signs and Symptoms
History
- History of preeclampsia
- Parity
- Weight gain
- Leg swelling
- Abdominal pain
- Nausea/vomiting
- Shortness of breath
- Headache
- Visual changes
- Jaundice
- Stroke symptoms
Physical Exam
- Check serial BP
- Palpate abdomen carefully, especially RUQ
- Assess extremities for edema
- Perform neurologic exam:
- 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
Lab
- Urinalysis:
- Protein >1+ correlates to 30 mg/dL
- >1+ requires 24 hr urine collection
- Urine sediment for RBC, WBC, casts
- CBC
- LFTs
- BUN/creatinine
- Uric acid
- LDH
- d-dimer
- Fibrinogen levels
- Coagulation studies
Imaging
- US:
- Gestational age
- Fetal viability/distress
- Oligohydramnios
- Fetal monitoring, nonstress test
- Head CT: Rule out mass or hemorrhage
Diagnostic Procedures/Surgery
- Lumbar puncture: Rule out infection or subarachnoid hemorrhage
- Urine toxicology: Rule out substance abuse:
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 control
- Goal is to lower BP by 25% initially and then to <160/100 over subsequent hours
- Mg toxicity:
- Hypotension
- Loss of patellar reflex
- Respiratory depression
- Decreased urine output
- Elevated creatinine
- Calcium 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 spectrum
- Expectant management if <30 wk gestation
- Delivery >30 wk
- Emergent delivery for severe symptoms: Induction vs. C-section
Medication
First Line
- MgSO4: 10 g IM or 4 g IV; followed by 1 " “2 g/hr IV infusion:
- MgSO4 bolus should not exceed 1 g/min
- Serum Mg goal: 4 " “7 mEq/L
- Hydralazine: 5 " “20 mg IV
- Labetalol: 10 mg IV initially, then 5 " “10 mg increments for desired effect
Second Line
- 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
Admission Criteria
- Preeclampsia
- Eclampsia
- HELLP syndrome
- ICU, labor and delivery, OR
Discharge Criteria
- 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:
- 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:
- Edema
- Shortness of breath
- Headache
- Seizure
- Airway considerations in preeclamptic or eclamptic patients:
- 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)