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Everything You Need to Know About Preeclampsia


Preeclampsia is a disease of pregnancy that causes blood pressure changes and potentially damage to other organs due to a defect in the lining of the arteries. In the most severe form, called eclampsia, a seizure occurs. One out of 200 women have a seizure if magnesium is not administered.

The incidence of preeclampsia in the US ranges from two to six percent in healthy, nulliparous (first baby) women. Worldwide, the rate is five to 14%. It usually occurs after 34 weeks of pregnancy, 90% of the time.

Classification of hypertensive disorders in pregnancy

Preeclampsia is one type of blood pressure problem in pregnancy. The National High Blood Pressure Education Program (NHBPEP) Working Group lists them as follows:

  • Chronic hypertension
  • Gestational hypertension
  • Preeclampsia/eclampsia
  • Superimposed preeclampsia (on chronic hypertension)

What causes preeclampsia?

The exact cause or mechanisms that result in preeclampsia is unknown but numerous maternal, paternal, placental, genetic, nutritional, cardiovascular, immune factors and fetal factors have been implicated. Women who have preeclampsia have an increased risk of cardiovascular problems later in life especially if they are obese, have elevated lipids (cholesterol), insulin resistance or diabetes.

Definition of preeclampsia

Preeclampsia is defined as:

  • A systolic blood pressure (SBP) greater than or equal to 140 mm Hg or a diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or higher, on two occasions at least 4 hours apart in a woman who did not have a blood pressure problem, or
  • An SBP greater than or equal to 160 mm Hg or a DBP greater than or equal to 110 mm Hg or higher.

The kidneys are the first to be affected by preeclampsia and results in protein spilling into the urine. If it is greater than or equal to 0.3 grams or 300 milligrams in a 24-hour urine specimen or a urine dipstick protein of 1+, then the diagnosis can be made. Preeclampsia is considered mild or severe.

Preeclampsia with severe features have at least of one of the following symptoms or signs:

  • Systolic BP of 160 mm Hg or higher or Diastolic BP of 110 mm Hg or higher, on two occasions at least four hours apart while the patient is resting in bed on her left side.
  • Abnormal liver function or severe mid or right upper quadrant pain that does not respond to medications or cannot be explained any other way.
  • Progressive kidney damage.
  • New-onset headache or visual disturbances.
  • Pulmonary edema (fluid in the lungs).
  • Low platelet count.

If there is no protein in the urine but the patient has new onset high blood pressure, then one of the following signs or symptoms would indicate preeclampsia:

  • Low platelet count.
  • Serum creatinine level above 1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease.
  • Liver enzymes levels at least twice the normal levels.
  • Pulmonary edema (fluid in the lungs).
  • Cerebral or visual symptoms

HELLP Syndrome is a unique form of severe preeclampsia that stands for Hemolysis (abnormal red blood cell breakdown), Elevated Liver enzymes, Low Platelets.

Risk factors for preeclampsia

Risk factors for preeclampsia are:

  • First time pregnant or nulliparity
  • Twins or more gestations
  • Preeclampsia in a previous pregnancy
  • Platelet disorders
  • Chronic hypertension
  • Pregestational diabetes
  • Gestational diabetes
  • Systemic lupus erythematosus
  • Antiphospholipid antibody syndrome
  • Pre-pregnancy body mass index (BMI) greater than 30
  • Age 35 years or older
  • Kidney disease
  • Assisted reproductive technology
  • Obstructive sleep apnea

Signs and symptoms of preeclampsia

Preeclampsia without severe features may have no symptoms but are picked up during a prenatal visit since blood pressure is measured and urine is collected at each visit.

Patients with preeclampsia with severe features may have the following:

  • Headache
  • Visual disturbances: Blurred, flashing lights, blindness
  • Mental status changes such as confusion
  • Shortness of breath
  • Edema: Sudden increase in swelling or facial edema
  • Mid or right upper quadrant abdominal pain
  • Weakness or fatigue
  • Clonus: abnormal flapping of feet when flexed

How to diagnose preeclampsia

All women who present with new-onset hypertension should have the following tests:

  • Complete blood cell (CBC) count to measure platelets and to detect anemia.
  • Liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST).
  • Serum creatinine for kidney function.
  • Uric acid for kidney function.
  • Collect a 24-Hour urine for protein and creatinine or urine dipstick analysis.
  • Coagulation profile to detect if there is a clotting disorder if the platelets. are less than 100,000.

Head CT scanning to detect a brain bleed in selected patients with:

  • Sudden severe headaches
  • Isolated neurologic deficits such as vision problems or clonus
  • Seizures
  • Atypical presentation for eclampsia

Ultrasound is performed on the baby to measure its size and amniotic fluid levels.

Management of preeclampsia

Delivery of the baby is the only cure for preeclampsia. Patients with mild preeclampsia are often induced after 37 weeks' gestation. The patient is usually hospitalized and checked for worsening preeclampsia. If the baby is premature (less than 37 weeks), then steroids may be given to hasten lung maturity. If severe preeclampsia occurs after 34 weeks but before 37 weeks, induction may be considered to avoid seizures or eclampsia.

If the baby has a non-reassuring heart rate or there are ruptured membranes, then women with severe preeclampsia should be delivered via induction of labor or Cesarean section.

There are other serious features that warrant immediate delivery such as a very small baby, low amniotic fluid, uncontrollable blood pressure, placental abruption, low urine output, platelets under 100,000, shortness of breath due to fluid in the lungs, seizures, persistent headache, or the development of HELLP syndrome.

Magnesium sulfate therapy is given in all cases of severe preeclampsia to prevent seizures or to treat seizures.

Conclusion

The incidence of preeclampsia in the US ranges from two to six percent in healthy, nulliparous (first baby) women. Worldwide, the rate is five to 14%. It usually occurs after 34 weeks of pregnancy, 90% of the time. In the most severe form, called eclampsia, a seizure occurs. One out of 200 women have a seizure if magnesium is not administered.

Key takeaways

Preeclampsia is a disease of pregnancy that causes blood pressure changes and potentially damage to other organs due to a defect in the lining of the arteries.

The incidence of preeclampsia in the US ranges from two to six percent in healthy, nulliparous (first baby) women.

Delivery of the baby is the only cure for preeclampsia.

One out of 200 women have a seizure if magnesium is not administered.

References:

American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. (2013). Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol.

Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. (2020). Obstet Gynecol.

Taylor, R.N., de Groot, C.J., Cho, Y.K., et al. (1988). Circulating factors as markers and mediators of endothelial cell dysfunction in preeclampsia. Semin Reprod Endocrinol.

Sibai, B.M. (2003). Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol.

Ness, R.B., Roberts, J.M. (1996). Heterogeneous causes constituting the single syndrome of preeclampsia: a hypothesis and its implications. Am J Obstet Gynecol.

Khedun, S.M., Moodley, J., Naicker, T., et al. (1997). Drug management of hypertensive disorders of pregnancy. Pharmacol Ther.

Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. (2000). Am J Obstet Gynecol.

Livingston, J.C., Livingston, L.W., Ramsey, R., et al. (2003). Magnesium sulfate in women with mild preeclampsia: a randomized controlled trial. Obstet Gynecol.

Bellamy, L., Casas, J.P., Hingorani, A.D., et al. (2007). Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ.

Cunningham, F.G., Veno, K.J., Bloom, S.L., et al. (2010). Pregnancy Hypertension. In: Williams Obstetrics.

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