Preeclampsia resident survival guide

Preeclampsia Resident Survival Guide Microchapters

Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Approach to preeclampsia , Approach to gestational hypertension with proteinuria

## Overview

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Preeclampsia is primarily defined as gestational hypertension with proteinuria 300 mg or more over a 24-hour period. The pathophysiologic abnormalities of preeclampsia include placental ischemia, generalized vasospasm, abnormal hemostasis with activation of the coagulation system, vascular endothelial dysfunction, abnormal nitric oxide and lipid metabolism, leukocyte activation and changes in various cytokines as well as in insulin resistance. It is important to identify those with high risk of developing preeclampsia during their pregnancy for better management. Maternal and fetal outcomes in preeclampsia depend on one or more of these factors: gestational age at onset of preeclampsia as well as at time of delivery, the severity of the disease process, the presence of multifetal gestation, and the presence of other preexisting medical conditions such as diabetes, renal disease, or thrombophilias. It is associated with an increased risk of placental abruption, preterm birth, fetal intrauterine growth restriction (IUGR), acute renal failure, cerebrovascular and cardiovascular complications, disseminated intravascular coagulation, and maternal death. Therefore, it is necessary to diagnose preeclampsia early.

## Causes

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The high risk factors of preeclampsia are:

* History of any hypertensive disease during a previous pregnancy.
* Maternal disease such as chronic kidney disease, autoimmune diseases, diabetes, chronic hypertension.

Women are at moderate risk if they are:

* Nulliparous
* ≥40 years of age
* Have a Body mass index (BMI) ≥ 35 kg/m [1]
* Have a family history of preeclampsia
* Have a Multifetal pregnancy
* Have a A pregnancy interval of more than 10 years[2]

Additional clinical factors associated with preeclampsia are :

* Raised mean arterial blood pressure before 15 weeks gestation[3]
* Polycystic ovarian syndrome[4][5]
* Sleep disordered breathing [6]
* Various infections such as periodontal disease,urinary tract infections[7] and helicobacter pylori[8].
* Vaginal bleeding for at least five days during pregnancy increases preeclampsia risk[3]
* Use of oocyte donation has a higher risk of preeclampsia than in vitro fertilization (IVF) without oocyte donation or natural conception.[9][10]

##### Common Causes

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Common causes of preeclampsia include uteroplacental ischemia and genetic predisposition due to the following:[11][12]

* The formation of atheromatous plaques and fibrinoid necrosis of the spiral vessel walls
* Oxidative stress in trophoblast cells
* Apoptosis in trophoblast cells
* Systemic inflammatory response
* Vasospasm
* Platelet aggregation
* Thrombin formation
* Deposition of the fibrin in multiple organs

## Diagnosis

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Shown below is an algorithm summarizing the diagnosis of Pre-eclampsia.
Abbreviations: BP: Blood pressure, RR=Respiratory rate, HR=Heart Rate, OCP= Oral Contraceptive Pill, P :Cr= Protein:Creatinine, sFlt-1= Soluble fms-like tyrosine kinase 1 , PlGF= placental growth factor, A:Cr= Albumin to Creatinine

| Pregnant woman comes with Hypertension|

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| Take complete history|

Record the vitals:

* * *

❑ Blood pressure

❑ Temperature

❑ Respiratory rate

❑ Heart rate

Take obstetric history :

* * *

❑ Date of last menstrual period?

❑ Estimated date of delivery.

❑ Confirm the gestational age, gravidity and parity.

❑ Check if this is a single or multiple gestation.

Ask about previous obstetric history if she was previously pregnant :

* * *

❑ Ask about previous pregnancies including miscarriages and terminations.

❑ Length of gestation.

❑ Ask about mode of delivery.

❑ Ask if there was similar complaints during previous pregnancy?

❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

Ask the following questions about menstrual history :

* * *

❑ Age of menarche

❑ Last menstrual period

❑ Is the menstrual flow normal? How many pads she has to use in a day?

❑ Is there any foul smell or colour change?

❑ How many days does the menstruation stay?

❑ Contraceptive history for example oral contraceptives, intrauterine device

See if following factors are present:

* * *

❑ History of hypertension

❑ Kidney disease

❑ Diabetes

❑ Hypertension with a previous pregnancy

❑ Mother's age younger than 20 or older than 40

❑ Multiple fetuses (twins, triplets)

❑ African-American race

Do the following laboratory tests [1]:

* * *

❑ Dipstick testing

❑ If dipstick test is positive (one protein or more), the use of either spot urine albumin to creatinine (A:Cr) or protein to creatinine (P:Cr) ratios are recommended to quantify proteinuria.[2]

❑ Haemoglobin

❑ Platelet count

❑ Serum creatinine

❑ Liver enzymes

❑ Serum uric acid

❑ Use of PlGF or sFlt-1:PlGF ratio to help rule out preeclampsia in women between 20 and 34 + 6 weeks of gestation in whom preeclampsia is suspected.[13]

❑ Ultrasound assessment of fetal growth and umbilical artery doppler velocimetry or cerebroplacental ratio measurements to assess blood flow redistribution in placental insufficiency.

PRE-ECLAMPSIA: Preeclampsia is defined as Gestational Hypertension associated with new-onset maternal or uteroplacental dysfunction at or after 20 Weeks of Gestation

* * *

❑ Gestational Hypertension : Blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart.[14]

Accompanied by at ≥1 of the following new-onset conditions[15]:

❑ Proteinuria: Automated dipstick urinalysis should be done. If not available, visual analysis can be used. If dipstick is positive (≥1+), confirmation is done with spot urine.
Abnormal if Protein:Creatinine ≥ 30 mg/mmol or Albumin:Creatinine ≥ 8 mg/mmol.[16][17]

❑ Renal complication: Acute Kidney Injury (creatinine ≥ 90 umol/L).

❑ Liver complications: Elevated transaminases, may be associated with right upper quadrant of epigastric abdominal pain.

❑ Neurological complications: Eclampsia, altered mental status, blindness, stroke, clonus, severe and persistent visual scotomata.

❑ Haematological complications: Thrombocytopenia (platelet count < 150000/µL, disseminated intravascular coagulation, hemolysis).

❑ Uteroplacental dysfunction: Fetal growth restriction, abnormal umbilical artery doppler wave form analysis, stillbirth.

## Treatment

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Shown below is an algorithm summarizing the treatment of mild hypertension and preeclampsia.[18]

Abbreviations: IV: Intravenous, IM= Intramuscular, IUGR= intrauterine growth restriction

| Woman with mild hypertension and preeclampsia[19]

Characterized by the following:

❑ Blood pressure of 140/90 or above

❑ Swelling, particularly of the arms, hands, or face that is reflected in greater than expected weight gain, which is a result of retaining fluid. (Swelling in the ankle area is considered normal during pregnancy.)

❑ Protein in the urine. Although uncommon, a woman can have preeclampsia without protein in the urine.

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| Evaluate maternal and fetal condition

❑ ≥40 weeks of gestation.

❑ ≥ 37 weeks of gestation, Bishop score ≥ 6, non-complaint patient.

❑ ≥34 weeks gestation, labor or rupture of membranes, abnormal fetal testing, intrauterine growth restriction.

| Yes|

| Delivery|

| No|

| ↑|

| <37 weeks|

| 37-39 weeks|

| →|

| Prostaglandin|

❑ Fetal and maternal monitoring on a regular basis.
❑ Inpatient and outpatient management.

| ↑|

❑ Worsening fetal and maternal condition.
❑ ≥40 weeks of gestation
❑ Bishop score ≥ 6 at ≥ 37 weeks of gestation.
❑ Labor

| →|

| |

Shown below is an algorithm summarizing the treatment of severe preeclampsia.[18][19]

| Woman with severe pre eclampsia[19]

Characterized by:

❑ Blood pressure of 160/110 mmHg or higher in more than one reading separated by at least six hours.

❑ Proteinuria

❑ Blood pressure of 140/90 mmHg or higher.

❑ Symptoms or signs of ongoing damage to internal organs, such as: Severe headache, changes in vision, reduced urine output, abdominal pain, fluid in the lungs and pelvic pain.

❑ Signs of the "HELLP" syndrome, which means the liver and blood-clotting systems are not functioning properly. HELLP stands for Hemolysis (damaged red blood cells), Elevated Liver enzymes (indicating ongoing liver cell damage) and Low Platelets that help the blood to clot. It occurs in about 10% of patients with severe preeclampsia.

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❑ Admit to the labor and delivery unit.

❑ Evaluate maternal and fetal condition for 24 hours.

❑ Administer Magnesium sulphate X 24 hours.

❑ Anti-hypertensives if systolic blood pressure ≥ 160mm Hg, diastolic blood pressure ≥110 mmHg and meant aretrial blood pressure ≥125 mmHg.

Check if following are present:

\

❑ Maternal distress

❑ Non-reassuring fetal status.

❑ Labor or rupture of membranes.

❑ >34 weeks of gestation.

| Yes|

| No|

❑ Magnesium Sulphate

❑ Delivery.

| ↑|

| Severe intrauterine growth restriction|

| Yes|

| No|

| ←|

| Steroids|

| ↑|

| ←|

| 33-34 weeks of gestation|

| 23-32 weeks of gestation|

| <23 weeks of gestation|

❑ Steroids at 24-32 weeks

❑ Anti-hypertensives if required.

❑ Daily maternal and fetal evaluation.

❑ Delivery at 34 weeks.

| termination of pregnancy |

Drugs for urgent controlling of hypertension in preeclampsia[20] | Dose | Specific considration | Onset of action

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Labetalol | ❑ 10–20 mg IV

❑ Then 20–80 mg every 10–30 minutes upto a maximum dosage of 300 mg;or infusion 1–2 mg/min IV

| Contraindications:

* Asthma
* Decompensated heart failure,
* Heart block
* Bradycardia

| 1-2 minutes
Hydralazine | ❑ 5 mg IV or IM

❑ Then 5–10 mg IV every 20–40 minutes upto a maximum dosage of 200 mg or keeping infusion of 0.5–10 mg/hr. | Side effects in higher dosage:

* maternal hypotension
* Headaches
* Abnormal fetal heart rate tracings

| 10-20 minutes
Nifedipine | ❑ 10–20 mg orally, repeat in 20 minutes if needed .

❑ Then 10–20 mg every 2–6 hours, maximum daily dose is 180 mg. | Side effect:

* Reflex tachycardia
* Headache

| 5-10 minutes

## Dos

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* Patient should start low-dose aspirin if she has two or more moderate risk factors.
* If a woman had preeclampsia during a previous pregnancy, the patient should maintain a healthy weight and make sure other conditions such as diabetes, are well managed before getting pregnant.
* Once a woman is pregnant with history of previous preeclampsia, the patient should complete early and regular prenatal care visits.
* If a pregnant woman has swelling, severe headache, changes in vision or other symptoms of preeclampsia, she should contact the doctor immediately.
* It is important to start leading a healthy lifestyle which includes maintaining a healthy weight, exercising regularly, eating a well-balanced diet, not smoking or not using alcohol.

## Don'ts

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* It's important that a pregnant woman does not take any medications, vitamins or supplements without first talking to her doctor.

## References

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1. ↑ 1.0 1.1 Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, Hall DR, Warren CE, Adoyi G, Ishaku S (July 2018). "Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice". Hypertension. 72 (1): 24–43. doi:10.1161/HYPERTENSIONAHA.117.10803. PMID 29899139.
2. ↑ 2.0 2.1 "Overview | Hypertension in pregnancy: diagnosis and management | Guidance | NICE".
3. ↑ 3.0 3.1 North RA, McCowan LM, Dekker GA, Poston L, Chan EH, Stewart AW, Black MA, Taylor RS, Walker JJ, Baker PN, Kenny LC (April 2011). "Clinical risk prediction for pre-eclampsia in nulliparous women: development of model in international prospective cohort". BMJ. 342: d1875. doi:10.1136/bmj.d1875. PMC 3072235. PMID 21474517.
4. ↑ Bahri Khomami M, Joham AE, Boyle JA, Piltonen T, Silagy M, Arora C, Misso ML, Teede HJ, Moran LJ (May 2019). "Increased maternal pregnancy complications in polycystic ovary syndrome appear to be independent of obesity-A systematic review, meta-analysis, and meta-regression". Obes Rev. 20 (5): 659–674. doi:10.1111/obr.12829. PMID 30674081.
5. ↑ Qin JZ, Pang LH, Li MJ, Fan XJ, Huang RD, Chen HY (June 2013). "Obstetric complications in women with polycystic ovary syndrome: a systematic review and meta-analysis". Reprod Biol Endocrinol. 11: 56. doi:10.1186/1477-7827-11-56. PMC 3737012. PMID 23800002.
6. ↑ Pamidi S, Pinto LM, Marc I, Benedetti A, Schwartzman K, Kimoff RJ (January 2014). "Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis". Am J Obstet Gynecol. 210 (1): 52.e1–52.e14. doi:10.1016/j.ajog.2013.07.033. PMID 23911687.
7. ↑ Rustveld LO, Kelsey SF, Sharma R (March 2008). "Association between maternal infections and preeclampsia: a systematic review of epidemiologic studies". Matern Child Health J. 12 (2): 223–42. doi:10.1007/s10995-007-0224-1. PMID 17577649.
8. ↑ Bellos I, Daskalakis G, Pergialiotis V (February 2018). "Helicobacter pylori infection increases the risk of developing preeclampsia: A meta-analysis of observational studies". Int J Clin Pract. 72 (2). doi:10.1111/ijcp.13064. PMID 29388723.
9. ↑ Blázquez A, García D, Rodríguez A, Vassena R, Figueras F, Vernaeve V (July 2016). "Is oocyte donation a risk factor for preeclampsia? A systematic review and meta-analysis". J Assist Reprod Genet. 33 (7): 855–63. doi:10.1007/s10815-016-0701-9. PMC 4930777. PMID 27007875.
10. ↑ Masoudian P, Nasr A, de Nanassy J, Fung-Kee-Fung K, Bainbridge SA, El Demellawy D (March 2016). "Oocyte donation pregnancies and the risk of preeclampsia or gestational hypertension: a systematic review and metaanalysis". Am J Obstet Gynecol. 214 (3): 328–39. doi:10.1016/j.ajog.2015.11.020. PMID 26627731.
11. ↑ Lye, P.; Bloise, E.; Dunk, C.; Javam, M.; Gibb, W.; Lye, S.J.; Matthews, S.G. (2013). "Effect of oxygen on multidrug resistance in the first trimester human placenta". Placenta. 34 (9): 817–823. doi:10.1016/j.placenta.2013.05.010. ISSN 0143-4004.
12. ↑ Mayrink, J.; Costa, M. L.; Cecatti, J. G. (2018). "Preeclampsia in 2018: Revisiting Concepts, Physiopathology, and Prediction". The Scientific World Journal. 2018: 1–9. doi:10.1155/2018/6268276. ISSN 2356-6140.
13. ↑ Zeisler H, Llurba E, Chantraine F, Vatish M, Staff AC, Sennström M, Olovsson M, Brennecke SP, Stepan H, Allegranza D, Dilba P, Schoedl M, Hund M, Verlohren S (January 2016). "Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia". N Engl J Med. 374 (1): 13–22. doi:10.1056/NEJMoa1414838. PMID 26735990.
14. ↑ Lo JO, Mission JF, Caughey AB (April 2013). "Hypertensive disease of pregnancy and maternal mortality". Curr Opin Obstet Gynecol. 25 (2): 124–32. doi:10.1097/GCO.0b013e32835e0ef5. PMID 23403779.
15. ↑ Fox R, Kitt J, Leeson P, Aye C, Lewandowski AJ (October 2019). "Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring". J Clin Med. 8 (10). doi:10.3390/jcm8101625. PMC 6832549 Check `|pmc=` value (help). PMID 31590294. Vancouver style error: initials (help)
16. ↑ Price CP, Newall RG, Boyd JC (September 2005). "Use of protein:creatinine ratio measurements on random urine samples for prediction of significant proteinuria: a systematic review". Clin Chem. 51 (9): 1577–86. doi:10.1373/clinchem.2005.049742. PMID 16020501.
17. ↑ Kucukgoz Gulec U, Sucu M, Ozgunen FT, Buyukkurt S, Guzel AB, Paydas S (October 2017). "Spot Urine Protein-to-Creatinine Ratio to Predict the Magnitude of 24-Hour Total Proteinuria in Preeclampsia of Varying Severity". J Obstet Gynaecol Can. 39 (10): 854–860. doi:10.1016/j.jogc.2017.04.035. PMID 28647444.
18. ↑ 18.0 18.1 "pqcnc-documents.s3.amazonaws.com" (PDF).
19. ↑ 19.0 19.1 19.2 "Preeclampsia And Eclampsia - Harvard Health".
20. ↑ "Gestational Hypertension and Preeclampsia". Obstetrics & Gynecology. 135 (6): e237–e260. 2020. doi:10.1097/AOG.0000000000003891. ISSN 0029-7844.

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