Diagnosis

Preeclampsia

Etiology

Cause

• Unknown factors resulting in uteroplacental ischemia

• Endothelial dysfunction (failure of physiologic transformation of the spiral arteries)

• Endothelial injury

• Comprimised placental perfusion

• Decreased glomerular filtration

• Genetics

Pathophysiology [16t][pbz]

1. During pregnancy, trophoblast normally invade the uterus and dilate spiral arteries

2. Shallow implantation of placenta result in placental hypoperfusion:

   • Increased circulatory resistance -> placental dysfunction (fetus: ischemia) -> inflammatory mediators -> activation of coagulation (maternal symtoms)

3. Early-onset (placental) preeclampsia: placental infarcts --> defective placenta --> preeclampsia

4. Late-onset (maternal) preeclampsia: interaction between a healthy placenta and maternal factors (maternal endothelial dysfunction) --> microvascular damage

Risk factors [16t][hub]

• Old age

• Previous preeclampsia

• Diabetes

• Antiphospholipid antibodies

• Genetics

• Hypertension

• Overweight

• Kidney disease

• Multiple pregnancy

• Nullipara

• Fetal trisomy

Complication [qyu][pbz]

• Eclampsia (seizures)

• Stroke, cortical blindness, retinal blindness

• Kidney failure

• Pulmonary edema

• Acute respiratory distress syndrome

• Myocardial infarction

• HELLP syndrome (Hemolysis, Elevated liver enzymes, Low Platelets)

• Jaundice

• Disseminated intravascular coagulation

• Microangiopathic hemolysis

• Placental infarction

• Placental abruption

• Preterm birth

• Intrauterine growth retardation

• Fetal or maternal death

Epidemiology

Incidence per 100.000 [1wm][ps8][16t][qyu][vzs][fih][n9u]

Approach

• Blood pressure

• Blood test: platelet count, liver enzymes, creatinine

• Blood gas

• Urine stix: proteinuria

  • 24-hour urine collection

  • Urine protein to creatinine ratio significant ≥ 0.3

• Ultrasound abdomen

• CT caput

• Peripheral blood smear

• Umbilical artery doppler ultrasonography

Treatment

1. Surveillance: [16t][hub]

   • Maternal blood: hemoglobin, platelet count, creatinine, uric acid, ASAT or ALAT

   • Clinical monitoring: urinary output, respiratory rate, and tendon reflexes

   • Fetal: CTG, ultrasound, AFI, umbilical artery Doppler

2. Antihypertensive therapy: Severe hypertension (systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg)

   • Nifedipine 5-10 mg orally every 30 min

   • Labetalol 20 mg IV, repeat 20–80 mg IV every 30 min, or 1–2 mg/min (max 300 mg)

   • Labetalol 100 mg orally every 45 min, maximum 1200 mg/day

   • Hydralazine (5–10 mg IV) every 30 min, maximum 20 mg

3. Eclampsia with seizure [pbz]

   • MgSO4 4 g IV loading dose over 15–20 min, followed by an infusion of 1 g/h

   • Recurrent seizure(s) treated with additional 2–4 g IV loading dose(s)

   • Recurrent seizure despite MgSO4:

     • Lorazepam: 2-4 mg IV x 1, may repeat x 1 after 10-15 min

     • Diazepam: 5-10 mg IV every 5-10 min to max dose 30 mg

     • Phenytoin: 15-20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 min

     • Levetiracetam: 500 mg IV or orally, may repeat in 12 hours

4. The definitive treatment of preeclampsia is the delivery of the fetus

Differential diagnoses

Acute pancreatitis, Antiphospholipid syndrome, Aortic coarctation, Brain tumor, Cardiomyopathy, Cholangitis, Cholecystitis, Chronic renal failure, Cushings disease, Epilepsy, Essential hypertension, Gastritis, Gastroesophageal reflux disease, Glomerulonephritis, Hemolytic uremic syndrome, Hyperaldosteronism, Immune thrombocytopenic purpura, Myocardial infarction, Nonalcoholic fatty liver disease, Pheochromocytoma, Pneumonia, Pulmonary embolism, Pyelonephritis, Renal failure, Retinal artery occlusion, Retinal detachment, Sepsis, Shock, Stroke, Systemic lupus erythematosus, Thrombotic thrombocytopenic purpura, Thyrotoxicosis, Ulcer disease, Viral hepatitis