INDEX

    Preeclampsia, Eclampsia & HELLP – Diagnosis

    Cardiovascular, Obstetrics and Gynecology, Special Populations

    Last Updated Feb 18, 2020
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    Context

    • Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm.
      • Occurs > 20 weeks gestation and up to 6 weeks post partum.
      • Most often onset is close to term, while earlier presentations are more severe.
      • Preeclampsia = new onset hypertension with proteinuria (most often) or organ dysfunction.
      • Preeclampsia with severe features = preeclampsia complicated by severe hypertension or organ dysfunction.
    • Eclampsia = preeclampsia with new onset of seizures or coma.
    • HELLP Syndrome = severe pre-eclampsia variant defined by hemolysis, elevated liver enzymes and low platelet count.
    • Worldwide approximately 4.6% of pregnancies are complicated by preeclampsia.
    • Preeclampsia is a leading cause of maternal and fetal mortality and morbidity.
      • Maternal: seizures (eclampsia), stroke, liver dysfunction, pulmonary edema, renal failure, placental abruption.
      • Fetal: stillbirth, preterm or small for gestational age.
    • Risk factors: diabetes, hypertension, kidney disease, obesity, prior preeclampsia, nulliparity, multifetal pregnancy, autoimmune disease, maternal age <20 or >35 yrs.
    • Presentations: headache, visual disturbances, chest pain, shortness of breath, abdominal pain, nausea/vomiting, or acute edema of face, hands or lower extremities.

    Require admission, discharge at obstetrical direction.

    Diagnostic Process

    Criteria

     

    Preeclampsia

    • Previously normotensive women after 20 weeks gestation, now with:
      • Systolic pressure ⩾140 mmHg or diastolic pressure ⩾90 mmHg, and proteinuria
      • Systolic pressure ⩾140 mmHg or diastolic pressure ⩾90 mmHg, and end organ dysfunction
    • Superimposed Preeclampsia = new onset/worsening of hypertension, proteinuria or end organ dysfunction in patients with preexisting hypertension and/or proteinuria
    • Proteinuria:
      • Urine Dipstick ⩾2+ Protein
      • Confirmation tests (not ED issue):
        • Protein:Creatinine ratio ⩾3omg/mmol
        • Proteinuria ⩾0.3g/d in a 24-hour urine collection
    • End organ dysfunction:
      • Thrombocytopenia: Platelet count <100,000/µL
      • Serum creatinine > 97.2 µmol/L or doubling, in the absence of other renal disease.
      • Liver transaminases 2X upper limit of the normal
      • Pulmonary edema
      • CNS:
        • Altered mental status
        • Visual changes
        • Hyperreflexia
        • Clonus
      • FHR abnormality

     

    Preeclampsia with Severe Features

    • Preeclampsia with ⩾ 160mmHg Systolic or ⩾110mmHg Diastolic, or if any end organ features are present.

     

    HELLP Syndrome

    • Variant of preeclampsia
    • NB: hypertension and proteinuria NOT required for diagnosis, although they are present in approximately 85% cases
    • Diagnosis requires all of:
    1. Hemolysis: LDH ⩾600 IU/L
    2. Elevated Liver Enzymes – AST or ALT > 2X upper limit of normal
    3. Low Platelets – Platelet count <100,000/µL
    4. Hemolysis can also be established by at least two of:
    • Peripheral smear with schistocytes and burr cells
    • Serum bilirubin ⩾52 µmol/L
    • Low serum haptoglobin (<25 mg/dL) or LDH ⩾2 times the upper limit
    • Severe anemia without hemorrhage

     

    Eclampsia

    • Preeclampsia with generalized tonic-clonic seizures, without other cause (epilepsy or drug use), or coma.

     

    Clinical Findings

    • Hypertension
    • Persistent or severe headache
    • CNS:
      • Altered mental status
      • Visual changes (blurred, scotoma, diplopia, loss of vision, visual field defects)
      • Hyperreflexia
      • Clonus
    • GU: RUQ/epigastric pain/tenderness
    • Pulmonary: pulmonary edema, O2 desaturation
    • Peripheral edema
    • Decreased Fetal movement

     

    Recommended Investigations:

    • Urinalysis: protein determination
    • Complete blood count + Peripheral blood smear
    • Haptoglobin level
    • Electrolytes
    • BUN, creatinine
    • LDH, AST, ALT, bilirubin,
    • INR, PTT, (fibrinogen if severe features present)
    • Neuroimaging – if focal neurologic signs/symptoms

    Assess fetal well-being: maternal perception of fetal movement, establish fetal heart rate (doppler or bedside ultrasound).

     

    Quality Of Evidence?

    Justification

    Most resources are consensus guidelines set out by various organizations.

    Moderate

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