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Preeclampsia, Eclampsia & HELLP – Diagnosis
Cardiovascular, Obstetrics and Gynecology, Special Populations
- 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.
- 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
- 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
- Altered mental status
- Visual changes
- FHR abnormality
Preeclampsia with Severe Features
- Preeclampsia with ⩾ 160mmHg Systolic or ⩾110mmHg Diastolic, or if any end organ features are present.
- Variant of preeclampsia
- NB: hypertension and proteinuria NOT required for diagnosis, although they are present in approximately 85% cases
- Diagnosis requires all of:
- Hemolysis: LDH ⩾600 IU/L
- Elevated Liver Enzymes – AST or ALT > 2X upper limit of normal
- Low Platelets – Platelet count <100,000/µL
- 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
- Preeclampsia with generalized tonic-clonic seizures, without other cause (epilepsy or drug use), or coma.
- Persistent or severe headache
- Altered mental status
- Visual changes (blurred, scotoma, diplopia, loss of vision, visual field defects)
- GU: RUQ/epigastric pain/tenderness
- Pulmonary: pulmonary edema, O2 desaturation
- Peripheral edema
- Decreased Fetal movement
- Urinalysis: protein determination
- Complete blood count + Peripheral blood smear
- Haptoglobin level
- 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).
Diagnostic evaluation of a pregnany or postpartum woman with persistent systolic blood pressure > 140mmHG or diastolic blood pressure >90 mmHG
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Most resources are consensus guidelines set out by various organizations.
Milne, F., & Philip, N. (2010). Identification, diagnosis, and management of suspected preeclampsia. In A. Heazell, E. Norwitz, L. Kenny, & P. Baker (Authors), Hypertension in Pregnancy (Cambridge Clinical Guides, pp. 109-124). Cambridge: Cambridge University Press. doi:10.1017/CBO9780511902529.010
Magee, L. A., Helewa, M., Moutquin, J. M., Von Dadelszen, P., & Hypertension Guideline Committee. (2008). Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Journal of Obstetrics and Gynaecology Canada, 30(3 Supplement 1), S1-48.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Feb 04, 2020
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