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2/1/2018

Evaluation of Preeclampsia at Term

Gravidas at term (≥37 weeks) with new-onset/worsening hypertension or symptoms suggesting end organ effects, such as persistent headache, visual changes, right upper quadrant or epigastric pain, should be evaluated for preeclampsia.  Preeclampsia (with or without severe features) at term requires hospital admission for management and delivery at time of diagnosis

Preeclampsia diagnosis includes elevated blood pressures (SBP ≥140 or DBP ≥90) on two occasions separated by ≥4 hours. If severe hypertension is present (SBP ≥160 or DBP ≥110), the diagnosis can be confirmed after a shortened interval (e.g. 15 minutes) to expedite initiation of anti-hypertensive therapy. Severe BP elevation raises risk for hemorrhagic stroke, placental abruption, and both maternal and fetal death. Optimal BP measurement is taken with the patient seated , legs uncrossed, relaxed, not talking, and arm supported so the cuff is at the level of the heart. 

In addition to BP criteria, diagnosis is supported by laboratory findings of proteinuria or one of the following: thrombocytopenia, renal insufficiency, impaired liver function. Clinical findings of pulmonary edema, or cerebral or visual symptoms are additionally supportive. Proteinuria is defined as either ≥300 mg/24-hour urine collection, the equivalent amount extrapolated from a timed collection, or spot urine protein/creatinine ratio ≥0.3. Thrombocytopenia is defined as platelets <100,000/microliter. Renal insufficiency is defined as creatinine >1.1 mg/dL or a doubling from baseline in the absence of other renal disease. Impaired liver function is diagnosed when transaminases are greater than or equal to twice normal. Other blood tests have been suggested, such as lactate dehydrogenase or uric acid, but are not required or diagnostic and are used mainly for monitoring disease progression while patient is still pregnant and resolution in postpartum period.

Rapid identification of pre-eclampsia with severe features allows initiation of magnesium sulfate for maternal seizure prevention. Severe features include both clinical (e.g. new-onset cerebral or visual disturbances, pulmonary edema) and objective findings (e.g. severe hypertension, thrombocytopenia, impaired liver function, and progressive renal insufficiency).

Superimposed preeclampsia complicates about 20% of pregnancies in women with pre-existing hypertension and is associated with increased maternal and perinatal morbidity compared with preeclampsia alone. The diagnosis of superimposed preeclampsia is based on the new development of thrombocytopenia, liver dysfunction, renal insufficiency, or symptoms suggestive of preeclampsia as well as sudden difficulty in maintaining normal blood pressure ranges on previously effective medication.

Fetal well-being should be ascertained by routine antenatal testing,

Initial evaluation for pre-eclampsia includes:

1. Blood pressure
2. Clinical evaluation with review of symptoms
3. Laboratory tests for proteinuria, CBC with platelets, creatinine, AST, and ALT
4. Assessment of fetal wellbeing with antenatal testing

Initial management includes:

1. Delivery with mode determined by fetal presentation, and usual maternal/fetal obstetric considerations
2. Anti-hypertensive therapy for severe hypertension
3. magnesium for seizure prophylaxis for preeclampsia with severe features

BP monitoring should continue for at least 72 hours postpartum, and again 7-10 days postpartum, or earlier if symptoms are present.  Blood pressure monitoring should continue until the patient is confirmed to be normotensive or the diagnosis of chronic hypertension is confirmed.

Further Reading:

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260. doi: 10.1097/AOG.0000000000003891. PMID: 32443079.

ACOG Committee Opinion No. 767: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2019 Feb;133(2):e174-e180. doi: 10.1097/AOG.0000000000003075. PMID: 30575639.

Kametas NA, Nzelu D, Nicolaides KH. Chronic hypertension and superimposed preeclampsia: screening and diagnosis. Am J Obstet Gynecol. 2022 Feb;226(2S):S1182-S1195. doi: 10.1016/j.ajog.2020.11.029. Epub 2021 Jun 17. PMID: 35177217.

Initial approval November 2017, Reaffirmed May 2019; Revised January 2021; Revised July 2022

 

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