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Evaluation of Preeclampsia at Term

Author: Cynthie K. Anderson, MD, MPH

Mentor: Tony Ogburn, MD
Editor: Natalie Bowersox, MD

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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 the 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 for monitoring disease progression while the patient is still pregnant.

Rapid identification of preeclampsia 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, severe or persistent RUQ or epigastric pain, pulmonary edema; or new-onset headache unresponsive to acetaminophen and not accounted for by alternative diagnoses or visual disturbances, 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, 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 (about 3 days) 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. (Reaffirmed 2023) 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; Revised May 2024.


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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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