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Updated: May 2 2022

Preeclampsia / Eclampsia / HELLP Syndrome

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  • Snapshot
    • A 36-year-old woman at 34 weeks gestation presents to the emergency room for abdominal pain and headaches. She reports noticing these symptoms last night but attributed it to eating some take-out last night. On physical exam, she has tenderness to palpation in the epigastrium. Her blood pressure is 166/115 mmHg. She begins having tonic-clonic seizures. She is immediately prepped for delivery via cesarean section and started on anti-seizure medications. (Eclampsia)
  • Introduction
    • Overview
      • hypertension during pregnancy can be chronic hypertension, gestational hypertension, preeclamspia, or eclampsia
      • some consider HELLP syndrome to be a form of preeclampsia/eclampsia although this is controversial
    • Diagnosis of preeclampsia
      • hypertension (> 140/90 mmHg on 2 separate occasions, or 160/110 mmHg) and proteinuria
      • can also be diagnosed without proteinuria if one of the following signs of severe preeclampsia
        • blood pressure >160/110
        • hepatic dysfunction
        • renal insufficiency
        • visual/cerebral disturbances
        • pulmonary edema
        • thrombocytopenia
      • Spectrum of Hypertensive Disorders in Pregnancy
      • Chronic Hypertension
      • Gestational Hypertension
      • Preeclampsia
      • History of hypertension(> 140/90 mmgHg) before pregnancy or before 20 weeks of gestation
      • Hypertension persists after delivery
      • Hypertension after 20 weeks of gestation
      • Hypertension returns to baseline by 6 weeks post-partum
      • Common in multiple gestations
      • Hypertension (> 140/90 mmHg on 2 separate occasions, or >160/110 mmHg) plus proteinuria
      • Preeclampsia plus seizures
      • Hemolysis
      • Elevated
      • Liver enzymes
      • Low Platelets
    • Epidemiology
      • incidence
        • preeclampsia/eclampsia
          • 2-6%
        • HELLP syndrome
          • 0.1-0.6%
      • risk factors
        • preeclampsia/eclampsia
          • nulliparity
          • multiple gestations
          • hyatidiform mole
          • diabetes
          • chronic hypertension
          • chronic renal disease
        • HELLP syndrome
          • maternal age > 34 years
          • multiparity
          • Caucasian/European descent
    • Pathogenesis
      • mechanism
        • preeclampsia/eclampsia
          • impaired vasodilation of spiral arteries cause placental ischemia
          • this results in increased vascular tone, increased vasoconstriction, and decreased vasodilation
          • other factors considered to contribute include maternal immunologic intolerance, inflammatory changes, and abnormal placental implantation
          • vasospasm of the renal arteries can lead to acute renal failure
        • HELLP syndrome
          • thought to be due to endothelial activation, consumption of platelets, microangiopathic hemolysis, and microvascular injury
          • complement dysfunction may also play a role
    • Prognosis
      • preeclampsia/eclampsia
        • maternal mortality 14%
      • HELLP syndrome
        • maternal mortality 1-3%
      • most resolve after delivery
  • Presentation
    • Symptoms
      • there is often overlap between preeclampsia/eclampsia and HELLP syndrome
      • common symptoms
        • headache
        • epigastric or right upper quadrant pain
        • visual changes
        • pulmonary edema
        • oliguria
        • water retention
    • Physical exam
      • inspection
        • hypertension > 140/90 mmHg
        • tonic-clonic seizures
        • hyperreflexia
        • periorbital and extremity edema
        • altered mental status
        • jaundice
  • Studies
    • Serum labs
      • proteinuria
        • 1-2+ on dipstick
        • > 300 mg on 24-hour urine
        • protein/creatinine ratio > 0.3
          • best confirmatory test is a spot urine protein to creatinine ratio
      • thrombocytopenia
      • hemoconcentration
      • elevated liver enzymes in HELLP syndrome
      • hemolysis in HELLP syndrome
        • elevated lactate dehydrogenase
        • elevated bilirubin
        • hemolysis on peripheral smear
        • schistocytes, helmet cells, or burr cells
  • Differential
    • Acute fatty liver of pregnancy
      • key distinguishing factor
        • characterized primarily with fulminant liver failure
  • Treatment
    • Medical
      • antihypertensive medication
        • indications
          • preeclampsia/eclampsia and HELLP syndrome
          • blood pressure > 160/100 mmHg
            • risk of decreased utero-placental blood flow
        • drugs
          • labetalol
          • methyldopa
          • hydralazine
      • intravenous steroids
        • indications
          • thrombocytopenia
          • HELLP syndrome
      • intravenous magnesium sulfate or diazepam
        • indications
          • seizure prophylaxis and treatment
          • preeclampsia/eclampsia and HELLP syndrome
        • magnesium toxicity can occur
          • hyporeflexia presents before bradypnea
          • treatment
            • calcium gluconate
    • Surgical
      • delivery
        • indications
          • the only definitive treatment
          • if mild preeclampsia or stable with HELLP syndrome, can monitor for progression
          • if severe preeclampsia, eclampsia, or unstable, deliver immediately
  • Complications
    • Complications
      • preeclampsia/eclampsia
        • maternal cerebral hemorrhage
        • disseminated intravascular coagulopathy
        • acute respiratory distress syndrome
        • abruptio placentae
        • recurrence of preeclampsia
      • HELLP syndrome
        • maternal complications
          • cerebral hemorrhage
          • disseminated intravascular coagulopathy
          • acute renal failure
          • hepatic rupture
          • risk of recurrence in subsequent pregnancies
          • increased risk of preeclampsia, preterm delivery, and placental abruption
        • neonatal complications
          • prematurity
          • intrauterine growth retardation
          • fetal demise
        • other complications
          • increased risk of cardiovascular disease
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