Updated: 1/21/2020

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
Eclampsia

HELLP Syndrome

  • 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
      • 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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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RP.17.4753) A 19-year-old primigravid woman at 33 weeks gestation arrives at her obstetrician's office. She complains she is feeling very tired and is sick of being pregnant. She notes that the swelling in her feet has been much worse recently. She has been having headaches and feels that her vision has been blurry today. Her blood pressure is 170/110 mmHg. Further testing is done showing serum aspartate aminotransferase of 110 U/L, serum alanine aminotransferase of 90 U/L, and 2+ protein on urine dipstick. Her peripheral blood smear is shown in Figure A. What is the most likely diagnosis for this patient? Review Topic | Tested Concept

QID: 108692
FIGURES:
1

Eclampsia.

9%

(8/92)

2

HELLP Syndrome.

82%

(75/92)

3

Gestational Hypertension

4%

(4/92)

4

Hepatorenal syndrome.

2%

(2/92)

5

Normal pregnancy.

3%

(3/92)

L 2 C

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(M1.RP.13.2) A 36-year-old primigravida woman visits her gynecologist during the 28th week of her pregnancy. Physical examination reveals pitting edema around her ankles and elevated systolic blood pressure. 24-hour urine collection yields 4 grams of protein. If left untreated, the patient is most at increased risk for which of the following: Review Topic | Tested Concept

QID: 100502
1

Urethral infection

4%

(7/180)

2

Thrombocytosis

24%

(43/180)

3

Hemolysis

54%

(97/180)

4

Gestational diabetes

7%

(13/180)

5

Placenta accreta

7%

(13/180)

L 4 D

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