Updated: 1/21/2020

Preeclampsia / Eclampsia / HELLP Syndrome

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
5 5
0
0
0%
0%
Evidence
3 3
0
0
0%
0%
Videos
1 1
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
 

Please rate topic.

Average 4.5 of 13 Ratings

Questions (5)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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? Tested Concept

QID: 108692
FIGURES:
1

Eclampsia.

9%

(9/101)

2

HELLP Syndrome.

80%

(81/101)

3

Gestational Hypertension

5%

(5/101)

4

Hepatorenal syndrome.

3%

(3/101)

5

Normal pregnancy.

3%

(3/101)

M 2 C

Select Answer to see Preferred Response

(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: Tested Concept

QID: 100502
1

Urethral infection

4%

(7/185)

2

Thrombocytosis

23%

(43/185)

3

Hemolysis

55%

(102/185)

4

Gestational diabetes

7%

(13/185)

5

Placenta accreta

7%

(13/185)

M 4 D

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (3)
VIDEOS (1)
Topic COMMENTS (6)
Private Note