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 login to view 1 more bullet HELLP syndrome login to view 1 more bullet risk factors preeclampsia/eclampsia login to view 6 more bullets HELLP syndrome login to view 3 more bullets Pathogenesis mechanism preeclampsia/eclampsia login to view 4 more bullets HELLP syndrome login to view 2 more bullets 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 login to view 1 more bullet 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 login to view 3 more bullets drugs login to view 3 more bullets intravenous steroids indications login to view 2 more bullets intravenous magnesium sulfate or diazepam indications login to view 2 more bullets magnesium toxicity can occur login to view 3 more bullets Surgical delivery indications login to view 3 more bullets Complications Complications preeclampsia/eclampsia maternal cerebral hemorrhage disseminated intravascular coagulopathy acute respiratory distress syndrome abruptio placentae recurrence of preeclampsia HELLP syndrome maternal complications login to view 6 more bullets neonatal complications login to view 3 more bullets other complications login to view 1 more bullet