OBSTETRICS AND GYNECOLOGY■ Preeclampsia superimposed upon chronic hypertension: Defined by new
onset proteinuria after 20 weeks gestation in a patient with preexisting hy-
pertensionordevelopment of severe hypertension (SBP ≥160 or DBP
≥110 mmHg) in a pregnant patient with a history of both hypertension
and proteinuria
DIAGNOSIS
■ Preeclampsiais new onset hypertension (systolic BP >140 and diastolic
BP >90) combined with proteinuria of 30 mg/dL or 300 mg/24 hours) in
patients >20 weeks gestation.
■ The elevation in blood pressure should be sustained, which is generally re-
garded as two measurements at least 6 hours apart.
TREATMENT
■ The cornerstone of treatment for preeclampsia/eclampsia is delivery of the fetus.
■ Expectant management can be attempted in a monitored setting for
preeclamptic patients <34 weeks gestation with only mild proteinuria.
■ Medical management includes magnesium sulfateand antihypertensive
drugs (hydralazine or labetalol).
■ Magnesium sulfate 4–6 g IV is given over 15 minutes followed by 1–2 g/hour.
■ Watch for signs of magnesium toxicity: Hyporeflexia, loss of deep tendon
reflexes, respiratory depression, and bradydysrhythmias.
■ These patients are ill. Call your consultant early.
HELLP Syndrome
HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) is
an uncommon but severe variant of preeclampsia. Unlike preeclampsia,
which occurs in primigravida patients, HELLP syndrome is more common in
the multigravid patient.
SYMPTOMS/EXAM
■ Epigastric/RUQ abdominal pain and tenderness
■ Patients may (or may not) have symptoms of preeclampsia.
DIFFERENTIAL
■ Other causes of upper abdominal pain in pregnancy: Cholecystitis, gastritis,
pancreatitis, appendicitis
■ Idiopathic thrombocytopenic purpura, hemolytic uremic syndrome
DIAGNOSIS
■ Primarily a laboratory diagnosis
■ LDH (marker for hemolysis) >600 U/L
■ Thrombocytopenia (<100,000/mm^3 , but suspect if <150,000/mm^3 ); may
predict severity
■ Elevated liver enzymes with AST >70 U/L
■ Peripheral smear may show evidence of microangiopathic hemolytic anemia
(schiztocytes).
TREATMENT
■ The cornerstone of treatment is delivery of the fetus.
■ Mild cases may be treated with corticosteroids and expectant management.
Eclampsia can occur up to
2 weeks postpartum.