Diagnosing and Managing Preeclampsia in the ED: Pressure’s Rising

-Case-

A 30-year-old woman at 34 weeks gestation arrives at the ED complaining of a pounding headache, blurry vision, and swelling in her hands and face over the past few days. Her blood pressure reads 168/102 mmHg, has bilateral 2+ pitting edema of the lower extremities, and she has 3+ proteinuria on urine dipstick.

-Evaluation-

Preeclampsia is a hypertensive disorder of pregnancy, typically occurring after 20 weeks gestation. It is a leading cause of maternal morbidity and mortality.

  • Diagnostic Criteria: BP ≥140/90 mmHg on two occasions at least 4 hours apart, proteinuria, or end-organ dysfunction in the absence of proteinuria (think thrombocytopenia, renal dysfunction, elevated LFTs, pulmonary edema, new-onset headache or visual disturbances)
  • Severe Features:
    • BP ≥160/110 mmHg
    • Persistent CNS symptoms (headache, vision changes, altered mental status)
    • RUQ pain (suggesting hepatic involvement)
    • Pulmonary edema
    • Severe thrombocytopenia or worsening renal function

-Management-

Let’s follow a step-wise approach to limit sequela of this disease!

  1. Lower BP to reduce stroke risk: IV labetalol (first-line) or Hydralazine for acute BP control, with a goal SBP of 140-155 (not too low, to maintain uteroplacental perfusion!)
  2. Seizure prophylaxis: magnesium sulfate IV is needed for patients with severe features! Additionally, for those that have seizures, give IV magnesium immediately!
  3. Definitive treatment is delivery, especially if at or later than 37 week gestation!

-Fast Facts-

  • Think preeclampsia in any pregnant patient with hypertension + systemic symptoms!
  • Severe HTN = increased stroke risk → lower BP (but not too low)
  • Seizure prophylaxis = magnesium sulfate
  • The only definitive cure is delivery!

Want to learn more? Read our in-depth study guide about preeclampsia!

Cheers,

Tamir Zitelny, MD

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-References-

  1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 222: Gestational hypertension and preeclampsia. Obstet Gynecol. 2020;135(6):e237–e260. doi:10.1097/AOG.0000000000003891
  2. Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. 2003;102(1):181–192. doi:10.1016/S0029-7844(03)00475-7
  3. Lisonkova S, Joseph KS. Incidence of preeclampsia: Risk factors and outcomes associated with early- versus late-onset disease. Am J Obstet Gynecol. 2013;209(6):544.e1–544.e12. doi:10.1016/j.ajog.2013.08.019
  4. Alzate A, Herrera-Medina R, Ramirez A, et al. Treatment of severe preeclampsia: Hydralazine, labetalol, and nifedipine-a randomized clinical trial. Pregnancy Hypertens. 2019;15:210–216. doi:10.1016/j.preghy.2019.01.010
  5. Menzies J, Magee LA, Li J, et al. Elevations in liver enzymes and creatinine in severe preeclampsia: A systematic review. Obstet Gynecol. 2007;110(5):1302–1310. doi:10.1097/01.AOG.0000290183.53178.41
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