Preeclampsia / Eclampsia / HELLP Syndrome

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 gestationHypertension persists after delivery	Hypertension after 20 weeks of gestationHypertension returns to baseline by 6 weeks post-partumCommon in multiple gestations	Hypertension (> 140/90 mmHg on 2 separate occasions, or >160/110 mmHg) plus proteinuria	Preeclampsia plus seizures	HemolysisElevated Liver enzymesLow 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
    - vasospasm of the renal arteries can lead to acute renal failure
  - 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

Studies

Differential

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

Complications