PRESENTATION AND DIAGNOSIS

In most cases, preeclampsia is detected during routine blood pressure screening and urine dipstick. Because of primary renal retention of salt and water, patients may have edema and rapid weight gain. A 24-hour urine collection or spot urine protein : creatinine ratio should be performed to monitor the degree of proteinuria. Serum creatinine concentration is normally low in pregnancy due to hemodilution and may begin to rise with preeclampsia. Serum uric acid may be elevated because of diminished renal clearance. Finally, there may be abnormal liver function tests and evidence of hemolysis on the complete blood count, which suggests HELLP syndrome. The presence of headache and/or visual changes should alert the physician of possible progression to eclampsia.

COMPLICATIONS: HELLP SYNDROME AND ECLAMPSIA

The complications of preeclampsia can be severe. HELLP syndrome affects up to 20% of patients with severe preeclampsia, and it is characterized by HEmolysis, abnormally elevated Liver function tests, and Low Platelets. This complication appears to reflect severe endothelial dysfunction in the liver, which leads to platelet aggregation and thrombotic occlusion of the hepatic sinusoids, resulting in transaminitis. Red cells are sheared while passing through the narrowed vessels, resulting in microangiopathic hemolytic anemia. Stretching of the Glisson capsule often leads to right upper quadrant pain, nausea, and vomiting, which are the major clinical symptoms. Less frequently, jaundice may occur. Major complications include subcapsular hepatic hematoma formation, placental abruption, retinal detachment, acute kidney injury, pulmonary edema, and disseminated intravascular coagulation.

Eclampsia affects 2% of patients with severe pre-eclampsia, and it is defined as the occurrence of seizures in the setting of preeclampsia. This complication appears to reflect severe endothelial dysfunction in the brain, which leads to cerebral edema and formation of microthrombi. Early warning signs include headaches and visual changes; indeed, the Greek word eklampsis means “sudden flashing” and refers to these visual signs. Cerebral hemorrhage is a potentially fatal complication.

Both HELLP syndrome and eclampsia are associated with a dramatic increase in morbidity and mortality for both mother and fetus.

TREATMENT

Delivery is the definitive treatment for preeclampsia and should be promptly undertaken in women past 37 weeks of gestation. If the fetus is not yet at term, however, patients with mild preeclampsia may undergo careful monitoring to ensure rapid diagnosis of fetal distress and/or maternal complications. Reliable patients can be managed with frequent checks on an outpatient basis; however, patients often need to be hospitalized for careful monitoring, especially if there is any evidence of disease progression.

Intravenous magnesium sulfate is used to treat eclamptic seizures and should be given to all patients with preeclampsia and HELLP syndrome as prophylaxis. Although there is no widely accepted regimen, it is typically given intrapartum and continued for 1 to 2 days postpartum.