Pregnancy, Preeclampsia
Diagnosis and Differentials
Clinical
History: Mild-to-moderate preeclampsia may be asymptomatic. Many cases are detected through routine prenatal screening. Patients with severe preeclampsia display end-organ effects and may complain of the following:
- CNS
- Headache
- Visual disturbances - Blurred, scintillating scotomata
- Altered mental status
- Blindness - May be cortical or retinal
- Dyspnea
- Edema - Exists in many pregnant women but sudden increase in edema or facial edema is more concerning for preeclampsia
- Epigastric or right upper quadrant (RUQ) abdominal pain
Physical: Findings on physical examination may include the following:
- Increased BP compared with the patient's baseline or greater than 140/90
- Tachypnea
- Altered mental status
- Decreased vision
- Rales
- Epigastric or RUQ abdominal tenderness
- Peripheral edema
- Seizures
- Focal neurologic deficit
Causes:
- Pregnancy-associated risk factors
- Chromosomal abnormalities
- Hydatidiform mole
- Multifetal pregnancy
- Oocyte donation or donor insemination
- Urinary tract infection
- Maternal-specific risk factors
- Extremes of age
- Black race
- Family history of preeclampsia
- Nulliparity
- Preeclampsia in a previous pregnancy
- Diabetes
- Obesity
- Chronic hypertension
- Renal disease
Differentials
Abdominal Trauma, Blunt
Abortion, Incomplete
Abortion, Threatened
Abruptio Placentae
Aneurysm, Abdominal
Appendicitis, Acute
Cholecystitis and Biliary Colic
Cholelithiasis
Congestive Heart Failure and Pulmonary Edema
Domestic Violence
Encephalitis
Headache, Migraine
Headache, Tension
Hypertensive Emergencies
Hyperthyroidism, Thyroid Storm, and Graves Disease
Ovarian Torsion
Pregnancy, Eclampsia
Status Epilepticus
Stroke, Hemorrhagic
Stroke, Ischemic
Subarachnoid Hemorrhage
Subdural Hematoma
Thrombocytopenic Purpura
Toxicity, Amphetamine
Toxicity, Sympathomimetic
Toxicity, Thyroid Hormone
Transient Ischemic Attack
Urinary Tract Infection, Female
Withdrawal Syndromes
Other Problems to be Considered:
Pheochromocytoma
Workup
Lab Studies:
- CBC
- Microangiopathic hemolytic anemia (HELLP)
- Thrombocytopenia
- Hemoconcentration may occur in severe preeclampsia.
- Liver function tests: Transaminase levels are elevated from hepatocellular injury and in HELLP syndrome.
- Serum creatinine: Levels are elevated due to decreased intravascular volume and decreased glomerular filtration rate (GFR).
- Urinalysis
- Proteinuria is one of the diagnostic criteria for preeclampsia.
- Proteinuria is defined as greater than or equal to 1+ protein on urine dipstick. Alternatively, protein concentration of 300 mg/L or more on urine dipstick.
- Proteinuria is also defined as 300 mg or more of protein in a 24-hour urine sample.
- Elevated PT, aPTT, fibrin split products, and decreased fibrinogen
- Consider DIC
- Uric acid
- Uric acid levels are increased in preeclampsia.
- Serial levels may be useful to indicate disease progression.
Imaging Studies:
- Head CT: This study is indicated for patients who present with focal neurologic deficits and also to look for possible hemorrhage, ischemia, or hematoma.
- Ultrasonography
- Ultrasonography is useful in less urgent cases for fetal assessment.
- Abruptio placentae is also a complication of preeclampsia, and ultrasonography might detect this.
| « Previous Page | Section 2 of 4 |
|
||||
Bibliography
- Doan-Wiggins L: Hypertensive disorders of pregnancy. Emerg Med Clin North Am 1987 Aug; 5(3): 495-508[Medline].
- Frakes MA, Richardson LE: Magnesium sulfate therapy in certain emergency conditions. Am J Emerg Med 1997 Mar; 15(2): 182-7[Medline].
- Lew M, Klonis E: Emergency management of eclampsia and severe pre-eclampsia. Emerg Med (Fremantle) 2003 Aug; 15(4): 361-8[Medline].
- Lipstein H, Lee CC, Crupi RS: A current concept of eclampsia. Am J Emerg Med 2003 May; 21(3): 223-6[Medline].
- Ogle ME, Sanders AB: Preeclampsia. Ann Emerg Med 1984 May; 13(5): 368-70[Medline].
- Powers DR, Papadakos PJ, Wallin JD: Parenteral hydralazine revisited. J Emerg Med 1998 Mar-Apr; 16(2): 191-6[Medline].
- Probst BD: Hypertensive disorders of pregnancy. Emerg Med Clin North Am 1994 Feb; 12(1): 73-89[Medline].
- Sibai B, Dekker G, Kupferminc M: Pre-eclampsia. Lancet 2005 Feb 26-Mar 4; 365(9461): 785-99[Medline].
- Wagner LK: Diagnosis and management of preeclampsia. Am Fam Physician 2004 Dec 15; 70(12): 2317-24[Medline].
Synonyms And Related Keywords
preeclampsia, HTN, hypertensive disease in pregnancy, pregnancy-induced hypertension, toxemia of pregnancy, hypertension, proteinuria, new-onset nondependent edema, seizure activity, eclampsia, seizure in pregnancy, microangiopathic hemolytic anemia, HELLP syndrome, hypertensive encephalopathy
