med 18

 

Figure 45-1. Measurement from symphysis pubis to

fundal height as a clinical estimator of gestational age.

measure the fetal heart rate with bedside ultrasound. A

complete neurologic examination is performed to identify

any new deficits.

DIAGNOSTIC STUDIES

� Laboratory

A urinalysis is indicated to identify proteinuria or infection.

A 24-hour urine collection with >300 mg protein is

significant and corresponds approximately to 2:1 + protein

on the dipstick (although the dipstick is thought to be an

unreliable measure). Additional testing includes electrolytes,

renal function, and liver function tests. With HELLP

syndrome, the complete blood count will reveal thrombo ­

cytopenia, and the peripheral smear may also show schisto ­

cytes. Lactate dehydrogenase will be elevated if hemolysis

is present. A magnesium level should be ordered as a base ­

line for potential magnesium therapy. In addition, a type

and cross should be sent in preparation for possible fetal

delivery.

� Imaging

A noncontrast head computed tomography should be

obtained in any patient with a new onset seizure to

differentiate an intracerebral hemorrhage or mass from

eclampsia as the etiology of the seizure. Ultrasonography

is recommended to assess the status of the fetus.

Continuous monitoring will alert providers to signs of

fetal distress.

MEDICAL DECISION MAKING

In a pregnant patient with hypertension, the presence of

proteinuria is enough to make a diagnosis of preeclampsia

(Figure 45-2). Before confirmation of proteinuria, other

diagnoses should be considered. If abdominal pain is present,

the differential diagnosis includes pancreatitis, hepatitis, cholecystitis, or gastritis. Headache and neurologic deficits may

be due to an intracerebral hemorrhage or stroke. Laboratory

studies will help identify patients with HELLP syndrome.

Pregnant female

(usually > 20 weeks)

BP > 1 40/90 mmHg +

proteinuria

Ask about symptoms of

headache, abdominal pain, visual

disturbances, or edema

HELLP syndrome

.&. Figure 45-2. Preeclampsia and eclampsia

diag nostic algorithm. BP, blood pressure; HELLP,

hemolysis, elevated l iver enzymes, and low platelets.

PREECLAMPSIA AND ECLAMPSIA

TREATMENT

Initial treatment is focused on stabilizing the patient. Place

the woman in the left lateral decubitus position to improve

circulation. Apply supplemental oxygen, cardiac monitoring, and establish intravenous (IV) access. Avoid over hydration, as it may result in pulmonary edema. Antihypertensive

therapy is indicated in the setting of severe hypertension

(systolic blood pressure �160 mmHg or diastolic blood

pressure �1 1 0 mmHg). Appropriate agents include hydralazine, labetalol, nifedipine, or nitroprusside. It is important

to avoid being overly aggressive with antihypertensive

agents, as a drastic drop in blood pressure can result in fetal

hypoperfusion.

Magnesium remains the drug of choice for the treatment of severe preeclampsia and eclampsia. In the setting

of severe preeclampsia, its primary role is prophylaxis

against eclampsia, although it may also have antihyperten ­

sive effects. The initial loading dose is 4-6 g IV infused over

15 minutes, followed by 1-2 g/hr. Signs of magnesium

toxicity include loss of deep tendon reflexes (8-12 mg/dL),

respiratory paralysis ( 12-18 mg/dL), and cardiac arrest

(24-30 mg/dL). Calcium gluconate should be given to

counteract cardiorespiratory compromise owing to mag ­

nesium toxicity. Phenytoin is an alternate antiepileptic

treatment, but is less effective than magnesium.

The definitive treatment of preeclampsia and eclampsia

is delivery of the fetus. Determining the appropriate timing

for this is challenging depending on the fetal age. After

37 weeks, most women with preeclampsia will be induced.

In women with severe preeclampsia, delivery should be

considered after 34 weeks or in the setting of worsening

symptoms regardless of fetal age. If the fetus is less than

34 weeks, steroids (betamethasone) are indicated to

improve fetal lung maturity.

DISPOSITION

� Admission

Patients with severe preeclampsia should be admitted to

the hospital for management of their symptoms and determination of the ideal time for delivery. Patients with

eclampsia require intensive care unit admission.

� Discharge

Patients with gestational hypertension or mild preeclampsia

may be managed as outpatients with close obstetric followup. Any signs of worsening preeclampsia should result in

admission.