Snapshot A 25-year-old woman comes to the clinic at 28 weeks gestation complaining of headaches and abdominal pain. She states that these symptoms began 5 days ago and have been worsening. The patient's vitals are notable for a blood pressure of 175/95 mmHg. On physical exam pain is elicited upon palpation of all 4 quadrants, in particular the right upper quadrant. A urine dipstick demonstrates 3+ protein. The patient is admitted to the hospital and started on IV magnesium sulfate and labetalol. Five hours after this treatment has begun she has a seizure. Introduction Chronic hypertension (> 140/90 mmHg) history of elevated blood pressure before the pregnancy or before 20 weeks gestation tends to persist after the pregnancy Gestational hypertension (> 140/90 mmHg) no history of hypertension hypertension that develops during pregnancy usually after 20 weeks gestation usually returns to baseline 6 weeks postpartum more common in twin and triplet pregnancies absence of symptoms found in preeclampsia (discussed below) Preeclampsia classically: hypertension + proteinuria of note gestational hypertension is new onset hypertension after 20 weeks of pregnancy but does NOT have proteinuria or other signs/symptoms of preeclampsia no evidence supporting treatment of mild to moderate gestational hypertension if proteinuria is absent diagnosis can be made if there is hypertension and a new onset of any of the following: thrombocytopenia (less than 100,000/microliter) serum creatinine greater than 1.1 mg/dL or doubling of serum creatinine in the absence of renal disease elevated liver transaminases (double) pulmonary edema cerebral or visual symptoms Eclampsia preeclampsia + seizures HELLP syndrome form of preeclampsia with Hemolysis, Elevated LFTs, Low Platelets should be distinguished from gestational thrombocytopenia in which platelets fall but rarely below 80, poses no risk to the mother or fetus, and resolves spontaneously after birth Acute fatty liver of pregnancy pathophysiology defect of long chain 3-hydroxyacyl-coenzyme A dehydrogenase symptoms nausea, vomiting, abdominal pain, jaundice, anorexia lab findings elevated AST/ALT elevated LDH hyperammonemia throbocytopenia elevated BUN and Cr diagnosis lab findings most accurate: liver biopsy treatment delivery of fetus differentiate from HELLP also has renal failure, hypoglycemia, hyperbilirubinemia, coagulopathy in acute fatty liver Risk factors preexisting hypertension nulliparity maternal age of < 20 years, > 35 years diabetes chronic renal disease autoimmune disorders Typically occurs from 20 weeks gestation to 6 weeks postpartum if symptoms occur before 20 weeks think molar pregnancy Pathophysiology placental ischemia secondary to impaired vasodilation of spiral arteries results in ↑ vascular tone ↑ vasoconstrictors ↓ vasodilators Presentation Symptoms headache blurred vision abdominal pain weight gain (water retention) Physical exam hypertension mild preeclampsia = > 140/90 severe preeclampsia = > 160/110 edema of face and extremities altered mentation hyperreflexia Evaluation Urinalysis proteinuria past guidelines were dependent on quantity of protein in the urine mild preeclampsia = > 300 mg/24 hrs severe preeclampsia = > 5 g/24 hrs protein/creatinine ratio > .3 generally sufficient for diagnosing proteinuria as criteria in preeclampsia this means higher urine protein levels does not equate with more severe preeclampsia with modern guidelines remember proteinuria is NOT mandatory for diagnosis of preeclampsia Serology thrombocytopenia hyperuricemia hemoconcentration Treatment Delivery only definitive treatment in severe preeclampsia and eclampsia deliver at any gestation age due to severe risk to mother with continued pregnancy in mild preeclampsia manage conservatively by observing for progression to severe preeclampsia Bed rest Salt restriction Monitoring and treatment of hypertension most common agents include labetalol, hydralazine, or nifedipine IV magnesium sulfate and diazepam 1st line prevention/treatment of eclamptic seizures magnesium toxicity manifests as hyporeflexia and bradypnea treatment involves stopping magnesium and giving calcium gluconate hyporeflexia presents before bradypnea - check patient reflexes regularly to avoid respiratory depression Prophylaxis low dose aspirin in high risk patients can reduce pre-eclampsia by 24% decreases TXA2 while maintaining vascular wall prostacyclin decreases ATII Complications Maternal cerebral hemorrhage DIC and ARDS Abrupto placentae