Preeclampsia and Eclampsia – Quick Consult
Last Updated / Reviewed: October 2024

Definition
Key History
Key Physical Exam
Risk Factors for Preeclampsia
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications

Definition

Preeclampsia New onset of hypertension and proteinuria OR hypertension and significant end organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. May also develop postpartum. Severe hypertension or signs/symptoms of significant end organ injury represent the severe end of the disease spectrum. In 2013, the American College of Obstetricians and Gynecologists removed proteinuria as an essential criterion for diagnosis of preeclampsia.
Eclampsia Refers to the development of grand mal seizures in a woman with preeclampsia in the absence of other neurologic conditions that could account for the seizures.
HELLP Syndrome HELLP stands for: hemolysis, elevated liver enzymes, low platelet count. It probably represents a severe form of preeclampsia, but that relationship remains controversial; it may be an independent disorder.

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Key History

  • Altered mental status
  • Apprehension
  • Blindness (rare)
  • Decreased urine output
  • Dyspnea
  • Visual disturbances – scintillating scotomata
  • Epigastric pain
  • Headache
  • Rapid excessive weight gain
  • Seizures (eclampsia)
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Key Physical Exam

  • Elevated blood pressure – greater than 140/90 mm Hg or a 30 mm Hg systolic BP increase over baseline, or a 15 mm Hg increase of diastolic BP over baseline
  • Papilledema
  • Cotton wool exudates
  • Decreased vision
  • Tachypnea
  • Rales
  • RUQ or epigastric tenderness
  • Hyperreflexia
  • Focal neurologic deficit
  • Edema
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Risk Factors for Preeclampsia

  • Nulliparity
  • Preeclampsia in a previous pregnancy
  • Age over 40 or under 18 years
  • Family history of preeclampsia
  • Chronic hypertension
  • Chronic renal disease
  • Autoimmune disease
  • Vascular disease
  • Gestational diabetes
  • Multi-fetal gestation
  • Obesity
  • Black race
  • Hydrops fetalis
  • Fetal growth restriction, abruptio placentae, or fetal demise in a previous pregnancy
  • Prolonged interpregnancy interval
  • In vitro fertilization
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Differential Diagnosis

  • Adrenal adenoma
  • Chronic hypertension
  • Pheochromocytoma
  • Pregnancy-induced hypertension
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Diagnostic Testing

Preeclampsia:
  • Blood Pressure Measurement: Hypertension is defined as a systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with previously normal blood pressure.
  • Proteinuria Assessment: Traditionally, proteinuria is defined as ≥300 mg of protein in a 24-hour urine collection or a protein-to-creatinine ratio (UPCR) of ≥0.3. The urine dipstick test is less reliable and not recommended for diagnosis.
  • Laboratory Tests: These include complete blood count, liver function tests (elevated transaminases), renal function tests (serum creatinine), and uric acid levels. Elevated levels of liver enzymes and low platelet count are indicative of severe preeclampsia.
  • Angiogenic Factors: The sFlt-1/PlGF ratio is a useful biomarker for diagnosing preeclampsia. A high ratio is indicative of preeclampsia, while a low ratio can rule out the condition.
Eclampsia:
  • Neurological Assessment: Eclampsia is diagnosed by the presence of new-onset tonic-clonic seizures in a woman with preeclampsia in the absence of other neurologic conditions.
  • Imaging Studies: In cases of complicated eclampsia, brain imaging such as CT or MRI may be necessary to rule out other causes of seizures and to assess for cerebral edema or hemorrhage.
  • Laboratory Tests: Similar to preeclampsia, but with additional focus on ruling out other causes of seizures. This includes electrolytes, glucose and coagulation panels.
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Clinical Risk and Safety Pearls

  • Maintain high index of suspicion for preeclampsia in pregnant patients presenting with any complaint AND abnormally elevated BP. Any pregnant patient, regardless of age or risk factors, is at risk for preeclampsia.
  • Eclampsia can occur after pregnancy—it has been reported up to several weeks after delivery.
  • Incidence: 7% of first pregnancies in the U.S.
  • Associated with placental abruption (abruptio placenta). See topic: Abruptio Placenta for further information.
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Treatment

The treatment of preeclampsia and eclampsia involves several key strategies aimed at managing hypertension, preventing seizures, and optimizing maternal and fetal outcomes.

Preeclampsia:

  • Antihypertensive Therapy:
    • Labetalol is often the first-line agent due to its efficacy and safety profile.
    • Nifedipine and methyldopa are also commonly used.
    • For severe hypertension (systolic BP >160 mmHg or diastolic BP >110 mmHg), immediate treatment is necessary to reduce maternal risks.
  • Seizure Prophylaxis:
    • Magnesium sulfate is the drug of choice for preventing seizures in severe preeclampsia. The typical regimen is a loading dose of 4-6 g IV over 15-20 minutes, followed by a maintenance dose of 1-2 g per hour.
  • Delivery:
    • The definitive treatment for preeclampsia is delivery of the placenta. Timing of delivery is critical and depends on the severity of the disease and gestational age. For severe preeclampsia, delivery is often recommended after 34 weeks of gestation, or earlier if maternal or fetal conditions deteriorate.

Eclampsia:

  • Seizure Management:
    • Magnesium sulfate is also the first-line treatment for eclamptic seizures. The same dosing regimen as for seizure prophylaxis is used, with additional doses if seizures recur.
  • Antihypertensive Therapy:
    • Similar to preeclampsia, labetalol and hydralazine are commonly used to manage severe hypertension in eclampsia.
  • Supportive Care:
    • Patients with eclampsia should be managed in an intensive care setting to monitor and manage complications such as intracranial hemorrhage, pulmonary edema, and renal failure.
  • Delivery:
    • Immediate delivery is often indicated once the mother is stabilized, regardless of gestational age, to prevent further maternal and fetal complications.
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Complications

  • Acute fatty liver
  • Acute pulmonary edema
  • Acute pyelonephritis
  • Eclampsia – seizures
  • HELLP* syndrome – 5% to 10%
  • Hypertensive crisis
  • Cerebral hemorrhage
  • Death – maternal and/or fetal
*HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant of preeclampsia. Both conditions occur during the later stages of pregnancy or sometimes after childbirth.

HELLP is an abbreviation of the main findings:

Hemolytic anemia
Elevated Liver enzymes and
Low Platelet count

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American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019;133(1):e1-e25.

American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-1131.

Bartsch E, Medcalf KE, Park AL, et al. Clinical risk factors for pre-eclampsia determined in early pregnancy: Systematic review and meta-analysis of large cohort studies. BMJ. 2016;353:i1753.

Bello NA, Woolley JJ, Cleary KL, et al. Accuracy of blood pressure measurement devices in pregnancy: A systematic review of validation studies. Hypertension. 2018;71(2):326-335.

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Lisonkova S, Sabr Y, Mayer C, Young C, Skoll A, Joseph KS. Maternal morbidity associated with early-onset and late-onset pre-eclampsia. Obstet Gynecol. 2014;124(4):771-781.

Magee LA, Pels A, Helewa M, et al. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: Executive summary. J Obstet Gynaecol Can. 2014;36(5):416-441.

Magley M, Hinson MR. Eclampsia. [Updated 2023 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554392/.

Roberts JM, Redman CWG. Global Pregnancy Collaboration. Global Pregnancy Collaboration symposium: Prepregnancy and very early pregnancy antecedents of adverse pregnancy outcomes: Overview and recommendations. Placenta. 2017;60:103-109.

Tanner MS, Davey MA, Mol BW, Rolnik DL. The evolution of the diagnostic criteria of preeclampsia-eclampsia. Am J Obstet Gynecol. 2022 Feb;226(2S):S835-S843. doi: 10.1016/j.ajog.2021.11.1371. PMID: 35177221.

Stefańska K, Zieliński M, Zamkowska D, Adamski P, Jassem-Bobowicz J, Piekarska K, Jankowiak M, Leszczyńska K, Świątkowska-Stodulska R, Preis K, Trzonkowski P, Marek-Trzonkowska N. Comparisons of Dipstick Test, Urine Protein-to-Creatine Ratio, and Total Protein Measurement for the Diagnosis of Preeclampsia. Int J Environ Res Public Health. 2020 Jun 12;17(12):4195. doi: 10.3390/ijerph17124195. PMID: 32545523; PMCID: PMC7344421.

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