Gestational hypertension/preeclampsia/eclampsia/HELLP: clinical

Hypertension in pregnancy encompasses a range of disorders, beginning with gestational hypertension, which is characterized solely by elevated blood pressure. When proteinuria is added to hypertension, it indicates preeclampsia without severe features. The progression to preeclampsia with severe features is marked by the presence of severely elevated blood pressures, laboratory evidence of end-organ damage such as thrombocytopenia, elevated liver enzymes, or renal insufficiency, and concerning symptoms like new-onset headache, visual changes, right upper quadrant pain, or epigastric pain.

HELLP syndrome is identified when a patient exhibits Hemolysis, Elevated Liver enzymes, and Low Platelets. These conditions pose significant risks to both the mother and fetus, including stroke, pulmonary edema, renal failure, and placental abruption. If a seizure occurs, it is classified as eclampsia. Most hypertensive disorders resolve within 12 weeks postpartum, but they increase the patient's risk of developing chronic hypertension in the future.

The first step in evaluating a pregnant patient presenting with symptoms suggestive of a hypertensive disorder is to perform a CABCDE assessment and conduct a primary obstetric survey.

For unstable patients, check for uncontrolled bleeding and manage any hemorrhage, as severely elevated blood pressure may lead to placental abruption. Stabilize the airway, breathing, and circulation, and consider intubation if necessary. Establish IV access and continuously monitor maternal vital signs. Conduct the primary obstetric survey, which includes monitoring the fetal heart rate, potentially testing for rupture of amniotic membranes, and assessing cervical dilation.

For stable patients, begin with a focused history and physical exam. Inquire about any history of hypertension, a significant risk factor, and other risk factors such as obesity, diabetes, kidney disease, age over 35, nulliparity, multifetal gestation, or a history of preeclampsia.

Measure the patient's blood pressure. Hypertensive disorders of pregnancy are suspected in patients more than 20 weeks pregnant if they have newly elevated blood pressures of at least 140 systolic or 90 diastolic, or both, on two separate occasions more than 4 hours apart.

Once a hypertensive disorder is suspected, check labs including CBC, CMP, LDH, and a urine protein-to-creatinine ratio, and possibly conduct a 24-hour urine collection to measure total protein.

If the patient has normal labs and no symptoms of preeclampsia, gestational hypertension can be diagnosed. Antepartum management involves monitoring blood pressure and initiating antihypertensive medication like labetalol or nifedipine if blood pressure remains above 140 systolic or 90 diastolic. Antenatal fetal surveillance with non-stress tests and serial ultrasounds to assess fetal growth is recommended.

Monitor for disease progression by regularly assessing blood pressure, performing serial labs, and asking about symptoms of preeclampsia with severe features. If maternal and fetal status are stable, delivery can be planned for 37 weeks, with vaginal delivery being appropriate unless contraindicated by factors such as fetal malpresentation or a prior classical C-section.

During labor, closely monitor maternal and fetal status for severe features, as these require additional interventions. Postpartum, schedule a short-interval blood pressure check and discuss return precautions for signs and symptoms of preeclampsia with severe features. Half of all patients with gestational hypertension will eventually develop preeclampsia, with the highest risk in those diagnosed before 32 weeks, underscoring the importance of close monitoring for disease progression.

Now let’s discuss patients with proteinuria. Patients who develop new-onset hypertension after 20 weeks of gestation along with proteinuria meet the criteria for a diagnosis of preeclampsia. Proteinuria is defined as a urine protein-to-creatinine ratio of 0.3 or higher, or a 24-hour urine collection with at least 300 mg of protein.

Upon diagnosing preeclampsia, the next step is to assess for severe features. These include blood pressures of at least 160 systolic or 110 diastolic on two occasions at least 4 hours apart; laboratory abnormalities such as thrombocytopenia with a platelet count below 100,000, renal insufficiency with a creatinine level above 1.1, elevated liver function tests more than twice the upper limit of normal; and signs or symptoms like pulmonary edema, a new-onset headache that does not improve with medication, visual disturbances like spots or blurry vision, severe, persistent right upper quadrant abdominal pain, or epigastric pain.

Here’s a clinical pearl! While blood pressure should be measured on two separate occasions at least 4 hours apart, in an acute setting with severely elevated blood pressures, the diagnosis can be made within minutes to allow for timely intervention.

Patients with preeclampsia without severe features should be monitored closely in an outpatient setting. Consider initiating an antihypertensive if blood pressure remains above 140 systolic, 90 diastolic, or both. Begin antenatal fetal surveillance with non-stress tests and serial ultrasounds, and monitor for severe features with serial labs and symptomatology. If they remain asymptomatic for severe features with reassuring blood pressure, fetal status, and labs, vaginal delivery at 37 weeks is recommended.

During labor, start an antihypertensive if elevated blood pressures occur, and closely monitor both maternal and fetal status. After delivery, schedule a short-interval blood pressure check and review return precautions for signs and symptoms of preeclampsia with severe features.

For patients exhibiting at least one severe feature, the diagnosis is preeclampsia with severe features. These patients should be admitted to the hospital for the remainder of their pregnancy for close maternal and fetal monitoring. Control severe-range blood pressures with antihypertensives like labetalol, nifedipine, or hydralazine, and consider starting a maintenance antihypertensive. Administer magnesium sulfate to prevent seizures. If the patient is preterm, consider giving corticosteroids to promote fetal lung maturity. If maternal and fetal status are reassuring, delivery should occur at 34 weeks, or at the time of diagnosis if further along.

If patients become unstable, indicated by uncontrolled blood pressures despite antihypertensives, abnormal or worsening labs, or unresolved symptoms of headache, visual changes, right upper quadrant, or epigastric pain, immediate delivery is necessary. Vaginal delivery is appropriate unless contraindicated.

During labor, control severe-range blood pressures, consider starting or adjusting maintenance antihypertensives, and administer magnesium sulfate. Monitor fluid status to prevent volume overload and pulmonary edema, and closely observe maternal and fetal status. Post-delivery, continue antihypertensive medications as indicated and magnesium sulfate for 24 hours. Before discharge, schedule a short-interval blood pressure check and review return precautions for preeclampsia with severe features.

Finally, let’s review HELLP syndrome, a severe form of preeclampsia. HELLP syndrome is characterized by its hallmark lab findings: Hemolysis, indicated by elevated LDH above 600; Elevated Liver function tests more than twice the upper limit of normal; and Low Platelets below 100. Patients may also present with proteinuria, right upper quadrant pain, generalized malaise, and severe-range blood pressure.

HELLP syndrome can progress rapidly, so swift action is crucial! Start treatment with magnesium sulfate, control severe-range blood pressures, and deliver the fetus; vaginal delivery is appropriate unless contraindicated. During labor, consider maintenance antihypertensive medication, manage severe-range blood pressures, continue magnesium sulfate, and closely monitor maternal and fetal status. Patients with HELLP syndrome are at increased risk for disseminated intravascular coagulation (DIC), so closely watch for bleeding from wounds or IV sites and signs of coagulopathy.

Postpartum, continue antihypertensives as indicated and magnesium sulfate for 24 hours. Additionally, monitor lab values for a return to baseline. Schedule a follow-up shortly after discharge for a blood pressure check, and provide return precautions for preeclampsia with severe features.

Let’s conclude with eclampsia. Eclampsia is diagnosed by a new-onset seizure in pregnancy not explained by other causes like epilepsy, stroke, or drug use. Patients may have warning signs of cerebral irritation before seizing, such as severe occipital or frontal headaches, visual symptoms like blurry vision or photophobia, and possible altered mental status. While most patients who develop eclampsia will exhibit classic signs of preeclampsia, such as hypertension or proteinuria, a small proportion will not.

Eclampsia requires immediate management. Call for help and activate an emergency response team. Provide maternal cardiorespiratory support by placing the patient on their left side, suctioning their airway to prevent aspiration, administering oxygen, and monitoring vital signs. Most eclamptic seizures resolve without medication, but if seizures persist, administer medications like benzodiazepines. Once the seizure has stopped, start magnesium sulfate to prevent recurrence and control severe-range blood pressures with antihypertensives. Once stabilized, deliver the fetus; vaginal delivery is appropriate unless contraindicated.

During labor, continue antihypertensives, magnesium sulfate, close maternal and fetal monitoring, and fluid management. Post-delivery, continue antihypertensive medications as needed and magnesium sulfate for 24 hours. Schedule a short-interval blood pressure check after discharge and provide return precautions for signs or symptoms of worsening disease.

Here’s a clinical pearl! Remember that preeclampsia with and without severe features, eclampsia, and HELLP syndrome can all present for the first time even after delivery, during the postpartum period.

Here’s a quick recap:

- **Patients with gestational hypertension or preeclampsia without severe features**: Managed with antenatal fetal surveillance, monitoring for disease progression, and delivery at 37 weeks, or at the time of diagnosis if further along than 37 weeks.

- **Preeclampsia with severe features**: Requires immediate intervention to control elevated blood pressures, seizure prophylaxis with magnesium sulfate, and delivery by 34 weeks, or at the time of diagnosis if further along.

- **HELLP syndrome and eclampsia**: These are severe forms of preeclampsia and require magnesium sulfate and immediate delivery.

Ref:

"ACOG committee opinion no. 828: Indications for outpatient antenatal fetal surveillance" Obstet Gynecol (2021)

"ACOG practice bulletin no. 222: Gestational hypertension and preeclampsia" Obstet Gynecol (2020)

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