Category Archives: PREECLAMPSIA

Preeclampsia: Taking the Focus Off Proteinuria

Preeclampsia is a progressive multisystemic disease of pregnancy that affects the lining of the mother’s blood vessels causing high blood pressure, leaking of fluid from the blood vessels, and may also cause damage to multiple organs.

Last year, In recognition of the multisystemic nature of preeclampsia, the American College of Obstetricians and Gynecologists (ACOG) recommended that elevated blood pressure in addition to alternative systemic findings can fulfill the diagnosis of preeclampsia. Proteinuria does not need to be present to make the diagnosis of preeclampsia. Necessary interventions, such as control of blood pressure, should not be delayed because there is no protein in the urine [1,2].

Although the presence of significant* protein in the urine would indicate mulitsystemic involvement, the degree of proteinuria correlates poorly with short-term adverse outcomes and  long-term maternal renal prognosis [1-5]. There is no longer a recognized quantity of  urinary protein that would affect recommendations to deliver, thus eliminating  any degree of proteinuria as a  “severe feature” [1,2].

(*300 mg or more in a 24 hour urine timed collection  or  a protein/creatinine ratio of at least 0.3 (each measured as mg/dL) (≥ 30mg/mmol) . 1+ on dipstick may be used only if the above methods are unavailable [1,2,6])

SEVERE FEATURES OF PREECLAMPSIA AS DEFINED BY ACOG 

The following findings are severe features of preeclampsia that indicate intervention including delivery may be indicated.

  • New-onset cerebral or visual disturbances .
  • Pulmonary edema (fluid in the lungs)
  • Low platelet count (less than 100,000 /microliter)
  • Elevated liver enzymes ( transaminases ) to  twice the normal concentration,  severe persistent pain in the right upper or middle upper abdomen that does not respond to medication and is not explained by another condition or both.
  • Renal insufficiency (serum creatinine greater than1.1 mg/dL) ,or a doubling of serum creatinine in the absence of other renal  disease
  • A systolic blood pressure (SBP) greater than or equal to 160 mm Hg OR a diastolic blood pressure (DBP) greater than or equal to 110 mm Hg measured on more than one occasion at least 4 hours apart while the patient is on bedrest (unless anti hypertensive therapy is initiated before this time)

TREATMENT OF SEVERE HYPERTENSION IS RECOMMENDED EVEN IF THERE ARE NO OTHER SEVERE FEATURES OF PREECLAMPSIA PRESENT 

Stroke is a major cause of death in women with  hypertensive disorders of pregnancy. As is  the case  in women who are not pregnant, control of the systolic blood pressure appears to be at least as important as control of the diastolic blood pressure [7, 8]. A review of  international clinical practice guidelines found that most authorities recommended  treatment during pregnancy for severe hypertension defined as a  blood pressure of   greater than or equal 160 / 110 mm Hg [9,12].

The American College of Obstetricians and Gynecologists (ACOG) recommends that systolic blood pressure greater than or equal to 160 mm Hg OR diastolic blood pressure greater than or equal to 110 mm Hg that persists greater than 15 minutes should be treated within 1 hour.  ACOG recommends intravenous labetalol or hydralazine, or nifedipine orally  for the  acute treatment of severe hypertension [1,2,11].

The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) recommends antihypertensive treatment for all pregnant women with blood pressure greater than or equal to 160 mm Hg systolic OR 110 mm Hg diastolic. Severe hypertension requiring urgent treatment is defined as a systolic blood pressure greater than or equal to 170 mm Hg with or
without diastolic blood pressure greater than or equal to 110 mm Hg.  SOMANZ recommends intravenous labetalol , hydralazine , or diazoxide, or oral nifedipine for the  acute treatment of severe hypertension [13].

REFERENCES

1. Hypertension in pregnancy: executive summary. Obstet Gynecol. 2013 Nov;122(5):1122-31. doi:10.1097/01.AOG.0000437382.03963.88.PMID:24150027
2. The American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy Hypertension in Pregnancy. Hypertension, Pregnancy Induced –Practice Guideline wq244 2013

3. Thangaratinam S, et. al., Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systematic review. BMC Med. 2009 Mar 24;7:10. doi: 10.1186/1741-7015-7-10. PMID: 19317889

4.Payne B, et al.; PIERS Study Group. PIERS proteinuria: relationship with adverse maternal and perinatal outcome. J Obstet Gynaecol Can 2011;33:588–97.PMID: 21846448

5. Lampinen KH, Rönnback M, Groop PH, Kaaja RJ. Renal and vascular
function in women with previous preeclampsia: a comparison of lowand
high-degree proteinuria. Kidney Int 2006;70:1818–22 PMID: 17003812

6. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P; Canadian Hypertensive Disorders of Pregnancy Working Group. J Obstet Gynaecol Can. 2014 May;36(5):416-41. English, French. PMID: 24927294

7. Martin JN, Jr., et al., Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstetrics & Gynecology. 2005;105(2):246-54. PMID: 15684147

8. Lindenstrøm E, et al., Influence of systolic and diastolic blood pressure on stroke risk: a prospective observational study. Am J Epidemiol. 1995 Dec 15;142(12):1279-90. PMID: 7503048

 9. Hypertensive disorders of pregnancy: a systematic review of international clinical practice guidelines. Gillon TE, Pels A, von Dadelszen P, MacDonell K, Magee LA. PLoS One. 2014 Dec 1;9(12):e113715. doi: 10.1371/journal.pone.0113715. eCollection 2014. PMID: 25436639

10. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Buchbinder A, Sibai BM, Caritis S, Macpherson C, Hauth J, Lindheimer MD, Klebanoff M, Vandorsten P, Landon M, Paul R, Miodovnik M, Meis P, Thurnau G; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol. 2002 Jan;186(1):66-71. PMID: 11810087

11.Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Committee Opinion No. 623. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:521–5.PMID: 25611642 

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Emergent-Therapy-for-Acute-Onset-Severe-Hypertension-During-Pregnancy-and-the-Postpartum-Period

12. National Institute for Health and Care Excellence.Hypertension in pregnancy: The management of hypertensive disorders during pregnancyNICE clinical guideline 107
Issued: August 2010 last modified: January 2011
Avilable at: http://www.nice.org.uk/guidance/cg107. http://www.nice.org.uk/guidance/cg107/resources/guidance-hypertension-in-pregnancy-pdf Accessed 12/29/2014.

13. Society of Obstetric Medicine of Australia and New Zealand. Guideline for the Management of Hypertensive Disorders of Pregnancy 2014
Available at: https://somanz.org/documents/HTPregnancyGuidelineJuly2014.pdf
Accessed 12/29/2014.

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A Patient With Possible Severe Preeclampsia

A 34 year old Gravida 3, Para 2 with a history of 2 cesarean deliveries and chronic hypertension was seen in the office at 25 weeks’ for a routine examination. She was noted to have a blood pressure of 210/105 mm Hg with 4 + proteinuria on urine dipstick. She did not have proteinuria on urine dipstick in the past and a 24 hour urine collection at 14 weeks’ showed 300 mg of protein. Her fetus measured 22 weeks’ and had oligohydramnios. Doppler examination of the umbilical artery showed absent end diastolic flow. She denied headache, epigastric pain, visual complaints, cough, and shortness of breath. She had been taking methyldopa 500 mg orally twice daily for the control of her blood pressure.
She was admitted for treatment of her severe hypertension and evaluation for possible superimposed preeclampsia. She was given a 4 gram loading dose of magnesium sulfate followed by 2 grams per hour infusion. She was also given Celestone 12 mg IM. Over the course of one hour she received three doses of hydralazine 5 mg IV followed by labetalol 20 mg , 40 mg, and 80 mg. Her blood pressure was decreased to 156 / 90 mm Hg.Laboratories
Platelet count: 120 X 10 9/L
Alanine aminotransferase , ALT, SGPT  : 33 U/L (0.55 µkat/L)
Aspartate aminotransferase ,AST, SGOT  : 32 U/L (0.53 µkat/L)
Urinalysis significant for 3+ protein, trace blood.
Urine toxicology screen: NegativeTwo hours after admission she began to complain of abdominal pain and cramping. Her blood pressure was 180 /100.Her fetal heart tracing showed the following pattern:
Her fetal heart tracing showed the following pattern:

Click image to view entire tracing

What would you do next?

References
1. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000;183:S
.PMID:10920346

Pregnant women at risk for developing preeclampsia should take low-dose aspirin

Pregnant women  at risk for developing preeclampsia should take low-dose aspirin daily to reduce their chance of developing the disorder according to new recommendations by the U.S. Preventive Services Task Force (USPSTF).

The USPSTF recommends low-dose aspirin (81 mg/day) preventive medication after 12 weeks’ gestation in women who are at high risk for preeclampsia.

Women at high risk include:

  • Prior preeclampsia, especially when accompanied by an adverse outcome
  • Multiple gestation pregnancy
  • Chronic hypertension
  • Type 1 or 2 diabetes
  • Renal disease
  • Autoimmune disease (i.e., systemic lupus erythematous, antiphospholipid syndrome)

In addition The U.S. Preventive Services Task Force (USPSTF)  recommends women with more than one moderate risk factor for pre-eclampsia should to take 81 mg of aspirin daily after 12 weeks of gestation

Moderate risk factors include:

  • Nulliparity (first pregnancy)
  • Obesity (i.e., body mass index >30 kg/m2)
  • Family history of preeclampsia (i.e., mother, sister)
  • Sociodemographic characteristics (i.e., African American race, low socioeconomic status)
  • Age ≥35 years
  • Personal history factors (e.g., low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval)

The USPSTF recommendations are similar to recommendation given by the National Institute for Health and Clinical Excellence (NICE) in previous years.

The USPSTF Draft Recommendation Statement is available at:

http://www.uspreventiveservicestaskforce.org/draftrec.htm