Pre-Eclampsia and Eclampsia (Toxemia of Pregnancy)

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Chapter 219 Pre-Eclampsia and Eclampsia (Toxemia of Pregnancy)

INTRODUCTION

Description: Pre-eclampsia is a pregnancy-specific syndrome (occurring after 20 weeks of gestation) of reduced organ perfusion, vasospasm, and endothelial activation characterized by hypertension, proteinuria, and other symptoms. Pregnancy can induce hypertension or aggravate existing hypertension. Edema and proteinuria (one or both) are characteristic pregnancy-induced changes. If pre-eclampsia is untreated, convulsions (eclampsia) may occur. Chronic hypertension may be worsened by or superimposed on pregnancy-induced changes. Severe cases may include hemolysis, elevated liver enzymes, and low platelet counts (HELLP syndrome; occurs in up to 20% of severe pre-eclampsia cases).

Prevalence: Five to eight percent of all births, 250,000 cases per year, result in 150 maternal deaths (18%) and 3000 fetal deaths per year. (Overall, hypertensive disease of some type occurs in approximately 12% to 22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States.)

Predominant Age: Rare before 20 weeks of gestation.

Genetics: Multifactorial, runs in families.

ETIOLOGY AND PATHOGENESIS

Causes: Unknown, genetic, endocrine/metabolic (including altered prostaglandin production), uteroplacental ischemia, immunologic all proposed.

Risk Factors: Prior history, body mass index >32.3, African American race, nulliparity, age older than 35 (2-fold to 3-fold increase) or younger than 18 years, multifetal pregnancy, fetal hydrops, hydatidiform mole, thrombophilia.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Hypertension without proteinuria or edema (gestational hypertension)

• Hypertension with proteinuria or edema (pre-eclampsia) (severe pre-eclampsia: headache, abdominal pain, weight gain, visual disturbances, thrombocytopenia, oliguria, hemoconcentration, pulmonary edema, proteinuria >3+)

• Hypertension, proteinuria, or edema and seizures (grand mal type) (eclampsia)

DIAGNOSTIC APPROACH

Workup and Evaluation

Laboratory: Liver and renal function studies (enzymes, renal clearance, 24-hour urinary protein measurement).

Imaging: Ultrasonography to monitor fetal growth (frequently restricted).

Special Tests: Assessment of fetal lung maturation may be performed, but if maternal disease is severe, management is based on maternal factors and not fetal maturation. Invasive hemodynamic monitoring may be required for patients with the most severe cases.

Diagnostic Procedures: History, physical examination (with blood pressure), urinalysis (or “dipstick”), laboratory assessment.

Pathologic Findings

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