Gestational hypertension, preeclampsia, and eclampsia represent a spectrum of potentially life-threatening diseases that must be diagnosed and treated aggressively.
Consider preeclampsia in any pregnant patient with an elevated blood pressure.
The degree of hypertension does not correlate with the severity of preeclampsia.
Delivery of the fetus is the definitive treatment of preeclampsia and eclampsia.
Hypertension in pregnancy occurs in approximately 10% of pregnancies and can be associated with significant maternal and fetal morbidity and mortality. The spectrum of disease is divided into 3 main categories: gestational hypertension, preeclampsia, and eclampsia. Preeclampsia affects 2–6% of pregnancies in the United States, with a higher incidence globally. Eclampsia occurs in <1% of patients with preeclampsia.
Gestational hypertension is defined as a blood pressure >140/90 mmHg in a pregnant patient without preexisting hypertension. The hypertension will resolve within 12 weeks postpartum. When proteinuria is also present, it is defined as preeclampsia. Preeclampsia typically occurs after 20 weeks' gestation. A subset of patients will develop severe preeclampsia, which is associated with one of more of the following: severe hypertension (>160/110 mmHg on 2 separate occasions >6 hours apart), large proteinuria, neurologic symptoms, epigastric/right upper quadrant (RUQ) pain, pulmonary edema, or thrombocytopenia. Eclampsia is preeclampsia with seizures. HELLP syndrome affects some patients with preeclampsia and eclampsia and is associated with hemolysis, elevated liver enzymes, and low platelets.
Although the exact etiology of preeclampsia is unknown, there are several factors that are thought to contribute. These include maternal immunologic intolerance, abnormal placental implantation, endothelial dysfunction, and genetic factors.
Patients with gestational hypertension and preeclampsia may be asymptomatic. Some women will report facial or extremity edema, epigastric or RUQ pain, headache, or visual disturbances. Seizures in a woman with preeclampsia is pathognomonic for eclampsia and may occur in the postpartum period. Risk factors for preeclampsia that should be screened for during the history include nulliparity, advanced maternal age, a multiple gestation pregnancy, diabetes, obesity, and previous preeclampsia.
It is critical to pay careful attention to the vital signs, particularly the blood pressure. Edema of the face or extremities may be appreciated. Examination of the lungs may reveal rales suggestive of pulmonary edema. The abdominal exam is important to assess for tenderness as well as to estimate the gestational age of the fetus (Figure 45-1). Listen for fetal heart tones with a Doppler or measure the fetal heart rate with bedside ultrasound. A complete neurologic examination is performed to identify any new deficits.
Measurement from symphysis pubis to fundal height as a clinical estimator of gestational age.