Gestational hypertension, preeclampsia, eclampsia, and HELLP: Clinical sciences

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Introduction0:00–1:30

Hypertension in pregnancy is not one disorder, but actually a spectrum. This spectrum begins with gestational hypertension, where a patient only has elevated blood pressure.If you add proteinuria to hypertension, then we’re talking about preeclampsia without severe features.
Now, progression to preeclampsia with severe features occurs if any of the following are observed; severely elevated blood pressures; labs indicating end-organ damage like thrombocytopenia, elevated liver enzymes, or renal insufficiency; or worrisome symptoms like new onset headache, visual changes, right upper quadrant pain, or epigastric pain.
Next, HELLP syndrome occurs when a patient presents with Hemolysis, Elevated Liver enzymes, and Low Platelets. These conditions have significant maternal and fetal risks, such as stroke, pulmonary edema, renal failure, and placental abruption.
Finally, if the patient had a seizure, that’s eclampsia. Most hypertensive disorders resolve by 12 weeks postpartum, and they all increase a patient's risk of developing chronic hypertension in the future.
Your first step in evaluating a pregnant patient who presents with a chief concern suggesting a hypertensive disorder in pregnancy is to perform a CABCDE assessment and conduct a primary obstetric survey.

Unstable Patient1:30–2:25

If the patient is unstable, check for uncontrolled bleeding and control any hemorrhage, as severely elevated blood pressure may cause a placental abruption.
Next, stabilize their airway, breathing, and circulation and consider intubation when appropriate. Obtain IV access and continuously monitor maternal vital signs.
Perform your primary obstetric survey, which includes monitoring the fetal heart rate; possibly testing for rupture of amniotic membranes; and consider checking cervical dilation.Alright, let’s talk about stable patients.

Stable Patient2:25–3:35

Your first step is to obtain a focused history and physical exam. Ask about any history of hypertension, which is a big risk factor.
Additional risk factors include obesity, diabetes, kidney disease, age greater than 35, nulliparity, multifetal gestation, or a history of preeclampsia.
Then, measure their blood pressure. In patients who are more than 20 weeks pregnant, a hypertensive disorder of pregnancy is suspected if they have newly elevated blood pressures of at least 140 systolic, or at least 90 diastolic, or both, on two separate occasions more than 4 hours apart.
Okay, once you suspect a hypertensive disorder in pregnancy, it’s time to check labs. Obtain a CBC, CMP, LDH, and a urine protein-to-creatinine ratio; and possibly a 24-hour urine collection to measure total protein.

Gestational hypertension3:35–5:19

Alright, if your patient has normal labs and has no symptoms of preeclampsia, you can confirm the diagnosis of gestational hypertension.
Antepartum management includes monitoring blood pressure and starting an antihypertensive medication like labetalol or nifedipine, if blood pressure is persistently above 140 systolic, 90 diastolic, or both.
Antenatal fetal surveillance with non-stress tests and serial ultrasounds to assess fetal growth are recommended. Additionally, monitor for disease progression by assessing blood pressure, serial labs, and asking about symptoms of preeclampsia with severe features.
If maternal and fetal status are reassuring, you can wait until 37 weeks to deliver the fetus. Vaginal delivery is appropriate unless there are contraindications like fetal malpresentation or prior classical C-section.While intrapartum, closely monitor maternal and fetal status for evidence of severe features, as they require additional interventions.
In the postpartum period, schedule a short-interval blood pressure check, and discuss return precautions if they experience signs and symptoms of preeclampsia with severe features.
Half of all patients with gestational hypertension will eventually develop preeclampsia, with those diagnosed prior to 32 weeks at highest risk.
This is why close monitoring for disease progression is so important!Now let’s talk about patients who have proteinuria.

Preeclampsia5:19–8:00

Patients with new-onset hypertension after 20 weeks gestation plus proteinuria meet the diagnosis of preeclampsia. Proteinuria is defined as a urine protein-to-creatinine ratio greater than or equal to 0.3, or a 24-hour urine collection with at least 300 mg of protein.
Once you’ve diagnosed preeclampsia, next 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 like thrombocytopenia with a platelet count of less than 100,000, renal insufficiency with a creatinine greater than 1.1, elevated liver function tests greater than two times the upper limit of normal; and signs or symptoms such as pulmonary edema, new-onset headache that does not improve with medication, visual symptoms 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 the outpatient setting. Consider starting an antihypertensive if blood pressure is persistently above 140 systolic, 90 diastolic, or both.
Initiate antenatal fetal surveillance with non-stress tests and serial ultrasounds, and monitor for severe features with serial labs and symptomatology.
As long as they remain asymptomatic for severe features with reassuring blood pressure, fetal status, and labs, vaginal delivery at 37 weeks is recommended.
While intrapartum, start an antihypertensive if elevated blood pressures occur, and perform close maternal and fetal monitoring.
After delivery, schedule patients for a short interval blood pressure check, and review return precautions if they experience signs and symptoms of preeclampsia with severe features.Okay, let’s go back to severe features.

Preeclampsia with Severe Features8:00–9:56

Patients who have at least one severe feature are diagnosed with preeclampsia with severe features. Admit them 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 as well.
Start 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, wait and deliver the fetus at 34 weeks, or at the time of diagnosis if further along.Now, some patients might become unstable, which is when blood pressures aren’t controlled on antihypertensives, when labs are abnormal or worsening, or when symptoms of headache, visual changes, right upper quadrant or epigastric pain don’t resolve.
If this happens, don’t wait until 34 weeks to deliver, but do it right away! Vaginal delivery is appropriate unless contraindicated.
While intrapartum, control severe-range blood pressures, consider starting or titrating maintenance antihypertensives, and administer magnesium sulfate.
Monitor fluid status to prevent volume overload and pulmonary edema, and keep a close eye on maternal and fetal status. After 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.

HELLP Syndrome9:56–11:33

Now, let's review a severe form of preeclampsia called HELLP Syndrome. HELLP is named after its hallmark lab findings of Hemolysis, as demonstrated by elevated LDH higher than 600; Elevated Liver function tests of more than twice the upper limit of normal, and Low Platelets lower than 100.
Patients may also have proteinuria, right upper quadrant pain with generalized malaise, and severe-range blood pressure.
HELLP syndrome can rapidly progress, so act quickly! Begin treatment with magnesium sulfate, control severe-range blood pressures, and deliver the fetus; vaginal delivery is appropriate unless contraindicated.
In labor, consider maintenance antihypertensive medication, control severe-range blood pressures, continue magnesium sulfate, and monitor maternal and fetal status.
These patients are at increased risk for disseminated intravascular coagulation or DIC, so watch closely for bleeding from wound or IV sites and coagulopathy.
While postpartum, continue antihypertensives as indicated and magnesium sulfate for 24 hours. Additionally, monitor labs for return to baseline.
Have patients follow up shortly after discharge for a blood pressure check, and give them return precautions for preeclampsia with severe features.
We’ve covered a lot, so let’s end with eclampsia. Eclampsia is diagnosed by a new-onset seizure in pregnancy that’s not explained by another reason like an epilepsy, stroke, or drug use.

Eclampsia11:33–13:30

Prior to seizing, patients may have warning signs of cerebral irritation, like severe occipital or frontal headaches, visual symptoms of blurry vision or photophobia, and possible altered mental status.
A majority of patients who develop eclampsia will present with the classic signs of preeclampsia, like hypertension or proteinuria; however, a small proportion will not.Eclampsia must be managed quickly, so immediately call for help and activate an emergency response team.
Provide maternal cardiorespiratory support by first placing the patient on their left side, suctioning their airway to prevent aspiration, administering oxygen, and monitoring vital signs.
Most eclamptic seizures will resolve without medication, but if seizures continue, you can administer medications like benzodiazepines.Once the seizure has stopped, start magnesium sulfate to prevent a recurrence, and control severe-range blood pressures with antihypertensives.
Once the patient is stabilized, deliver the fetus; vaginal delivery is appropriate unless contraindicated.While intrapartum, continue antihypertensives, magnesium sulfate, close maternal and fetal monitoring, and fluid management.
After delivery, continue antihypertensive medications as needed, and magnesium sulfate for 24 hours. After discharge, have them come in for a short interval blood pressure check, and be sure to give return precautions for signs or symptoms of worsening disease.

Review13:30–14:28

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.Alright, as a quick recap...
Patients with gestational hypertension or preeclampsia without severe features are managed with antenatal fetal surveillance, monitoring for disease progression, and delivery at 37 weeks, or at the time of diagnosis if after 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.
Finally, HELLP syndrome and eclampsia are severe forms of preeclampsia and require magnesium sulfate and immediate delivery.