Preeclampsia, Eclampsia, and HELLP Syndrome

Definition/Etiology:

Preeclampsia usually presents >34 weeks, and is characterized by new-onset  hypertension/proteinuria or hypertension/end-organ dysfunction.

During pregnancy, HTN is SBP >140 or DBP >90.  Severe HTN is SBP >160 or DBP>110.

Eclampsia is a new-onset tonic-clonic seizure or coma in a patient with preeclampsia who does not already have another neurological cause for seizures.

HELLP is a syndrome in pregnant or post-partum women who develop Hemolysis, Elevated Liver enzymes, and Low Platelets.  Symptoms usually resolve at birth, which is commonly preterm.  Complications are usually related to bleeding.

There is some overlap between pre-eclampsia, eclampsia, and HELLP, but it is not a continuum.

Pathophysiology:

Preeclampsia and eclampsia are caused by abnormal development of blood vessels in the placenta. 

Cause of seizures and development of eclampsia is unclear.  It can also occur in the first/second week post-partum.

Pathogenesis of HELLP is unclear. Patients develop small clots in small vessels, causing acute kidney injury and liver injury.  It can be similar to DIC (disseminated intravascular coagulopathy).

Clinical Presentation:

Preeclampsia/Eclampsia:

• Headache
• Altered mental status
• Visual changes
• Pulmonary edema (dyspnea, orthopnea, pink/frothy sputum)
• Hyper-reflexia
• Oliguria
• Seizure (in eclampsia)
• Fetal bradycardia is common after maternal seizure

HELLP:

• Rapid onset, usually late 2nd trimester, but sometimes can be post-partum
• RUQ/epigastric pain
• Elevated AST/ALT
• Nausea/vomiting
• Occasional jaundice/ascites
• >140/90 in 85% of cases
• Proteinuria in 85% of cases

HELLP mortality related to:

• Placental abruption
• Liver hematoma
• Acute kidney injury
• DIC develops in 21% of cases

Collaborative Management:

Testing:

• CMP, coags, CBC, type/cross
• Peripheral blood smear (looks for fragmented RBCs)
• Urinalysis with micro
• Fetal monitoring
• Fetal ultrasound
• Uterine ultrasound
• Liver ultrasound
• Chest x-ray

Medications:

• Labetalol drip to manage BP
• Low-dose aspirin can sometimes prevent preeclampsia.
• Magnesium drip to prevent seizures and for fetal neuroprotection

HELLP: 

• Monitor RUQ pain, which could indicate hepatic rupture.  Can radiate to back and shoulder.
• Monitor for hypovolemic shock (hypotension with tachycardia).
• Surgical team experienced in liver trauma

Eclampsia:

• Neuro consult 
• Maternal oxygen if seizing
• Brain MRI
• EEG

Evaluation | Patient Monitoring | Education:

• Monitor for hypovolemic shock
• Continuous maternal cardiac monitor
• Fetal heart rate monitor
• Serial labs
• Protect from trauma in seizure
• Continuous oxygen saturation monitoring
• Maternal oxygen PRN

Linchpins: (Key Points)

• Delivery is the cornerstone of treatment.
• HELLP can develop DIC.
• Preeclampsia can look like heart failure.
• Add maternal oxygen during seizures.