DIAGNOSIS PREEKLAMPSIA DAN

SUSPECT COVID-19
BERDASARKAN GEJALA KLINIS
DAN HASIL LABORATORIUM
Clinical presentation and
workup findings

Clinical and laboratory tests are intended to

define and determine the severity of pre-
eclampsia.
Headaches, tinnitus, phosphene signals, visual
disorders, brisk tendon reflexes, and vigilance
disorders are related to cerebral edema;
oliguria to acute renal failure; uterine
contraction, vaginal bleeding to placental
abruption; vomiting to HELLP syndrome; band-
like epigastric pain to subcapsular hepatic
hematoma; and dyspnea to cardiac failure. 
The fetus should be assessed by electrocardiotocography.
Laboratory tests include:
a complete blood count with platelets, haptoglobin, and lactate
dehydrogenase;
a blood smear to test for schistocytes;
bilirubin, aspartate transaminase, and alanine transaminase in order
to identify potential HELPP syndrome;
electrolyte, urea, and creatinine assessment to check for acute renal
failure or uremia;
24-hour proteinuria;
prothrombin, activated thrombin time, and fibrinogen
(microangiopathic hemolytic anemia);
blood group; and irregular antibody screening.

Other examinations include fetal ultrasound with Doppler

velocimetry of the umbilical, cerebral, and uterine arteries, estimation
of fetal weight, assessment of fetal well-being by Manning score, and
examination of the placenta.
Although the definition of severe pre-eclampsia varies,
several components of this definition are usually accepted:
• maternal systolic blood pressure ≥160 mmHg or diastolic
blood pressure ≥110 mmHg;
• maternal neurological disorders such as persistent
headaches, phosphene signals, tinnitus, and brisk,
diffuse, polykinetic tendon reflexes, eclampsia, acute
pulmonary edema, proteinuria ≥5 g/day, oliguria <500
cc/day, creatinine >120 μmol/L, HELLP syndrome,
thrombocytopenia <100,000/mm3, and fetal criteria,
especially intrauterine growth retardation,
oligohydramnios, or fetal death in utero.
Mild pre-eclampsia is defined as diastolic blood pressure
≥90 mmHg measured on two occasions at least 6 hours
apart, combined with proteinuria (two or more occurrences
of protein on dipstick, >300 mg total protein in a 24-hour
urine collection, or a protein creatinine ratio >30
mg/mmol).
Clinical Definition of Preeclampsia

Classically, the American College of Obstetrics and Gynecology (ACOG)

defines preeclampsia as the presence of hypertension and proteinuria
occurring after 20 weeks of gestation in a previously normotensive patient.
However, a significant proportion of women develop systemic manifestations
of preeclampsia—such as low platelets or elevated liver enzymes—before
the hallmark of proteinuria is detectable, resulting in delayed diagnoses.
The evolving understanding of preeclampsia as a heterogeneous hypertensive
disorder of pregnancy led to ACOG’s hypertension 2013 task force to revise
the definition of preeclampsia to include the presence of severe features with
or without proteinuria and to exclude degree of proteinuria as a criterion of
severe features. These criteria were confirmed more recently in an update of
the ACOG’s practice guidelines.
Preeclampsia with severe features is defined as the
presence of one of the following symptoms or signs
in the presence of preeclampsia  :

• SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher, on two occasions at

least 4 hours apart while the patient is on bed rest (unless antihypertensive therapy
has previously been initiated)
• Impaired hepatic function as indicated by abnormally elevated blood concentrations
of liver enzymes (to double the normal concentration), severe persistent upper
quadrant or epigastric pain that does not respond to pharmacotherapy and is not
accounted for by alternative diagnoses, or both.
• Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL or a
doubling of the serum creatinine concentration in the absence of other renal disease)
• New onset cerebral or visual disturbances
• Pulmonary edema
• Thrombocytopenia (platelet count < 100,000/μL)
In a patient with new-onset hypertension without
proteinuria, the new onset of any of the following is
diagnostic of preeclampsia:

• Platelet count below 100,000/μL

• Serum creatinine level above 1.1 mg/dL or doubling of
serum creatinine in the absence of other renal disease
• Liver transaminase levels at least twice the normal
concentrations
• Pulmonary edema
• Cerebral or visual symptoms
Patients with preeclampsia with severe features display end-organ
effects and may complain of the following:
– Headache
– Visual disturbances: Blurred, scintillating scotomata
– Altered mental status
– Blindness: May be cortical [3] or retinal
– Dyspnea
– Edema: Sudden increase in edema or facial edema
– Epigastric or right upper quadrant abdominal pain
– Weakness or malaise: May be evidence of hemolytic anemia
– Clonus: May indicate an increased risk of convulsions

Diagnosis
All women who present with new-onset hypertension should have the
following tests:
– CBC
– Serum alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels
– Serum creatinine
– Uric acid
– 24-hour urine collection for protein and creatinine (criterion
standard) or urine dipstick analysis
The following symptoms
may indicate COVID-19:

• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
 Diagnosis of COVID-19

– COVID-19 should be considered a possibility in (1) patients with respiratory tract symptoms
and newly onset fever or (2) in patients with severe lower respiratory tract symptoms with no
clear cause. Suspicion is increased if such patients have been in an area with community
transmission of SARS-CoV-2 or have been in close contact with an individual with confirmed
or suspected COVID-19 in the preceding 14 days.
– Microbiologic (PCR) testing is required for definitive diagnosis. At present, such testing is of
limited availability.
– Patients who do not require emergency care are encouraged to contact their healthcare provider
over the phone. Patients with suspected COVID-19 who present to a healthcare facility should
prompt infection-control measures. They should be evaluated in a private room with the door
closed (an airborne infection isolation room is ideal) and asked to wear a surgical mask. All
other standard contact and airborne precautions should be observed, and treating healthcare
personnel should wear eye protection. [21]
Lower Respiratory Tract Specimens
– Bronchoalveolar lavage, tracheal aspirate
– Two to 3 mL should be collected in a sterile, leak-proof, screw-cap sputum collection cup or sterile, dry container.
– Sputum
– The patient should rinse his or her mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof,
screw-cap sputum collection cup or sterile, dry container.
Upper Respiratory Tract Specimens
– Nasopharyngeal swab/oropharyngeal swab
– Only synthetic fiber swabs with plastic shafts should be used. Calcium alginate swabs or swabs with wooden shafts—both of
which may contain substances that inactivate some viruses and inhibit polymerase chain reaction (PCR) testing—should not be
employed. Swabs should immediately be placed in sterile tubes containing 2-3 mL of viral transport media.  In general, the
CDC recommends that only an NP should be collected. If an OP is collected as well, it should be combined at collection with
the NP in a single vial.
– To collect an NP, the swab should be inserted into the nostril parallel to the palate, reaching a depth equal to the distance from
the nostrils to the ear’s outer opening. To absorb secretions, the swab should be left in place for several seconds. It should then
be slowly removed while the clinician rotates it.
– In collecting an OP (eg, a throat swab), the posterior pharynx should be swabbed, with avoidance of the tongue.
Nasopharyngeal wash/aspirate or nasal aspirate
– Two to 3 mL should be collected in a sterile, leak-proof, screw-cap sputum collection cup or sterile, dry container.
Storage
– Specimens should be stored at 2-8°C for up to 72 hours after collection.  If testing or shipping may be delayed, the specimens
should be stored at -70°C or below.
References

 Emedicine.medscape.com. 2020. Preeclampsia: Practice Essentials,

Overview, Pathophysiology. [online] Available at:
<https://emedicine.medscape.com/article/1476919-overview#a1>
 NCBI Journal
Rana, Sarosh et al. “Preeclampsia: Pathophysiology, Challenges, and
Perspectives.” Circulation research vol. 124,7 (2019): 1094-1112.
doi:10.1161/CIRCRESAHA.118.313276
Uzan, Jennifer et al. “Pre-eclampsia: pathophysiology, diagnosis, and
management.” Vascular health and risk management vol. 7 (2011):
467-74. doi:10.2147/VHRM.S20181