Preeclampsia: A

Patient Case
MICHAEL COMMONS
PGY1 PHARMACY RESIDENT
FRANCISCAN HEALTH INDIANAPOLIS
 Objectives

 Identify signs and symptoms of preeclampsia

 Recognize risk factors for preeclampsia
 Understand general treatment options for preeclampsia
 The Patient
 Patient: 29 YOF 36 weeks gestation
 Chief Complaint: patient came to the hospital feeling unwell with a
possible infection to the leg as well as bilateral lower extremity
edema
 PMH: Leg infection, ADHD, anxiety, depression
 Home medications: aripiprazole, and prenatal vitamins
 Inpatient medications: Iron sucrose, hydrocodone/acetaminophen,
aripiprazole, prenatal vitamins, and cefazolin
 Labs and Vitals
Urinalysis Liver Function • WBC: 15
WBC 6-10 AST 20 • Temp: 98.8
• Pulse: 94
Leukocyte Esterase Occasional ALT 18
• Blood pressure: 146/90  150/92
RBC 8-10 Alk. Phos 92 • BMI: 37
Specific Gravity >1.03 Albumin 2.7
Ketones Trace
Epithelial Cells Moderate
Urine Protein 100
140 106 13
Protein/Creatinine 0.4
Ratio 130
3.8 20 0.7
Bacteria Occasional
 Pathophysiology of Preeclampsia

Bisson C, et al. Preeclampsia pathophysiology doi:10.3389/fmed.2023.1144170

 Preeclampsia

What is preeclampsia?

• Newly diagnosed hypertension + one other key feature

• Normally after 20 weeks

Why is preeclampsia important?

• Increases the risk of complications for mother and child

• Increased healthcare associated costs

Gestational hypertension and preeclampsia. ACOG.

 Risk Factors for Preeclampsia

• BMI >30 kg/m^2

• ≥ 35 years old
• Chronic HTN
• Diabetes: gestational and pregestational
• Lupus
• Antiphospholipid syndrome, thrombophilia
• History of preeclampsia
• Kidney disease
• Sleep apnea
• History of multiple pregnancies as well as no history pregnancy

Gestational hypertension and preeclampsia. ACOG.

 The Diagnosis of Preeclampsia
Proteinuria:
≥300 mg in 24 hours
Protein/creatinine ratio ≥0.3
Blood Pressure: Dipstick reading of 2+
SBP ≥140 mmHg or DBP ≥90 mmHg
- two readings >4 hours apart
- >20 weeks of pregnancy
OR Miscellaneous:
SBP ≥160 mmHg or DBP ≥110 mmHg Thrombocytopenia <100,000
SCr >1.1 mg/dL or a doubling of SCr
Doubling of LFTs
Pulmonary edema
New-onset headache from no other cause
and refractory to treatment

Gestational hypertension and preeclampsia. ACOG.

 Preeclampsia with Severe Features

• SBP ≥160 mmHg or DBP ≥110 mmHg

• Two readings >4 hours apart
• Platelets <100,000
• LFTs >2 x the upper limit of normal or severe upper right quadrant pain or epigastric pain
• SCr >1.1 mg/dL or doubling of SCr
• Pulmonary edema
• Headache unresponsive to treatment
• Visual disturbances (blurred vision etc.)

Gestational hypertension and preeclampsia. ACOG.

 Prevention of Preeclampsia
Recommended Agents

• Low dose aspirin

Agents Lacking Evidence

• Vitamin C, D, E, and B9
• Fish oil
• Garlic
• Sodium restriction
• Calcium

Gestational hypertension and preeclampsia. ACOG.

 Who Should get Aspirin?
Consider Low dose Aspirin not
Low dose aspirin
aspirin recommended
• History of • Obesity • Previous health
preeclampsia • Family history of pregnancy with no
• Diabetes preeclampsia issues
• Renal disease • ≥35 years old
• Autoimmune diseases • African American
• Multifetal gestation • Socioeconomic status
• Nulliparity

Gestational hypertension and preeclampsia. ACOG.

 Aspirin in Preeclampsia
Proposed Mechanism

• Inhibition of thromboxane

Dosing

• Low dose aspirin (81 mg daily)

Guideline Recommendation

• Initiate between 12 and 28 weeks and continue through the remainder of the
pregnancy
Gestational hypertension and preeclampsia. ACOG.
Rolnik DL, et al. Prevention of preeclampsia with aspirin. doi:10.1016/j.ajog.2020.08.045
 Discontinuing Aspirin Early

Methods

• Multicenter, open-label, non-inferiority study, and randomized 1:1

• Located in Spain

Inclusion Criteria

• ≥18 years old, living single pregnancy, 24 to 28 weeks gestational age, high risk of preterm
preeclampsia, and sFlt-1PlGF ratio of ≤ 38

Study Groups n=936

• Standard of care n=463: Aspirin 150 mg daily through completion of pregnancy

• Intervention n=473: Stopped taking aspirin at randomization of 24-28 weeks

Mendoza M, et al. Aspirin doi:10.1001/jama.2023.0691

 Discontinuing Aspirin Early
Primary Endpoint
• Preterm preeclampsia (delivery before 37 weeks due to preeclampsia)

Secondary Endpoints
• Preeclampsia <34 weeks, preeclampsia <37 weeks, and adverse outcomes associated with
pregnancy

Definition of Preeclampsia
• Blood pressure SBP ≥140 mmHg, DBP ≥90 mmHg, or worsening of previous HTN +
proteinuria/creatinine ratio ≥0.3 or worsening of proteinuria
• One or more: cerebral/visual disturbances, doubling of LFTs, platelets <100,000 u/L, SCr >1.1
mg/dL, or pulmonary edema

Mendoza M, et al. Aspirin doi:10.1001/jama.2023.0691

 Results
Primary Endpoints
Outcome Aspirin Discontinuation Control Incidence difference
n=473 n=463
Preterm preeclampsia 7(1.48) 8(1.73) -0.25(-1.86 to 1.36)
Non-inferiority defined as the upper limit of the confidence interval <1.9

Primary Endpoints
Outcome Aspirin Discontinuation Control Incidence difference
n=473 n=463
AE <34 weeks 7(1.48) 7(1.51) -0.03(-1.59 to 1.52)
AE <37 weeks 27(5.71) 25(5.4) 0.31(-2.63 to 3.24)
AE ≥37 weeks 63(13.32) 85(18.38) -5.04(-9.71 to -0.37)

Mendoza M, et al. Aspirin doi:10.1001/jama.2023.0691

 Hypertension Management in
Preeclampsia
Blood Pressure Medications
10-20 mg IV, followed by 20-80 mg q20-30 min: Max
300 mg
Labetalol Continuous infusion @ 1-2 mg/min Well tolerated
Normal dose: 200-1,400 mg/day in divided doses
5 mg IV/IM followed by 5-10 mg IV q20-40 min Hypotension,
Hydralazine Continuous infusion 0.5-10 mg/hr headaches, and
abnormal fetal heart
rate
10-20 mg orally q30 minutes followed by 10-20 mg q2- Reflex tachycardia
Nifedipine 6 hours and headaches
Normal dose: 30-120 mg/day in divided doses
Methyldopa 500-3,000 mg/day in divided doses
 Eclampsia

Definition • Development of seizures

• Frontal/occipital headaches, blurred vision, photophobia,

Predictors abdominal pain or altered mental status

• Magnesium sulfate 4-6 grams IV over 15-30 minutes followed

Treatment by 1-2 grams/hour for 24 hours after induction

Gestational hypertension and preeclampsia. ACOG.

 What patients should receive
magnesium?
Preeclampsia
WITH severe Eclampsia
features

Prevention Prevention

Treatment

Gestational hypertension and preeclampsia. ACOG.

 Mechanism of Magnesium

NDMA? Vasodilation?

Preventing cerebral edema?

Euser AG et al. Magnesium Sulfate doi:10.1161/STROKEAHA.108.527788.

What criteria did the
patient have for
preeclampsia?
 Labs and Vitals
Urinalysis Liver Function • WBC: 15
WBC 6-10 AST 20 • Temp: 98.8
• Pulse: 94
Leukocyte Esterase Occasional ALT 18
• Blood pressure: 146/90  150/92
RBC 8-10 Alk. Phos 92 • BMI: 37
Specific Gravity >1.03 Albumin 2.7
Ketones Trace
Epithelial Cells Moderate
Urine Protein 100
140 106 13
Protein/Creatinine 0.4
Ratio 130
3.8 20 0.7
Bacteria Occasional
 Conclusion

 The patient did have preeclampsia per the urine creatinine/protein

ratio of > 0.3
 The patient was not treated with aspirin as prevention, however, did
have risk factors for preeclampsia: 1st pregnancy, obesity, and low
socioeconomic status
Preeclampsia: A
Patient Case
MICHAEL COMMONS
PGY1 PHARMACY RESIDENT
FRANCISCAN HEALTH INDIANAPOLIS