From the Guidelines
Diagnosing superimposed preeclampsia in women with chronic hypertension requires careful monitoring for new-onset proteinuria or sudden worsening of existing hypertension after 20 weeks of gestation, with diagnosis made when a woman with pre-existing hypertension develops new-onset proteinuria or experiences sudden blood pressure increases requiring medication adjustments, as defined by the 2013 ACOG Hypertension in Pregnancy Task Force 1. To diagnose superimposed preeclampsia, the following criteria should be considered:
- New-onset proteinuria, defined as a 50% increase in proteinuria compared to baseline pre-pregnancy or first trimester proteinuria, or a urine protein/creatinine ratio (UPC) ≥ 0.5 with a baseline UPC ≥ 0.3 1
- Sudden increase in blood pressure, defined as previously well-controlled blood pressure that worsens to severe range blood pressure (≥160 mmHg systolic or ≥105 mmHg diastolic) despite escalation of antihypertensive therapy 1
- Other signs of maternal organ dysfunction, such as thrombocytopenia (platelets <100,000/μL), elevated liver enzymes (twice normal), renal insufficiency (creatinine ≥ 1.1 mg/dL), pulmonary edema, or neurological symptoms like severe headaches or visual disturbances 1 Blood pressure measurements should be taken correctly using an appropriately sized cuff after the patient has been seated quietly for 5-10 minutes. Protein measurement should ideally be done with a 24-hour urine collection, though spot protein/creatinine ratio can be used for initial assessment. Laboratory tests should include complete blood count, comprehensive metabolic panel, uric acid, and urinalysis. The diagnosis of superimposed preeclampsia is critical, as it can progress rapidly to severe complications, including eclampsia, HELLP syndrome, and placental abruption, making prompt diagnosis and management essential for maternal and fetal wellbeing 1.
From the Research
Diagnosing Superimposed Preeclampsia
To diagnose superimposed preeclampsia, the following criteria should be considered:
- New onset hypertension after the 20th week of pregnancy with proteinuria 2
- Systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg 3
- Proteinuria is defined as 300 mg or more of protein in a 24-hour urine collection or a protein: creatinine ratio of 0.3 mg/dL using a spot urine specimen 2
- However, proteinuria is no longer required for the diagnosis of preeclampsia, according to the American College of Obstetricians and Gynecologists 3
Clinical Signs and Symptoms
Clinical signs and symptoms of superimposed preeclampsia may include:
- Hypertension
- Proteinuria
- Renal impairment
- Thrombocytopenia
- Epigastric pain
- Liver dysfunction
- Hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome
- Visual disturbances
- Headache
- Seizures 3
Severity Criteria
Severity criteria for superimposed preeclampsia include:
- Severe hypertension (SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg)
- Thrombocytopenia < 100.000/μL
- Liver transaminases above twice the normal values
- HELLP syndrome
- Renal failure
- Persistent epigastric or right upper quadrant pain
- Visual or neurologic symptoms
- Acute pulmonary edema 3
Management
Management of superimposed preeclampsia depends on the severity of the disease and may include: