How do you diagnose pre eclampsia with severe features versus pre eclampsia with non-severe features?

Diagnosis of Preeclampsia with Severe Features vs. Non-Severe Features

Preeclampsia is diagnosed when new-onset hypertension (≥140/90 mmHg) appears after 20 weeks of gestation, accompanied by either proteinuria OR evidence of maternal organ dysfunction or uteroplacental dysfunction—proteinuria is no longer required for diagnosis. 1, 2, 3

Core Diagnostic Criteria for Preeclampsia

Blood Pressure Requirements

• Systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg confirmed on two separate occasions at least 15 minutes apart 1, 2
• For severe hypertension (≥160/110 mmHg), confirmation should occur within 15 minutes 1
• Blood pressure must be measured with properly calibrated equipment using appropriate cuff size (large cuff if mid-upper arm circumference >33 cm) 1

Proteinuria Assessment (When Present)

• Initial screening with automated dipstick urinalysis; if ≥1+ (30 mg/dL), proceed to quantification 1, 4
• Abnormal proteinuria defined as spot urine protein/creatinine ratio ≥30 mg/mmol (0.3 mg/mg) or >0.3 g/24h 1, 2
• A negative dipstick can usually be accepted without further testing 1

Alternative Diagnostic Criteria (Without Proteinuria)

In the absence of proteinuria, preeclampsia can be diagnosed when gestational hypertension is accompanied by any of the following: 2

• Renal dysfunction: Serum creatinine ≥1.1 mg/dL or doubling of baseline 2, 3
• Hepatic dysfunction: Liver transaminases ≥2 times upper limit of normal 2, 3
• Hematological dysfunction: Thrombocytopenia <100,000/μL 2, 3
• Neurological complications: Severe headache, visual disturbances, eclampsia 2
• Pulmonary edema 2
• Uteroplacental dysfunction: Fetal growth restriction, abnormal umbilical artery Doppler, intrauterine fetal death 2

Distinguishing Severe Features from Non-Severe Features

Critical Concept

Do not attempt to clinically classify preeclampsia as "mild" versus "severe" because all cases may rapidly progress to emergencies. 1, 4 However, you must recognize severe features to guide immediate management decisions.

Preeclampsia WITH Severe Features (Any of the Following):

Blood Pressure Criteria

• Severe hypertension: Systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg 1, 3, 5
• Inability to control BP despite using ≥3 classes of antihypertensives in appropriate doses 1

Laboratory Criteria

• Thrombocytopenia <100,000/μL 4, 3
• Progressive thrombocytopenia (worsening platelet count over time) 1, 4
• Liver transaminases >2 times upper limit of normal, especially with right upper quadrant or epigastric pain 4, 3
• Progressively abnormal liver enzymes 1, 4
• Renal insufficiency: Serum creatinine ≥1.1 mg/dL or doubling of baseline creatinine 3
• Progressive deterioration in renal function 1, 4

Clinical Criteria

• Persistent severe headache unresponsive to medication 1, 3
• Visual disturbances (scotomata, cortical blindness, retinal vasospasm) 1, 3
• Persistent epigastric or right upper quadrant pain 1, 3
• Pulmonary edema (maternal pulse oximetry <90%) 1, 3
• Eclampsia (seizures) 1

Fetal Criteria

• Reversed end-diastolic flow on umbilical artery Doppler 1
• Non-reassuring fetal status 1
• Severe fetal growth restriction 3

Preeclampsia WITHOUT Severe Features

Diagnosed when hypertension ≥140/90 mmHg with proteinuria or organ dysfunction is present, but NONE of the severe features listed above are present. 1

Essential Laboratory Monitoring Protocol

Initial Assessment at Diagnosis

• Complete blood count (hemoglobin, platelet count) 4
• Liver function tests (transaminases) 4
• Renal function tests (creatinine, uric acid) 4
• Urinalysis and protein quantification 4
• Electrolytes 1

Ongoing Monitoring Frequency

• Minimum twice weekly blood tests for hemoglobin, platelet count, liver transaminases, creatinine, and uric acid in all women with preeclampsia 1, 4
• More frequent testing (every 2 days or daily) required with clinical deterioration or severe features 4, 6
• Blood pressure monitoring every 4 hours or more frequently if severe features present 6

Management Implications Based on Classification

Preeclampsia WITHOUT Severe Features

• Outpatient management may be considered once stability is established and patient is reliable 1
• Weekly clinic visits with laboratory testing and twice weekly non-stress tests 1
• Delivery indicated at ≥37 weeks gestation 1

Preeclampsia WITH Severe Features

• Immediate hospitalization required for daily surveillance 1
• Urgent antihypertensive treatment when BP ≥160/110 mmHg using nifedipine oral, labetalol IV, or hydralazine IV 1, 6
• Magnesium sulfate for seizure prophylaxis in women with severe hypertension and neurological symptoms 1, 6
• Delivery indicated at ≥34 weeks gestation 1
• Delivery at any gestational age if progressive thrombocytopenia, progressively abnormal liver/renal function, uncontrolled severe hypertension, neurological complications, pulmonary edema, or non-reassuring fetal status 1, 4

Critical Pitfalls to Avoid

• Never use uric acid or proteinuria levels alone as indications for delivery—these should not determine timing of delivery in isolation 1, 4
• Do not wait for proteinuria to diagnose preeclampsia—approximately 25% of cases lack proteinuria 2, 3
• Do not dismiss symptoms in the absence of severe hypertension—34% of eclamptic women had maximum diastolic BP ≤100 mmHg 1
• Headache is an independent risk factor for eclampsia and epigastric pain predicts serious morbidity—these symptoms mandate immediate assessment even without severe BP elevation 1
• Inadequate monitoring frequency (failure to perform twice weekly labs) may miss rapid disease progression 1, 4
• Edema is not predictive and should not be used for diagnosis or severity assessment 1