What indicates end organ dysfunction in a pregnant woman with preeclampsia?

End Organ Dysfunction Indicators in Preeclampsia

End organ dysfunction in preeclampsia is indicated by renal impairment (creatinine >1.1 mg/dL or doubling of baseline), thrombocytopenia (platelets <100,000/µL), hepatic involvement (transaminases ≥2× upper limit of normal or severe right upper quadrant/epigastric pain), neurological complications (new-onset headache unresponsive to medication, visual disturbances, or seizures), or pulmonary edema. 1, 2

Renal Dysfunction

• Serum creatinine >1.1 mg/dL or a doubling of baseline creatinine indicates significant renal impairment in pregnancy, where normal creatinine levels are typically lower than non-pregnant values. 2
• Oliguria <400 mL/24 hours represents severe renal dysfunction and warrants immediate evaluation. 1
• Acute tubular necrosis, cortical necrosis, and hematuria may develop as progression markers of renal end organ damage. 1

Hematologic Dysfunction

• Platelet count <100,000/µL is the threshold for clinically significant thrombocytopenia indicating severe disease and end organ dysfunction. 1, 2
• Platelet counts <150,000/µL may indicate mild thrombocytopenia but do not meet criteria for severe features. 2
• The degree of thrombocytopenia correlates well with the degree of liver dysfunction in HELLP syndrome. 1
• Hemolytic anemia with evidence of microangiopathic hemolysis on peripheral blood smear indicates severe disease. 1, 3

Hepatic Dysfunction

• Liver transaminases ≥2 times the upper limit of normal indicate hepatic involvement resulting from liver capsule distension due to hepatic edema and potential hemorrhage. 2, 4
• Severe persistent right upper quadrant or epigastric pain is a clinical indicator of hepatic involvement even before laboratory abnormalities appear. 1, 2
• Upper abdominal tenderness, jaundice, and nausea/vomiting may accompany hepatic dysfunction. 1
• Rare but catastrophic complications include subcapsular hematomas and acute liver rupture. 3

Neurological Dysfunction

• New-onset cerebral or visual disturbances such as headache unresponsive to medication, blurred vision, scotomata, or cortical blindness indicate cerebral edema and increased risk of eclamptic seizures. 2, 4
• Persistent headache in the presence of hypertension should be considered part of preeclampsia until proven otherwise. 1
• Visual symptoms including photopsia and visual field defects represent end organ damage to the central nervous system. 4
• Eclamptic seizures represent the most severe manifestation of neurological end organ dysfunction. 4

Pulmonary Dysfunction

• Acute pulmonary edema is a life-threatening manifestation of end organ dysfunction in preeclampsia. 4, 5
• Respiratory failure may develop as a complication of severe disease. 1
• Chest X-ray should be obtained to exclude early pulmonary edema in severe cases. 1

Uteroplacental Dysfunction

• Fetal growth restriction in the context of new-onset gestational hypertension, even without other maternal features, should be considered to define preeclampsia as it reflects placental end organ dysfunction. 1
• Abnormal umbilical artery Doppler waveform analysis or stillbirth indicate severe uteroplacental dysfunction. 1

Critical Diagnostic Considerations

• Proteinuria is NOT required for diagnosis of preeclampsia if end organ dysfunction is present—approximately 25% of preeclampsia cases occur without proteinuria. 1, 6
• The degree of proteinuria does NOT correlate with disease severity or outcomes and should NOT be used to determine timing of delivery. 2, 6
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is considered part of the preeclampsia spectrum, not a separate disorder, and represents severe end organ dysfunction. 1, 3

Hypertensive Emergency Criteria

• Severe hypertension (SBP ≥160 mmHg or DBP ≥110 mmHg) with progressive acute end organ damage defines hypertensive emergency in pregnancy, including aortic dissection, acute myocardial infarction, pulmonary edema, and respiratory failure. 1
• The majority of hypertensive emergencies occur with DBP >120 mmHg. 1

Laboratory Evaluation Algorithm

When encountering new-onset hypertension after 20 weeks without proteinuria, obtain the following to exclude end organ dysfunction: 1, 6

• Complete blood count with platelet count
• Comprehensive metabolic panel including serum creatinine
• Liver function tests (AST, ALT)
• Urine protein quantification (spot protein/creatinine ratio or 24-hour collection)
• Peripheral blood smear if hemolysis suspected

Any single severe feature mandates immediate management as severe disease regardless of other parameters. 2