What are the clinical symptoms and signs of preeclampsia in a pregnant woman after 20 weeks gestation?

Clinical Symptoms and Signs of Preeclampsia

Preeclampsia after 20 weeks of gestation presents with new-onset hypertension (≥140/90 mmHg) combined with either proteinuria or evidence of maternal organ dysfunction, and clinicians must actively assess for specific symptoms including headache, visual disturbances, epigastric pain, and vomiting at every antenatal visit. 1

Cardinal Diagnostic Features

Hypertension (Required)

• Blood pressure ≥140 mmHg systolic or ≥90 mmHg diastolic confirmed on two separate occasions at least 15 minutes apart 1
• Must represent new onset after 20 weeks of gestation in previously normotensive women 2
• Severe hypertension defined as BP ≥160/110 mmHg 3

Proteinuria or Organ Dysfunction (Required)

• Proteinuria ≥300 mg/24 hours when present 1
• However, proteinuria is no longer required for diagnosis if maternal organ dysfunction is present 1, 4

Key Clinical Symptoms to Assess

At every assessment after 20 weeks, actively screen for these symptoms: 2

Neurological Symptoms

• Headache (persistent, severe, unresponsive to treatment) 2
• Visual disturbances (blurred vision, scotomata, photophobia) 2
• These symptoms indicate severe features requiring immediate evaluation 3

Gastrointestinal Symptoms

• Epigastric pain (severe, persistent right upper quadrant or epigastric pain) 2, 3
• Vomiting 2
• These symptoms suggest liver involvement or capsular distension 3

Fetal-Related Signs

• Reduced fetal movements 2
• Small for gestational age infant 2

Physical Signs and Laboratory Evidence of Organ Dysfunction

Renal Dysfunction

• Serum creatinine ≥1.1 mg/dL or doubling of baseline creatinine 1, 3
• New-onset proteinuria (≥+ on dipstick on more than one occasion) 2

Hepatic Dysfunction

• Liver transaminases ≥2× upper limit of normal 3, 4
• Severe persistent right upper quadrant pain 3

Hematological Dysfunction

• Platelet count <100,000/µL (progressive thrombocytopenia) 3, 4
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) 3, 4

Neurological Complications

• New cerebral or visual symptoms unresponsive to treatment 3
• Hyperreflexia and clonus 5

Pulmonary Complications

• Pulmonary edema 3, 4

Cardiovascular Signs

• Edema (though not specific) 5

Critical Clinical Pitfalls

Timing Considerations

• Preeclampsia by definition cannot be diagnosed before 20 weeks' gestation 2
• Rare exceptions include molar pregnancy or fetal triploidy, which can present with preeclampsia-like features before 20 weeks 6

Severity Assessment

• Proteinuria does not define severity - even a single severe feature mandates management as severe disease regardless of proteinuria level 3
• The term "severe preeclampsia" should not be used in clinical practice according to ISSHP; instead use "preeclampsia with severe features" 2

Progressive Nature

• Transient gestational hypertension (BP elevations that settle with repeated readings) carries a 40% risk of progressing to true gestational hypertension or preeclampsia, requiring close follow-up 2, 3
• Even modest BP elevations (130-139/80-89 mmHg) after 20 weeks increase risk of developing preeclampsia with severe features 7

Referral Thresholds Based on Symptoms and Signs

Same-Day Hospital Assessment Required

• Diastolic BP ≥90 and <100 mmHg with proteinuria ≥+ on dipstick 1
• Any severe features present 3

Hospital Assessment Within 48 Hours

• Diastolic BP ≥90 and <100 mmHg without proteinuria 1

Immediate Delivery Consideration

• Non-reassuring fetal status 3
• Maternal end-organ dysfunction at any gestational age 4

Postpartum Presentation

Preeclampsia can develop or persist postpartum (48 hours to 6 weeks after delivery) with the same symptoms: 1, 5

• New-onset hypertension ≥140/90 mmHg 1
• Right upper quadrant/epigastric pain 5
• Headache and visual disturbances 5
• Hyperreflexia and clonus 5
• Eclampsia can still occur postpartum, requiring continued vigilance 5