I. Definition

  1. EPH gestosis: Edema, Proteinuria, Hypertension

II. Epidemiology

  1. Incidence
    1. All pregnancies: 6-8%
    2. Preterm births: 20%
  2. Mortality: 100,000 maternal deaths per year worldwide
    1. Accounts for 10-30% of all maternal deaths yearly

III. Pathophysiology

  1. Decreased Intravascular volume
    1. Hemoconcentrated
    2. Increased Hemoglobin
  2. Increased Vascular Resistance
  3. Endothelial Cell dysfunction
    1. Very active organ system (not just vessel lining)
    2. Surface Area >6300 square meters over 100g of tissue
    3. Associated findings
      1. Edema
      2. Proteinuria
  4. Coagulation abnormalities
  5. Multiple system effects by oxygen free radicals
    1. Perfusion and re-perfusion injury
    2. Lipid peroxidation
    3. Antioxidant Mechanisms are protective
  6. Trophoblastic Invasion
    1. Two phases
      1. First: Decidua
      2. Second: 12-18 weeks gestation
    2. Effects of PIH are reversed with Trophoblast delivery
  7. Model System
    1. Pregnant ewes
    2. Used to study prostaglandin synthesis inhibitor
  8. Hypertension is a major mental roadblock
    1. Prevents understanding and treatment of toxemia
    2. Hypertension is an effect of PIH, not a cause

IV. Classification

  1. Pregnancy Induced Hypertension (PIH)
    1. Hypertension without Proteinuria or pathologic edema (Gestational Hypertension)
    2. Preeclampsia with Proteinuria or pathologic edema
      1. Mild Preeclampsia
      2. Severe Preeclampsia
    3. Eclampsia
      1. Convulsions
      2. Proteinuria
      3. Edema
    4. HELLP Syndrome
      1. Hemolysis
      2. Elevated Liver Function Tests
      3. Low Platelets
  2. Coincidental Hypertension
    1. See Chronic Hypertension in Pregnancy
    2. Pregnancy Aggravated Chronic Hypertension
      1. Superimposed Preeclampsia
      2. Superimposed Eclampsia

V. Risk Factors

  1. Primigravid or new paternity
  2. Family History of Preeclampsia (25%)
  3. Diabetes Mellitus
  4. Multiple Gestation
  5. Obesity
  6. Maternal age >40 years
  7. Preexisting Hypertension
  8. Angiotensin gene T235
  9. Antiphospholipid Syndrome
  10. Hydatiform mole
  11. Fetal hydrops

VI. Symptoms: Onset after 20 weeks gestation

  1. Hand and face edema
    1. Least reliable PIH indicator
    2. Absent in 33% of PIH cases
    3. Often present in healthy third trimester pregnancies
  2. Headache
  3. Visual disturbance
  4. Epigastric Pain

VII. Signs: General

  1. Excessive weight gain
  2. Hyperreflexia and Clonus
  3. Blood Pressure
    1. Assumes normal Blood Pressure before pregnancy
    2. Based on two supine Blood Pressures, 6 hours apart
    3. Mild Preeclampsia
      1. Blood Pressure exceeds 140/90
      2. Prior guideline: Relative BP increase 30/15
        1. NHLBI Working Group does not recommend using due to high False Positive Rate
        2. Use 140/90 cutoff for all pregnant patients
    4. Severe Preeclampsia
      1. Blood Pressure exceeds 160/110

VIII. Signs: Severe Preeclampsia

  1. Blood Pressure exceeds 160/110
  2. Proteinuria >5 grams per 24 hours (see labs below)
  3. Urine Output decreased
    1. Urine output less than 500 ml in 24 hours
  4. Increased Serum Creatinine
  5. Thrombocytopenia
  6. Pulmonary edema

IX. Labs

  1. Proteinuria is not a useful screening measure
    1. Proteinuria is a late finding
    2. Rely on BP and other measures for screening
    3. Proteinuria assesses degree of Pre-Eclampsia
  2. Urine Protein and 24 Hour Urine Protein
    1. Non-proteinuric Hypertension in Pregnancy
      1. Trace or no Urine Protein present
    2. Mild Preeclampsia
      1. Urine chemstrip exceeds 1+ protein (>0.3 g/liter)
        1. Based on 2 random urines >6 hours apart
      2. Urine Protein exceeds 300 mg in 24 hours
    3. Severe Preeclampsia
      1. Urine chemstrip exceeds 3+ protein
        1. Based on 2 random urines >6 hours apart
      2. Urine Protein exceeds 5 grams in 24 hours
  3. Urine for single Specimen protein to Creatinine ratio
    1. Correlates with 24 Hour Urine Protein
    2. PIH unlikely if protein to Creatinine ratio < 0.21
      1. Negative Predictive Value: 83%
    3. Confirm abnormal tests with 24 hour urine
    4. References
      1. Wheeler (2007) Am J Obstet Gynecol 196(5): 465 [PubMed] (or open in [QxMD Read])
      2. Young (1996) J Fam Pract 42:385-9 [PubMed] (or open in [QxMD Read])
  4. Complete Blood Count with platelets
    1. Thrombocytopenia seen in Severe Preeclampsia
  5. Serum Electrolytes
  6. Serum Creatinine (>0.9 in Severe Preeclampsia)
  7. Uric Acid
  8. Liver Function Tests
    1. Aspartate Aminotransferase
    2. Alanine Aminotransferase
    3. Serum Bilirubin
    4. Serum Albumin
    5. Lactic Acid dehydrogenase
  9. Coagulation Studies for Severe Preeclampsia or HELLP
    1. ProTime (PT)
    2. Partial Thromboplastin Time (aPTT)
    3. Fibrin split products (Fibrin Degradation Products)
    4. Fibrinogen

X. Diagnostic studies: fetus

XIII. Prevention

XV. Complications: Fetus

XVI. Course: Postpartum

  1. Most PIH cases improve in first 1-2 days after delivery
    1. Blood Pressure decreases
    2. Diuresis
  2. Eclampsia may occur after delivery (usually <24 hours)
    1. Consider continuing Magnesium Sulfate for 24 hours
    2. Continue to follow Blood Pressure and urine output
    3. Observe for signs of HELLP Syndrome
  3. Hypertension remits by 6-12 weeks postpartum

XVII. Prognosis

  1. Isolated Preeclampsia risks outside of pregnancy
    1. Confers future risk of Hypertension, vascular disease
    2. Wilson (2003) BMJ 326:845-9 [PubMed] (or open in [QxMD Read])
  2. Increased risk of Preeclampsia in future pregnancies
    1. All women with history of Preeclampsia
    2. Onset before 30 weeks gestation (40% recurrence risk)
    3. Black race
    4. Different father than prior gestation
    5. Preeclampsia previously in multiparous patient

Images: Related links to external sites (from Google)

Ontology: Pre-Eclampsia (C0032914)

Definition (NCI) A pregnancy-related disorder characterized by an increase in the blood pressure after the twentieth week of gestation, and by the presence of proteinuria. It may appear up to six weeks post-partum. It may lead to eclampsia with development of tonic-clonic seizures.
Definition (CHV) A condition of hypertension occurring in pregnancy
Definition (CHV) A condition of hypertension occurring in pregnancy
Definition (CHV) A condition of hypertension occurring in pregnancy
Definition (NCI) A pregnancy induced hypertensive state that occurs after 20 weeks of gestation characterized by an increase in blood pressure, along with body swelling and proteinuria.
Definition (MSH) A complication of PREGNANCY, characterized by a complex of symptoms including maternal HYPERTENSION and PROTEINURIA with or without pathological EDEMA. Symptoms may range between mild and severe. Pre-eclampsia usually occurs after the 20th week of gestation, but may develop before this time in the presence of trophoblastic disease.
Definition (CSP) pregnancy induced hypertensive states, including EPH gestosis when edema and proteinuria accompany hypertension; other hypertensive disorders that develop during pregnancy or the puerperium are preeclampsia and eclampsia, either of which may be superimposed upon chronic hypertensive vascular or renal disease.
Definition (CSP) toxemia occurring in women in the second half of their pregnancy, characterized by hypertension, and usually by edema and proteinuria, but without the convulsions and coma associated with eclampsia.
Concepts Pathologic Function (T046)
MSH D011225
ICD10 O14.9 , O14.90, O14
SnomedCT 6758009, 156109003, 198979002, 199011002, 237280005, 288201007, 15394000, 398254007, 156106005, 267306006, 46764007, 198972006
English Toxemia, preeclamptic, Pre Eclampsia, Preeclampsia, PREECLAMPSIA, TOXEMIA, TOXEMIA OF PREGNANCY, preeclampsia, MATERNAL TOXEMIA, Pre-eclampsia, NOS, Pre-eclamptic toxemia, NOS, Toxemia of pregnancy, NOS, EPH - Edema/prot/hyper, preg, EPH - Oedema/prot/hyper, preg, Prot hypertension of pregnancy, Toxaemia NOS, Toxemia NOS, Pre-eclampsia, unspecified, Pre-eclamptic toxaemia, NOS, Toxaemia of pregnancy, NOS, Toxemia (pre)eclampsia, PREG1, PREECLAMPSIA/ECLAMPSIA 1, PEE1, PEE, PREGN TOXEMIAS, PRE-ECLAMPSIA, Pre-eclampsia NOS, Pre-eclampsia NOS (disorder), Proteinuric hypertension of pregnancy (disorder), toxemia of pregnancy (diagnosis), pre-eclampsia, pre-eclampsia (diagnosis), toxemia of pregnancy, Pre-eclampsia toxemia, Toxemia NOS (disorder), Unspecified pre-eclampsia, unspecified trimester, Unspecified pre-eclampsia, Pre-Eclampsia [Disease/Finding], eph gestosis, toxemia pregnancy, toxaemia pregnancy, Toxaemia (in);pregnancy, maternal toxemia, pregnancy toxaemia, toxemia, pre eclampsia, pregnancy toxemias, pregnancy toxemia/hypertension, Toxemia, pregnancy toxemia, Toxemia of pregnancy, Pre-eclampsia, EPH - Edema, proteinuria and hypertension of pregnancy, EPH - Oedema, proteinuria and hypertension of pregnancy, Proteinuric hypertension of pregnancy, PE - Pre-eclampsia, PET - Pre-eclamptic toxaemia, PET - Pre-eclamptic toxemia, Pre-eclamptic toxaemia, Pre-eclamptic toxemia, Toxaemia of pregnancy, Pre-eclampsia (disorder), Toxemia of pregnancy (disorder), maternal; toxemia, pre-eclamptic; toxemia, pregnancy; pre-eclampsia, pregnancy; toxemia, toxemia; maternal, toxemia; pre-eclamptic, toxemia; pregnancy, Edema Proteinuria Hypertension Gestosis, Edema-Proteinuria-Hypertension Gestosis, EPH Complex, EPH Gestosis, EPH Toxemia, EPH Toxemias, Gestosis, Edema-Proteinuria-Hypertension, Gestosis, EPH, Gestosis, Hypertension-Edema-Proteinuria, Gestosis, Proteinuria-Edema-Hypertension, Hypertension Edema Proteinuria Gestosis, Hypertension-Edema-Proteinuria Gestosis, Pregnancy Toxemia, Pregnancy Toxemias, Proteinuria Edema Hypertension Gestosis, Proteinuria-Edema-Hypertension Gestosis, Toxemia, EPH, Toxemia, Pregnancy, Toxemias, EPH, Toxemias, Pregnancy, Pre-Eclampsia, Toxemia of Pregnancy, Pre-eclamptic NOS, Toxemia (in);pregnancy, toxemia in pregnancy, toxaemia in pregnancy
Portuguese PRE-ECLAMPSIA, Toxemia pré-eclâmptica, Toxemia da gravidez, Toxemia/(pre)eclampsia, Pré-eclampsia, Pré-Eclâmpsia, Toxemias Gravídicas
Dutch pre-eclampsie toxicose, zwangerschapvergiftiging, pre-eclamptische toxicose, zwangerschapstoxicose, Toxicose/(pre-)eclampsie, Zwangerschapstoxicose, maternaal; toxemie, preëclamptisch; toxemie, toxemie; preëclamptisch, toxemie; van moeder, toxemie; zwangerschap, zwangerschap; preëclampsie, zwangerschap; toxemie, Preëclampsie, niet gespecificeerd, pre-eclampsie, Preëclampsie, Vergiftiging, zwangerschaps-
French Toxémie prééclamptique, Eclampisme, PRE-ECLAMPSIE, Toxemie/preeclampsie, Pré-éclampsie, Prééclampsie, Toxémie gravidique, Éclampsisme
German Toxaemie bei Praeeklampsie, Toxaemie waehrend Schwangerschaft, EPH-Gestose, (Prae-)Eklampsie, Praeeklampsie, nicht naeher bezeichnet, Praeeklampsie, Präeklampsie
Italian Tossiemia pre-eclamptica, Tossiemia(pre)eclampsia, EPH-gestosi, Gestosi con edema, proteinuria e ipertensione, Tossiemia gravidica, Preeclampsia, Pre-eclampsia
Spanish Toxemia del embarazo, Toxemia preeclampsica, Toxemia preeclámpsica, Toxaemia of pregnancy, Pre-eclampsia, Toxemia of pregnancy, Toxaemia NOS, Proteinuric hypertension of pregnancy, Toxemia NOS, Toxemia, (pre)eclampsia, Pre-eclampsia NOS, preeclamsia, preeclamsia (trastorno), preeclampsia (trastorno), edema, proteinuria e hipertensión durante el embarazo, preeclampsia, edema, proteinuria e hipertensión gestacional, pre - eclampsia, preeclampsia (concepto no activo), preeclampsia, SAI (trastorno), preeclampsia, SAI, toxemia del embarazo (trastorno), toxemia del embarazo, toxemia gravídica, toxemia preeclámpsica, toxemia, SAI (trastorno), toxemia, SAI, Preeclampsia, Toxemias del Embarazo
Japanese 子癇前症性中毒症, 妊娠中毒症, シカンゼンショウセイチュウドクショウ, ニンシンチュウドクショウ, シカンゼンショウ, 晩期妊娠中毒症, 高血圧浮腫蛋白尿妊娠中毒症, 妊娠中毒症-晩期, 妊娠中毒症-EPH, 蛋白尿浮腫高血圧妊娠中毒症, 浮腫蛋白尿高血圧妊娠中毒症, EPH妊娠中毒症, 子かん前症, 妊娠中毒症-重症, 子癇前症, 類子癇症, 重症妊娠中毒症
Czech preeklampsie, Preeklamptická toxemie, Těhotenská toxemie, Preeklampsie, EPH gestóza, pozdní gestóza
Danish Svangerskabsforgiftning
Swedish TOXEMI/PRE-EKLAMPSI, Havandeskapsförgiftning
Hungarian toxaemia/(prae)eclampsia, Praeeclampsiás toxaemia, Prae-eclampsia, Prae-eclampsiás toxaemia, Terhességi toxaemia
Korean 상세불명의 전자간증
Hebrew toksemia, pre-eklampsia
Polish Stan przedrzucawkowy, Zatrucie ciążowe, Gestoza EPH

Ontology: Hypertension induced by pregnancy (C0340274)

Definition (NCI) The most common complication of pregnancy. It may appear as chronic hypertension or preeclampsia. It may cause brain hemorrhage, pulmonary edema, abruptio placentae, gestational diabetes mellitus, renal failure, premature delivery and fetal growth abnormalities.
Definition (MSH) A condition in pregnant women with elevated systolic (>140 mm Hg) and diastolic (>90 mm Hg) blood pressure on at least two occasions 6 h apart. HYPERTENSION complicates 8-10% of all pregnancies, generally after 20 weeks of gestation. Gestational hypertension can be divided into several broad categories according to the complexity and associated symptoms, such as EDEMA; PROTEINURIA; SEIZURES; abnormalities in BLOOD COAGULATION and liver functions.
Concepts Disease or Syndrome (T047)
MSH D046110
ICD10 O13
SnomedCT 198969004, 156112000, 267307002, 308551004, 48194001, 30354006, 156106005, 267306006
English GESTATIONAL HYPERTENSION, H/T - pregnancy, Hypertension induced by pregnancy, Pregnancy-induced hypertension, NOS, HYPERTENSION, PREGNANCY-INDUCED, HYPERTENSION PREGN IND, Hypertension of pregnancy NOS, pregnancy-induced hypertension, pregnancy-induced hypertension (diagnosis), Hypertension induced by pregnancy (disorder), Hypertension of pregnancy NOS (disorder), PIH - Preg-ind hypertension, PREGNANCY INDUCED HYPERTENSION, Induced Hypertension, Pregnancy, Pregnancy Induced Hypertension, Induced Hypertensions, Pregnancy, Hypertensions, Pregnancy Induced, gestational hypertension NOS, Hypertension, Pregnancy-Induced [Disease/Finding], PIH Pregnancy induced hypertension, Pregnancy induced hypertension, high blood pressure disorder caused by pregnancy, high blood pressure caused by pregnancy, hypertension in pregnancy, pregnancy induced hypertension, gestational hypertension, Gestational hypertension, GH - Gestational hypertension, PIH - Pregnancy-induced hypertension, Gestational hypertension (disorder), Pregnancy-induced hypertension (disorder), Pregnancy-induced hypertension, pregnancy; hypertension, Hypertension of preg., Hypertension of pregnancy, Gestational Hypertension, Hypertension, Gestational, Hypertension, Pregnancy Induced, Hypertension, Pregnancy-Induced, Pregnancy-Induced Hypertension, Pregnancy Associated Hypertension
Swedish Graviditetshypertoni
Czech hypertenze indukovaná těhotenstvím, Těhotenstvím indukovaná hypertenze, Gestační hypertenze
Spanish Hypertension of pregnancy, Hypertension induced by pregnancy, Hypertension of preg., Hipertensión Inducida en el Embarazo, Hipertension Inducida en el Embarazo, Hypertension of pregnancy NOS, Hipertensión inducida por el embarazo, Hipertensión gestacional, hipertensión durante el embarazo, SAI (trastorno), hipertensión durante el embarazo, SAI, hipertensión gestacional (trastorno), hipertensión gestacional, hipertensión gestacional [dup] (trastorno), hipertensión inducida por el embarazo, hipertensión inducida por el embarazo (trastorno), Hipertension Gestacional, Hipertensión Gestacional
Finnish Raskauteen liittyvä kohonnut verenpaine
Japanese 妊娠中毒症, 妊娠中毒, 妊娠高血圧, 妊娠誘発性高血圧, 高血圧-妊娠誘発性, 高血圧症合併妊娠, 妊娠性高血圧, 高血圧症-妊娠, 妊娠高血圧症, ニンシンコウケツアツ, ニンシンコウケツアツショウコウグン, 妊娠高血圧症候群, 高血圧-妊娠性
Dutch zwangerschapsgeinduceerde verhoogde bloeddruk, zwangerschapshypertensie, zwangerschap; hypertensie, Hypertensie, zwangerschaps-, Zwangerschapshypertensie
Portuguese Hipertensão gestacional, Hipertensão induzida pela gravidez, Hipertensão arterial induzida pela gravidez, Hipertensão Induzida por Gravidez, Hipertensão Induzida pela Gravidez, Hipertensão Gestacional
Italian Ipertensione gestazionale, Ipertensione gravidica (PIH), Ipertensione da gravidanza, Ipertensione gravidica
German Bluthochdruck in der Schwangerschaft, schwangerschaftsbedingte Hypertonie, PIH schwangerschaftsbedingte Hypertonie, Gestationshypertonie, Hypertonie, schwangerschaftsinduzierte, Schwangerschaftsinduzierte Hypertonie
French Gestational hypertension, Hypertension gestationnelle (HG), Hypertension artérielle gravidique, Hypertension gestationnelle, Hypertension liée à la grossesse, Hypertension induite par la grossesse, Hypertension de la grossesse
Polish Nadciśnienie wywołane ciążą
Hungarian Terhesség által kiváltott hypertonia, Gestationalis hypertonia, PIH terhesség által kiváltott hypertonia

Ontology: Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium (C0477811)

Concepts Disease or Syndrome (T047)
ICD10 O10-O16.9 , O10-O16
SnomedCT 200494008
English Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium, Edema,proteinuria+hypertens in pregnancy,childbrth,puerp, Edema,protur+HT preg+puerp, Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium, Oedema,proteinuria+hypertens in pregnancy,childbrth,puerp, Oedema,protur+HT preg+puerp, [X]Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium, [X]Edema,proteinuria+hypertens in pregnancy,childbrth,puerp, [X]Edema,protur+HT preg+puerp, [X]Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium, [X]Oedema,proteinuria+hypertens in pregnancy,childbrth,puerp, [X]Oedema,protur+HT preg+puerp, [X]Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium (disorder), Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium (O10-O16)
Spanish (X)edema, proteinuria y trastornos hipertensivos en el embarazo, el parto y el puerperio, (X)edema, proteinuria y trastornos hipertensivos en el embarazo, el parto y el puerperio (trastorno)

Ontology: Unspecified maternal hypertension (C0495183)

Concepts Pathologic Function (T046)
ICD10 O16 , O16.9
English Unspecified maternal hypertension, Unspecified maternal hypertension, unspecified trimester
German Nicht naeher bezeichnete Hypertonie der Mutter
Korean 상세불명의 모성 고혈압
Dutch Niet gespecificeerde hypertensie van moeder