Rosen & Barkin's 5-Minute Emergency Medicine Consult (323 page)

Preeclampsia

CODES

• 642.50 Severe pre-eclampsia, unspecified as to episode of care
  
• 642.51 Severe pre-eclampsia, delivered, with or without mention of antepartum condition
  
• 642.52 Severe pre-eclampsia, delivered, with mention of postpartum complication
  

BASICS

• Microscopic hematuria: ≥3 red blood cells per high-power field in 2 of the 3 properly collected urine specimens
  
• Gross hematuria: Visible blood in properly collected urine specimen
  
• Proteinuria: Urinary protein excretion of >150 mg/day
  
• Risk factors for disease in asymptomatic proteinuria:
  
  • Diabetes
    
  • HTN
    
  • NSAID abuse
    
  • Heroin use
    
• Risk factors for disease in asymptomatic hematuria:
  
  • Tobacco use
    
  • Occupational exposure to benzenes, aromatic amines, and dyes
    
  • History of gross hematuria
    
  • Age >40 yr old
    
  • History of urologic disorder or disease
    
  • History of painful voiding
    
  • History of UTI
    
  • Analgesic abuse
    
  • History of pelvic irradiation
    

• Proteinuria:
  
  • Glomerular:
    
    • Nephritic (postinfectious, IgA, lupus, vasculitis)
      
    • Nephrotic (minimal change, diabetes, preeclampsia)
      
  • Tubular
    
  • Overflow (hemolysis, rhabdomyolysis, multiple myeloma)
    
• Hematuria:
  
  • UTI
    
  • Stones (renal, bladder)
    
  • BPH
    
  • Cancer (bladder, renal, prostate)
    
  • Transient unexplained
    
  • Acute glomerulonephritis
    

DIAGNOSIS

• Dysuria
  
• Blood in urine
  
• Fever
  
• Flank pain
  
• Flank ecchymosis
  
• Initial hematuria (anterior urethral lesion)
  
• Terminal hematuria (posterior urethra, bladder, neck, trigone)
  
• Cyclic hematuria (endometriosis or urinary tract)
  
• Previous upper respiratory tract infection (10–21 days prior)
  
• Previous skin infection (10–21 days prior)
  
• Deafness (Alport syndrome)
  
• Peripheral edema
  
• CHF
  
• Hemoptysis (Goodpasture disease)
  
• Concurrent menstruation
  
• Testicular, epididymal, and prostatic tenderness or trauma
  
• Terminal urethral lesion
  
• Enlarged prostate
  
• Penile/scrotal hematoma
  
• Atrial fibrillation:
  
  • Renal artery embolus or thrombus
    
• Organomegaly, flank mass
  
• Pregnancy consideration
  
• Headache
  
• HTN (>140/90 mm Hg)
  
• Right upper quadrant pain
  

• Characteristics of complaint (onset, duration)
  
• Associated symptoms (recent illness)
  
• Past medical history (DM, HTN, pregnancy)
  
• Medications (nephrotoxic, anticoagulation, antibiotics)
  

• Complete physical exam, special attention to:
  
  • Edema, including periorbital
    
  • Thorough GU exam, including prostate
    
  • Rashes
    
  • Flank (ecchymosis, tenderness)
    

• Urine dipstick
  
• Urinalysis with microscopic analysis
  
• Consider urine culture.
  
• BUN level
  
• Serum creatinine level
  
• CBC
  
• Pregnancy consideration
  
• Liver function test
  
• Platelet count
  
• Consider coagulation panel.
  

• Urine:
  
  • Culture
    
  • Cytology
    
  • 24 hr urine protein and creatinine levels
    
  • Spot ratio of urine protein to creatinine
    
  • Spot ratio of urine protein to osmolality
    
  • Protein electrophoresis
    
• Serum:
  
  • Coagulation studies
    
  • Protein electrophoresis
    

• Helical CT scan
  
• Renal US
  

• Cystourethroscopy
  
• Urethrogram
  
• Cystogram
  
• Retrograde pyelogram
  
• IV pyelogram
  

• Glomerular hematuria:
  
  • IgA nephropathy (Berger disease)
    
  • Postinfectious glomerulonephritis
    
  • Membranoproliferative glomerulonephritis
    
  • Focal glomerular sclerosis
    
  • Lupus nephritis
    
  • Wegener granulomatosis
    
  • Polyarteritis nodosa
    
  • Henoch–Schönlein syndrome
    
• Thrombotic thrombocytopenic purpura:
  
  • Hemolytic uremic syndrome
    
  • Alport syndrome
    
  • Goodpasture disease
    
• Nonglomerular hematuria:
  
  • Infection (pyelonephritis, tuberculosis, schistosomiasis)
    
  • Inflammation (drug induced, radiation induced)
    
  • Urothelial malignancy
    
  • Renal and extrarenal tumor
    
  • Interstitial nephritis
    
  • Papillary necrosis
    
  • Polycystic kidney disease
    
  • Medullary sponge disease
    
  • Renal artery embolism/thrombosis
    
  • Renal vein thrombosis
    
  • Sickle cell disease
    
  • Malignant HTN
    
  • Hypercalciuria
    
  • Hyperuricosuria
    
  • Urolithiasis
    
  • Strictures
    
  • Endometriosis
    
  • Foreign bodies
    
  • Benign prostatic hypertrophy
    
  • Coagulopathy/bleeding disorders
    
  • Trauma (renal pedicle injuries, urethral disruptions, bladder rupture)
    
  • Recent instrumentation
    
  • Frequent or interrupted coitus
    
  • Factitious
    
• Glomerular proteinuria (>2 g/day):
  
  • Minimal-change disease
    
  • Membranous glomerulonephritis
    
  • Focal segmental glomerulonephritis
    
  • Membranoproliferative glomerulonephritis
    
  • DM
    
  • Collagen vascular diseases
    
  • Amyloidosis
    
  • Preeclampsia
    
  • Infection (HIV, hepatitis B, hepatitis C, poststreptococcal infection, syphilis)
    
  • Lymphoma
    
  • Chronic renal transplant rejection
    
  • Heroin use
    
  • Penicillamine
    
• Tubular proteinuria:
  
  • Hypertensive nephrosclerosis
    
  • Uric acid nephropathy
    
  • Acute hypersensitivity interstitial nephritis
    
  • Fanconi syndrome
    
  • Sickle cell disease
    
• Overflow proteinuria:
  
  • Monoclonal gammopathy
    
  • Leukemia
    
• Proteinuria, other:
  
  • Dehydration
    
  • Stress
    
  • Fever
    
  • Heat injury
    
  • Inflammatory process
    
  • Orthostatic proteinuria
    

TREATMENT

• Airway, breathing, and circulation management
  
• Control other trauma, if present.
  

• Airway, breathing, and circulation management
  
• Treat hemodynamically unstable injuries 1st, if present.
  
• Obtain initial labs (urinalysis with microscopic analysis, BUN, serum creatinine, electrolytes).
  

If considering preeclampsia:

• Aggressive BP control
  
• Magnesium if indicated
  
• Prompt OB/GYN consultation
  

• Uncomplicated UTIs:
  
  • Antibiotics (see Urinary Tract Infection, Adult or Urinary Tract Infection, Pediatric)
    
• Pyelonephritis:
  
  • Antibiotics (see Urinary Tract Infection, Adult or Urinary Tract Infection, Pediatric)
    
  • Analgesics
    
  • Antipyretics
    
• Rapidly progressing glomerulonephropathy:
  
  • Steroid therapy
    
  • Nephrology consultation
    
• Acute renal failure:
  
  • Hemodialysis
    
  • Renal US
    
  • Urine electrolytes
    
  • Nephrology consultation
    
• Renal colic:
  
  • IV fluids
    
  • Analgesics
    
  • If initial presentation, noncontrast helical CT scan
    
• Gross hematuria:
  
  • Insertion of 3-way Foley catheter with bladder irrigation to clear blood clots that may cause urinary retention from bladder obstruction