December 15, 2004
Volume 70, Number 12
American Family Physician
Risk factors for preeclampsia include medi-cal conditions with the potential to causemicrovascular disease (e.g., diabetes mellitus,chronic hypertension, vascular and connec-tive tissue disorders), antiphospholipid anti-body syndrome, and nephropathy.
Otherrisk factors are associated with pregnancy itself or may be specific to the mother orfather of the fetus
Although the exact cause of preeclampsiaremains unclear,
many theories center onproblems of placental implantation and thelevel of trophoblastic invasion.
It is impor-tant to remember that although hypertensionand proteinuria are the diagnostic criteriafor preeclampsia, they are only symptoms of the pathophysiologic changes that occur inthe disorder. One of the most striking physi-ologic changes is intense systemic vasospasm,which is responsible for decreased perfusionof virtually all organ systems.
Perfusion also is diminishedbecause of vascular hemocon-centration and third spacing of intravascular fluids. In addition,preeclampsia is accompaniedby an exaggerated inflamma-tory response and inappropri-ate endothelial activation.
Activation of the coagulation cascade andresultant microthrombi formation furthercompromise blood flow to organs.
The clinical presentation of preeclampsiamay be insidious or fulminant. Some womenmay be asymptomatic at the time they arefound to have hypertension and proteinuria;others may present with symptoms of severepreeclampsia, such as visual disturbances,severe headache, or upper abdominal pain.From 4 to 14 percent of women with pre-eclampsia present with superimposed HELLPsyndrome.
HELLP syndrome may be a vari-ant of preeclampsia or a separate entity, butits development is ominous because mortal-ity or serious morbidity occurs in 25 percentof affected women.
Preeclampsia-eclampsia may developbefore, during, or after delivery. Up to 40percent of eclamptic seizures occur beforedelivery; approximately 16 percent occurmore than 48 hours after delivery.
Deathassociated with preeclampsia-eclampsia may be due to cerebrovascular events, renal orhepatic failure, HELLP syndrome, or othercomplications of hypertension.
As part of the initial prenatal assessment,pregnant women should be questioned aboutpotential risk factors for preeclampsia. They should be asked about their obstetric history,specifically the occurrence of hypertensionor preeclampsia during previous pregnan-cies. A thorough medical history should beobtained to identify medical conditions that
Up to 40 percent of eclamp-tic seizures occur beforedelivery; approximately 16percent occur more than 48hours after delivery.
Risk Factors for Preeclampsia
Chromosomal abnormalitiesHydatidiform moleHydrops fetalisMultifetal pregnancyOocyte donation or donor inseminationStructural congenital anomaliesUrinary tract infection
Age greater than 35 yearsAge less than 20 yearsBlack raceFamily history of preeclampsiaNulliparityPreeclampsia in a previous pregnancySpecific medical conditions: gestationaldiabetes, type I diabetes, obesity, chronichypertension, renal disease, thrombophiliasStress
First-time fatherPreviously fathered a preeclamptic pregnancyin another woman
Information from references 4 and 8.