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Diag and Managment of Preeclampsia

Diag and Managment of Preeclampsia

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02/04/2013

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See page 2252 fordefinitions of strength-of-recommendation labels.
 P
reeclampsia is a pregnancy-specific,multisystem disorder that is char-acterized by the development of hypertension and proteinuria after20 weeks of gestation. The disorder compli-cates approximately 5 to 7 percent of preg-nancies,
1
with an incidence of 23.6 cases per1,000 deliveries in the United States.
2
Complications of hypertension are thethird leading cause of pregnancy-relateddeaths, superseded only by hemorrhage andembolism.
3
Preeclampsia isassociated with increased risksof placental abruption, acuterenal failure, cerebrovascularand cardiovascular complica-tions, disseminated intravascu-lar coagulation, and maternaldeath.
3
Consequently, early diagnosis of preeclampsia and close obser-vation are imperative.
Diagnosis
Diagnostic criteria for preeclampsia includenew onset of elevated blood pressure andproteinuria after 20 weeks of gestation. Fea-tures such as edema and blood pressure ele-vation above the patient’s baseline no longerare diagnostic criteria.
4,5
Severe preeclamp-sia is indicated by more substantial bloodpressure elevations and a greater degree of proteinuria. Other features of severe pre-eclampsia include oliguria, cerebral or visualdisturbances, and pulmonary edema or cya-nosis
(Table 1)
.
4,5
 Diagnosis becomes less difficult if physi-cians understand where preeclampsia “fits”into the hypertensive disorders of pregnancy.These disorders include chronic hyperten-sion, preeclampsia-eclampsia, preeclampsiasuperimposed on chronic hypertension, andgestational hypertension
(Figure 1)
.
5
Chronic hypertension is defined by ele-vated blood pressure that predates the preg-nancy, is documented before 20 weeks of gestation, or is present 12 weeks after deliv-ery.
5
In contrast, preeclampsia-eclampsiais defined by elevated blood pressure andproteinuria that occur after 20 weeks of gestation. Eclampsia, a severe complica-tion of preeclampsia, is the new onset of seizures in a woman with preeclampsia.Eclamptic seizures are relatively rare andoccur in less than 1 percent of women withpreeclampsia.
1
Preeclampsia superimposed on chronic
Preeclampsia is a pregnancy-specific multisystem disorder of unknownetiology. The disorder affects approximately 5 to 7 percent of pregnan-cies and is a significant cause of maternal and fetal morbidity and mor-tality. Preeclampsia is defined by the new onset of elevated blood pres-sure and proteinuria after 20 weeks of gestation. It is considered severeif blood pressure and proteinuria are increased substantially or symp-toms of end-organ damage (including fetal growth restriction) occur.There is no single reliable, cost-effective screening test for preeclampsia,and there are no well-established measures for primary prevention.Management before the onset of labor includes close monitoring of maternal and fetal status. Management during delivery includes seizureprophylaxis with magnesium sulfate and, if necessary, medical manage-ment of hypertension. Delivery remains the ultimate treatment. Accessto prenatal care, early detection of the disorder, careful monitoring,and appropriate management are crucial elements in the preventionof preeclampsia-related deaths. (Am Fam Physician 2004;70:2317-24.Copyright© 2004 American Academy of Family Physicians.)
Diagnosis and Management of Preeclampsia
LANA K. WAGNER, M.D.,
First Choice Community Healthcare, Albuquerque, New Mexico
December 15, 2004
 
 
Volume 70, Number 12
 
www.aafp.org/afp
 
 American Family Physician
2317
Diagnostic criteria forpreeclampsia include newonset of elevated bloodpressure and proteinuriaafter 20 weeks of gestation.
Downloaded from the
 American Family Physician
Web site at www.aafp.org/afp. Copyright©
200
4
American Academy of Family Physicians. For the private, noncommercialuse of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
 
2318
 American Family Physician
www.aafp.org/afp
 
Volume 70, Number 12
 
 
December 15, 2004
hypertension is characterized by new-onsetproteinuria (or by a sudden increase inthe protein level if proteinuria already ispresent), an acute increase in the level of hypertension (assuming proteinuria already exists), or development of the HELLP(
h
emolysis,
levated
iver enzymes,
ow
 p
latelet count) syndrome.
4
Gestational hypertension is diagnosedwhen elevated blood pressure without pro-teinuria develops after 20 weeks of gesta-tion and blood pressure returns to normalwithin 12 weeks after delivery.
4
One fourthof women with gestational hypertensiondevelop proteinuria and thus progress topreeclampsia.
6,7
TABLE 1
Diagnostic Criteria for Preeclampsia*
Preeclampsia
Blood pressure: 140 mm Hg or higher systolic or 90 mm Hg or higher diastolic after 20 weeks ofgestation in a woman with previously normal blood pressureProteinuria: 0.3 g or more of protein in a 24-hour urine collection (usually corresponds with 1+ orgreater on a urine dipstick test)
Severe preeclampsia
Blood pressure: 160 mm Hg or higher systolic or 110 mm Hg or higher diastolic on two occasions atleast six hours apart in a woman on bed restProteinuria: 5 g or more of protein in a 24-hour urine collection or 3+ or greater on urine dipsticktesting of two random urine samples collected at least four hours apartOther features: oliguria (less than 500 mL of urine in 24 hours), cerebral or visual disturbances,pulmonary edema or cyanosis, epigastric or right upper quadrant pain, impaired liver function,thrombocytopenia, intrauterine growth restriction
*—For the diagnosis of preeclampsia, both hypertension and proteinuria must be present.Information from references 4 and 5.
Preeclampsia as a Hypertensive Disorder of Pregnancy
Figure 1.
An algorithm for differentiating among hypertensive disorders in pregnant women.(HELLP =
h
emolysis,
e
levated
iver enzymes,
ow
 p
latelet count)
Information from reference 5.
Pregnant woman with blood pressurehigher than 140/90 mm HgBefore 20 weeks of gestationNo or stable proteinuriaChronic hypertensionNew or increased proteinuria,development of increasing bloodpressures, or HELLP syndromePreeclampsia superimposedon chronic hypertensionAfter 20 weeks of gestationProteinuriaPreeclampsiaNo proteinuriaGestationalhypertension
 
December 15, 2004
 
 
Volume 70, Number 12
 
www.aafp.org/afp
 
 American Family Physician
2319
Preeclampsia
Risk Factors
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.
4,8
Otherrisk factors are associated with pregnancy itself or may be specific to the mother orfather of the fetus
(Table 2)
.
4,8
Pathophysiology
Although the exact cause of preeclampsiaremains unclear,
4,5
many theories center onproblems of placental implantation and thelevel of trophoblastic invasion.
9,10
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.
11
 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.
10
 Activation of the coagulation cascade andresultant microthrombi formation furthercompromise blood flow to organs.
11
Clinical Presentation
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.
12
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.
13
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.
1
Deathassociated with preeclampsia-eclampsia may be due to cerebrovascular events, renal orhepatic failure, HELLP syndrome, or othercomplications of hypertension.
3
Diagnostic Evaluation
HISTORY
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.
TABLE 2
Risk Factors for Preeclampsia
Pregnancy-associated factors
Chromosomal abnormalitiesHydatidiform moleHydrops fetalisMultifetal pregnancyOocyte donation or donor inseminationStructural congenital anomaliesUrinary tract infection
Maternal-specific factors
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
Paternal-specific factors
First-time fatherPreviously fathered a preeclamptic pregnancyin another woman
Information from references 4 and 8.

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