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Pre-eclampsia and eclampsia are forms of high blood pressure that occur during pregnancy and are accompanied

by protein in the urine and edema(swelling). As the names suggest, these two disorders are related. Pre-eclampsia, sometimes called toxemia of pregnancy, may develop into the more severe eclampsia, which is pre-eclampsia together with seizure. These conditions usually develop during the second half of pregnancy (after 20 weeks), though sometimes they develop shortly after birth, and, in very rare situations, they occur before 20 weeks of pregnancy.

You are at increased risk of developing pre-eclampsia if:

This is your first pregnancy. Your mother or sister had pre-eclampsia or eclampsia during pregnancy. You are carrying more than one baby. You are a teenager. You are over 40 years old. You already have high blood pressure, kidney disease or diabetes. You are a smoker. You are obese. You suffer from malnutrition. You carry a baby with so-called "non-immune hydrops."

If you are pregnant, increasing blood pressure may not make you feel different until it is dangerously high. So you should watch for signs of pre-eclampsia. If you develop preeclampsia, the first thing you notice may be rapid weight gain, on the order of two to five pounds in a single week. Many pregnant women have swelling of their feet or legs; however, swelling of your face or arms may be a sign of pre-eclampsia. If pre-eclampsia progresses from mild to moderate or severe, you may begin to notice other symptoms. Headache, vision changes and abdominal pain should prompt concern.

It is dangerous to allow blood pressure to stay high during pregnancy. High blood pressure may interfere with the placenta's ability to deliver oxygen and nutrition to your fetus, so your baby may be born weighing less than normal and may have other health problems. If your blood pressure continues to get higher and higher, your kidneys may have trouble functioning. You may have changes in the makeup of your blood, such as destruction of red blood cells (causing anemia), disturbed liver function, and decreased platelets (blood cells involved in clotting). Too few platelets can increase your risk of bleeding uncontrollably during delivery or even spontaneously. Your blood pressure may continue to climb, and you may develop seizures.

Once you begin to have seizures, you are considered to have eclampsia. This is a lifethreatening situation for both you and your baby. During a seizure, you and your baby are at risk of being deprived of oxygen. In addition, the high blood pressure may cause the placenta to begin to separate from the wall of the uterus (called abruptio placentae). This can cause severe bleeding and death of the fetus and possibly the mother.

Symptoms

Rapid weight gain Swelling of the arms or face Headache Changes in vision (blurred vision, seeing double, seeing spots of light) Dizziness, faintness Ringing in the ears Abdominal pain Decreased production of urine Nausea, vomiting Blood in vomit or urine

Confusion Seizures

Pre-eclampsia and Eclampsia: Causes and Treatments

Causes

Doctors are not sure exactly what causes pre-eclampsia or eclampsia.

Diagnostic and Test Procedures

During your pregnancy, your health-care provider will check your blood pressure at every prenatal visit. If your blood pressure increases greatly compared to before or early in pregnancy, or if your blood pressure numbers reach certain thresholds and you start having protein in your urine, then your health-care provider may diagnose you with pre-eclampsia. You can be diagnosed with this disorder without ever having had noticeable symptoms. Mild pre-eclampsia is diagnosed when your blood pressure is only a little elevated, while severe pre-eclampsia is diagnosed with very high blood pressures and other symptoms, such as headache, abdominal pain, blood and liver abnormalities, and having a large amount of protein in your urine.

Your health-care provider will want to perform urine tests and blood tests, too. These will reveal whether your kidneys and liver are functioning normally, as well as whether you are developing other complications of pre-eclampsia (such as low red blood cells or low platelets).

Treatment

The only way to truly resolve pre-eclampsia and eclampsia is to deliver your baby and placenta. If you are close to your due date, your doctor may induce labor.

If you develop pre-eclampsia too early in your pregnancy for your baby to be delivered safely, then your health-care provider may try to treat you for a while, until the baby has developed enough to be delivered. Your provider will also order on a regular basis tests such as ultrasounds, non-stress testing, or biophysical profiles to check whether the baby is doing well.

You probably will be put on bed rest and allowed to get up only to use the bathroom. You'll be asked to lie on your left side as much as possible, to take pressure off certain important blood vessels, allowing your kidneys and the placenta to benefit from greater blood flow. You may be given medication to lower your blood pressure to a safe range.

Many women with pre-eclampsia are admitted to hospital. If you are allowed to go home, you'll probably have to have your blood pressure checked at home, or have a home nurse visit every day or two, to make sure that your blood pressure is stable. In the past, women with preeclampsia were asked to eliminate their salt intake. Current understanding of pre-eclampsia, however, suggests that this is incorrect advice, and that women with pre-eclampsia can continue to eat salt, though not excessively.

If home bed rest doesn't improve your blood pressure, or at least stabilize it, or if you develop severe pre-eclampsia, then you may need to be admitted to the hospital. You'll probably need to receive fluids and medicines intravenously (through a needle in your vein). You might be given medication to lower your blood pressure, as well as a medication called magnesium sulfate, which is used to prevent seizures.

If your blood pressure stays dangerously high, if you develop seizures, or once your baby reaches a safe point in development, your health-care provider will deliver your baby. This does not necessarily mean that you will need a cesarean section. Many times your provider can give you medicines to start labor. In some special cases, you may need to have a cesarean section. If your health-care provider is convinced that your baby must be delivered before his or her lungs are fully matured, you may be given special medicines to speed lung development prior to delivery.

Because pre-eclampsia and eclampsia take several days to resolve after delivery, you will probably need to stay on blood pressure medications or magnesium sulfate for some time after your baby is born.

Prevention

Methods of preventing pre-eclampsia and eclampsia are somewhat controversial. Researchers are investigating whether taking an aspirin or more calcium each day would help decrease the risk of developing these disorders.

Call Your Doctor If:

You notice sudden weight gain during pregnancy. You begin to experience swelling of the arms or face. You develop a severe headache. You notice changes in your vision. You have abdominal pain. You have vaginal bleeding. You feel dizzy or faint. You hear ringing in your ears. You have trouble with nausea or vomiting. You notice a decrease in your urine production. There is blood in your urine or vomit. You become confused. You develop seizures.

Pathophysiology Of Preeclampsia preeclampsia

preeclampsia is a condition of new-onset hypertension, proteinuria, and edema most often appearing after 20 weeks of pregnancy. pathogenesis is still poorly understood. existing literature favors preexisting maternal endothelial dysfunction that are triggered by pregnancy. observations that support this include:

women with preexisting vascular disease are more susceptible high plasma fibronectin (involved in wound healing), Factor VIII antigen, andthrombomodulin (coactivator of anticoagulant Protein C) impaired vasodilation (decrease flow-mediation, NO, prostacyclin) and increased vasoconstriction (high endothelins, thromboxanes)

some other possible etiologies include:


immune rejection of the placenta compromised placental perfusion


o

incomplete cytotrophoblastic growth into the myometrial layer

pathophysiology is thought to involve an unregulated release of free thrombin occurs. this can proceed to DIC. a number of factors may cause this:

an imbalance between circulatory VEGF and anti-VEGF (sFlt-1, sEng) factors shifts against angiogenesis

o o

this could lead to inadequate vascularization of the placenta could be a primary placental ischemia or secondary to other ischemic factors

placental hypoperfusion due to abnormal uterine vasculature that is unable to accommodate the normal rise in blood flow to the fetus/placenta
o o

this can lead to atherosis, fibrinoid necrosis, thrombosis, sclerotic narrowing of arterioles, and placental infarction could be a primary placental ischemia or secondary to other ischemic factors

one unifying hypothesis:

HELPP one variant of preeclampsia is HELPP, an abbreviation of:


Hemolytic anemia Elevated Liver enzymes Low Platelet count

this condition involves preeclampsia with headache, malaise, edema, and right upper quadrant pain. HELPP often indicates that preeclampsia has triggered hepatic failure. preeclamptic patients are already prone to spontaneous hemorrhages. the liver is thought to be particularly prone because fibrin split products can deposit in the reticuloendothelial system of the liver. multiple previous subclinical spontaneous hemorrhages within the small hepatic sinusoids and arterioles may go unnoticed symptomatically and leave the liver in a fragile state. fibrin thrombi may be left uncleared in the liver. occasionally, a trigger (such as DIC) may cause extreme hypoperfusion of the liver, leading toinfarction. periportal necrosis can coalesce and form a subcapsular hematoma with ruptureof Glissons capsule. this results in intraperitoneal hemorrhage. this progression is rare, but has a high mortality. right upper quadrant pain along with preeclamptic pain is a diagnostic hallmark for HELPP. however, it is best diagnosed withabdominal ultrasound. termination of pregnancy is considered the first step in treatment.

eclampsia the patient may progress to full eclampsia, which is only defined by convulsions, and is oftenaccompanied by seizures or coma. though preeclampsia often occurs prior to eclampsia, but no preeclamptic signs have to appear for eclamptic convulsion. the underlying pathophysiology is thought to be the same as preeclampsia with additional fulminant DIC triggering vasospasms and the convulsions.

N ursing management for preeclampsia Preeclampsia is a common problem during pregnancy. The condition sometimes referred to as pregnancy-induced hypertension is defined by high blood pressure and excess protein in the urine after 20 weeks of pregnancy. Often, preeclampsia causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious even fatal complications for both mother and baby. A. Mild Preeclampsia BP of 140/90 1+ to 2+ proteinuria on random weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the 3rd trimester Slight edema in upper extremities and face B. Severe Preeclampsia BP of 160/110 3-4+ protenuria on random Oliguria (less than 500 ml/24 hrs) Cerebral or visual disturbances Epigastric pain Pulmonary edema Peripheral edema Hepatic dysfunction Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures. NURSING MANAGEMENT 1. Monitor for, and promote the resolution of, complications. Monitor vital signs and FHR. Minimize external stimuli; promote rest and relaxation Measure and record urine output, protein level, and specific gravity. Assess for edema of face, arms, hands, legs, ankles, and feet. Also assess for pulmonary edema.

Weigh the client daily. Assess deep tendon reflexes every 4 hours. Assess for placental separation, headache and visual disturbance, epigastric pain, and altered level of consciousness. Test Findings Blood Hematocrit Renal Function Serum uric acid Creatinine Creatinine clearance BUN Coagulation Platelets Fibrin degradation products >40% ?5.5 mg/dL >6.0 mg/dL (severe PIH) ?1.0 mg/dL 2.0-3.0 md/dL (severe PIH) <150 mL/min 8-10 mg/dL (severe PIH) 10-16 mg/dL (severe PIH) <100,000 mL (severe PIH) ?16 g/mL (severe PIH)

2. Provide treatment as prescribed. Mild preeclampsia treatment consists of bed rest in left lateral recumbent position,balanced diet with moderate to high protein and low to moderate sodium, and administration of magnesium sulfate Severe preeclampsia treatment consists of complete bed rest, balanced diet with high protein and low to moderate sodium, administration of sulfate, fluid and electrolyte replacements and sedative hypertensives such as diazepam or phenobarbital or an anticonvulsant such as phenytoin Eclampsia treatment consists of administration of magnesium sulfate intravenously 3. Institute seizure precautions. Seizures may occur up to 72 hours after delivery. 4. Address emotional and psychosocial needs.

Treatments and drugs


By Mayo Clinic staff

The only cure for preeclampsia is delivery. You're at increased risk of seizures, placental abruption, stroke and possibly severe bleeding until your blood pressure decreases. Of course, if it's too early in your pregnancy, delivery may not be the best thing for your baby. If you've had preeclampsia in one or more previous pregnancies, some experts recommend more frequent prenatal visits than normally recommended for pregnancy.

Your doctor may ask you to come in every two weeks between the 20th and 32nd week of your gestation, and weekly after that until delivery. Medications Your doctor may recommend the following:

Medications to lower blood pressure. These medications, called antihypertensives, are used to lower your blood pressure until delivery.

Corticosteroids. If you have severe preeclampsia or HELLP syndrome, corticosteroid medications can temporarily improve liver and platelet functioning to help prolong your pregnancy. Corticosteroids can also help your baby's lungs become more mature in as little as 48 hours an important step in helping a premature baby prepare for life outside the womb.

Anticonvulsive medications. If your preeclampsia is severe, your doctor may prescribe an anticonvulsive medication, such as magnesium sulfate, to prevent a first seizure.

Bed rest If you aren't near the end of your pregnancy and you have a mild case of preeclampsia, your doctor may recommend bed rest to lower your blood pressure and increase blood flow to your placenta, giving your baby time to mature. You may need to lie in bed, only sitting and standing when necessary. Or you may be able to sit on the couch or in bed and strictly limit your activities. Your doctor may want to see you a few times a week to check your blood pressure, urine protein levels and your baby's well-being. If you have more severe preeclampsia, you may need bed rest in the hospital. In the hospital, you may have regular nonstress tests or biophysical profiles to monitor your baby's well-being and measure the volume of amniotic fluid. A lack of amniotic fluid is a sign of poor blood supply to the baby. Delivery If you're diagnosed with preeclampsia near the end of your pregnancy, your doctor may recommend inducing labor right away. The readiness of your cervix whether it's beginning to open (dilate), thin (efface) and soften (ripen) also may be a factor in determining whether or when labor will be induced.

In more severe cases, it may not be possible to consider your baby's gestational age or the readiness of your cervix. If it's not possible to wait, your doctor may induce labor or schedule a C-section earlier in your pregnancy. During delivery, you may be given magnesium sulfate intravenously to increase uterine blood flow and prevent seizures. After delivery, expect your blood pressure to return to normal within a few weeks.

Diagnosis and Management of Preeclampsia LANA K. WAGNER, M.D., First Choice Community Healthcare, Albuquerque, New Mexico Am Fam Physician. 2004 Dec 15;70(12):2317-2324. Preeclampsia is a pregnancy-specific multisystem disorder of unknown etiology. The disorder affects approximately 5 to 7 percent of pregnancies and is a significant cause of maternal and fetal morbidity and mortality. Preeclampsia is defined by the new onset of elevated blood pressure and proteinuria after 20 weeks of gestation. It is considered severe if blood pressure and proteinuria are increased substantially or symptoms of endorgan damage (including fetal growth restriction) occur. There is no single reliable, costeffective 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 seizure prophylaxis with magnesium sulfate and, if necessary, medical management of hypertension. Delivery remains the ultimate treatment. Access to prenatal care, early detection of the disorder, careful monitoring, and appropriate management are crucial elements in the prevention of preeclampsia-related deaths. Preeclampsia is a pregnancy-specific, multisystem disorder that is characterized by the development of hypertension and proteinuria after 20 weeks of gestation. The disorder complicates approximately 5 to 7 percent of pregnancies,1 with an incidence of 23.6 cases per 1,000 deliveries in the United States.2 STRENGTH OF RECOMMENDATIONS Key clinical recommendation All pregnant women should be screened for preeclampsia at the first prenatal visit and periodically throughout the remainder of the pregnancy. Pregnant women with diastolic blood pressure of 105 to 110 mm Hg or Label References B 25 C 4,5

Key clinical recommendation higher should receive antihypertension medication. Women at increased risk for preeclampsia who have low calcium intake should increase their calcium intake.

Label References B 27

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. Complications of hypertension are the third leading cause of pregnancy-related deaths, superseded only by hemorrhage and associated with increased risks of placental abruption, acute renal failure, cerebrovascular and cardiovascular complications, disseminated intravascular coagulation, and maternal death.3 Consequently, early diagnosis of preeclampsia and close observation are imperative. Diagnosis Diagnostic criteria for preeclampsia include new onset of elevated blood pressure and proteinuria after 20 weeks of gestation. Features such as edema and blood pressure elevation above the patients baseline no longer are diagnostic criteria.4,5 Severe preeclampsia is indicated by more substantial blood pressure elevations and a greater degree of proteinuria. Other features of severe preeclampsia include oliguria, cerebral or visual disturbances, and pulmonary edema or cyanosis (Table 1).4,5 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 of gestation in a woman with previously normal blood pressure Proteinuria: 0.3 g or more of protein in a 24-hour urine collection (usually corresponds with 1+ or greater 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 at least six hours apart in a woman on bed rest Proteinuria: 5 g or more of protein in a 24-hour urine collection or 3+ or greater on urine dipstick testing of two random urine samples collected at least four hours apart Other 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.

Diagnosis becomes less difficult if physicians understand where preeclampsia fits into the hypertensive disorders of pregnancy. These disorders include chronic hypertension, preeclampsia-eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension (Figure 1).5

Preeclampsia as a Hypertensive Disorder of Pregnancy

Figure 1. An algorithm for differentiating among hypertensive disorders in pregnant women. (HELLP =hemolysis,elevated liver enzymes, low platelet count) Chronic hypertension is defined by elevated blood pressure that predates the pregnancy, is documented before 20 weeks of gestation, or is present 12 weeks after delivery.5 In contrast, preeclampsia-eclampsia is defined by elevated blood pressure and proteinuria that occur after 20 weeks of gestation. Eclampsia, a severe complication of preeclampsia, is the new onset of seizures in a woman with preeclampsia. Eclamptic seizures are relatively rare and occur in less than 1 percent of women with preeclampsia.1 Preeclampsia superimposed on chronic hypertension is characterized by new-onset proteinuria (or by a sudden increase in the protein level if proteinuria already is present), an acute increase in the level of hypertension (assuming proteinuria already exists), or development of the HELLP (hemolysis, elevatedliver enzymes, low platelet count) syndrome.4 Gestational hypertension is diagnosed when elevated blood pressure without proteinuria develops after 20 weeks of gestation and blood pressure returns to normal within 12 weeks after delivery.4 One fourth of women with gestational hypertension develop proteinuria and thus progress to preeclampsia.6,7

Risk Factors Risk factors for preeclampsia include medical conditions with the potential to cause microvascular disease (e.g., diabetes mellitus, chronic hypertension, vascular and connective tissue disorders), antiphospholipid antibody syndrome, and nephropathy.4,8 Other risk factors are associated with pregnancy itself or may be specific to the mother or father of the fetus (Table 2).4,8 TABLE 2 Risk Factors for Preeclampsia Pregnancy-associated factors Chromosomal abnormalities Hydatidiform mole Hydrops fetalis Multifetal pregnancy Oocyte donation or donor insemination Structural congenital anomalies Urinary tract infection Maternal-specific factors Age greater than 35 years Age less than 20 years Black race Family history of preeclampsia Nulliparity Preeclampsia in a previous pregnancy Specific medical conditions: gestational diabetes, type I diabetes, obesity, chronic hypertension, renal disease, thrombophilias Stress Paternal-specific factors First-time father Previously fathered a preeclamptic pregnancy in another woman Information from references 4 and 8. Pathophysiology Although the exact cause of preeclampsia remains unclear,4,5 many theories center on problems of placental implantation and the level of trophoblastic invasion.9,10 It is important to remember that although hypertension and proteinuria are the diagnostic criteria for preeclampsia, they are only symptoms of the pathophysiologic changes that occur in the disorder. One of the most striking physiologic changes is intense

systemic vasospasm, which is responsible for decreased perfusion of virtually all organ systems.11Perfusion also is diminished because of vascular hemoconcentration and third spacing of intravascular fluids. In addition, preeclampsia is accompanied by an exaggerated inflammatory response and inappropriate endothelial activation.10Activation of the coagulation cascade and resultant microthrombi formation further compromise blood flow to organs.11 Clinical Presentation The clinical presentation of preeclampsia may be insidious or fulminant. Some women may be asymptomatic at the time they are found to have hypertension and proteinuria; others may present with symptoms of severe preeclampsia, such as visual disturbances, severe headache, or upper abdominal pain. From 4 to 14 percent of women with preeclampsia present with superimposed HELLP syndrome.12HELLP syndrome may be a variant of preeclampsia or a separate entity, but its development is ominous because mortality or serious morbidity occurs in 25 percent of affected women.13 Preeclampsia-eclampsia may develop before, during, or after delivery. Up to 40 percent of eclamptic seizures occur before delivery; approximately 16 percent occur more than 48 hours after delivery.1 Death associated with preeclampsia-eclampsia may be due to cerebrovascular events, renal or hepatic failure, HELLP syndrome, or other complications of hypertension.3 Diagnostic Evaluation HISTORY As part of the initial prenatal assessment, pregnant women should be questioned about potential risk factors for preeclampsia. They should be asked about their obstetric history, specifically the occurrence of hypertension or preeclampsia during previous pregnancies. A thorough medical history should be obtained to identify medical conditions that increase the risk for preeclampsia, including diabetes mellitus, hypertension, vascular and connective tissue disease, nephropathy, and antiphospholipid antibody syndrome. During prenatal visits after 20 weeks of gestation, pregnant women should be asked about specific symptoms, including visual disturbances, persistent headaches, epigastric or right upper quadrant pain, and increased edema. Questions about these symptoms are included in many standardized prenatal documentation forms. PHYSICAL EXAMINATION Blood pressure should be measured at each prenatal visit. As mentioned previously, increases above the patients baseline (greater than 30 mm Hg systolic or 15 mm Hg diastolic) are no longer considered to be criteria for the diagnosis of preeclampsia. However, such increases warrant close observation.5 To ensure

accurate readings, an appropriate-size blood pressure cuff should be used, and blood pressure should be measured after a rest period of 10 minutes or more. During the blood pressure measurement, the patient should be in an upright or left lateral recumbent position with the arm at the level of the heart.4 Fundal height should be measured at each prenatal visit because size less than dates may indicate intrauterine growth retardation or oligohydramnios. These conditions may become apparent long before diagnostic criteria for preeclampsia are met. Increasing maternal facial edema and rapid weight gain also should be noted because fluid retention often is associated with preeclampsia. Although these symptoms (e.g., facial edema, rapid weight gain) are not unique to preeclampsia, it is wise to follow affected patients for hypertension and proteinuria.5 Edema involving the lower extremities frequently occurs during normal pregnancy and therefore is of less concern. LABORATORY EVALUATION There currently is no single reliable, cost-effective screening test for preeclampsia.4 The serum uric acid level once was used as an indicator of preeclampsia but has been found to lack sensitivity and specificity as a diagnostic tool.14 However, an elevated serum uric acid level may be of some use in identifying pregnant women with chronic hypertension who have an increased likelihood of having superimposed preeclampsia.14 A baseline laboratory evaluation should be performed early in pregnancy in women who are at high risk for preeclampsia. Tests should include a hepatic enzyme level, a platelet count, a serum creatinine level, and a 12to 24-hour urine collection for total protein measurement. Once the diagnosis of preeclampsia has been made, an expanded set of laboratory tests should be performed (Table 3).15 In women who have preeclampsia with no suspected progression, all laboratory tests should be conducted weekly.4,5 If progression of eclampsia is suspected, the tests should be repeated more frequently. TABLE 3 Laboratory Tests Women at high risk for eclampsia Hemoglobin level Hematocrit Platelet count Urine protein collection (12 or 24 hour) Serum creatinine level Serum uric acid level Women developing hypertension after 20 weeks of gestation Same tests as in women at high risk Serum transaminase levels

Serum albumin level Lactic acid dehydrogenase level Peripheral blood smear Coagulation profile Adapted from National High Blood Pressure Education Program. Working Group on High Blood Pressure in Pregnancy. Working group report on high blood pressure in pregnancy. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 2000; NIH publication no. 00-3029. Accessed online November 8, 2004, athttp://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_preg.pdf. Small studies1618 have shown that random There currently is no single reliable, cost-effective screening test for preeclampsia. urinary protein-to-creatinine ratios predict the 24-hour urine total protein level and may provide a faster, simplified method of estimating proteinuria, providing that the protein values are less than 1 g in 24 hours.19 The urinary protein-to-creatinine ratio is not sensitive enough to differentiate mild and severe preeclampsia if significant proteinuria exists. However, a ratio of less than 0.2 effectively excludes the presence of significant proteinuria.20 A cutoff ratio of greater than 0.19 is a good predictor of significant proteinuria, with a sensitivity of 90 percent and a specificity of 70 percent. The negative predictive value of the urinary protein-to-creatinine ratio is 87 percent.17 OTHER STUDIES A baseline sonogram should be considered at 25 to 28 weeks of gestation to evaluate fetal growth in pregnant women at high risk for preeclampsia.5 In women who have already been diagnosed with preeclampsia, antepartum testing with a nonstress test, a biophysical profile, or both should be performed on a weekly basis starting at the time of diagnosis.5 If intrauterine growth retardation or oligohydramnios is suspected, the tests should be performed at least twice weekly, and delivery should be contemplated if there are any signs of fetal compromise.4,5 Immediate antepartum testing or delivery is indicated for suspected placental abruption and nonreassuring fetal surveillance.5 Treatment Delivery remains the ultimate treatment for preeclampsia.4,5 Although maternal and fetal risks must be weighed in determining the timing of delivery, clear indications for delivery exist (Table 4).15 When possible, vaginal delivery is preferable to avoid the added physiologic stressors of cesarean delivery.5 If cesarean delivery must be used, regional anesthesia is preferred because it carries less maternal risk.5 In the presence of coagulopathy, use of regional anesthesia generally is contraindicated.5 TABLE 4 Indications for Delivery in Preeclampsia

Fetal indications Severe intrauterine growth restriction Nonreassuring fetal surveillance Oligohydramnios Maternal indications Gestational age of 38 weeks or greater* Platelet count below 100 103 per mm3 (100 109 per L) Progressive deterioration of hepatic function Progressive deterioration of renal function Suspected placental abruption Persistent severe headache or visual changes Persistent severe epigastric pain, nausea, or vomiting Eclampsia *Delivery should be based on maternal and fetal conditions as well as gestational age. Adapted from National High Blood Pressure Education Program. Working Group on High Blood Pressure in Pregnancy. Working group report on high blood pressure in pregnancy. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 2000; NIH publication no. 00-3029. Accessed online July 19, 2004, athttp://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_preg.pdf. Women with preeclampsia and preterm pregnancy can be observed on an outpatient basis, with frequent assessment of maternal and fetal well-being. Women who are noncompliant, who do not have ready access to medical care, or who have progressive or severe preeclampsia should be hospitalized. Women whose pregnancy is remote from term should be cared for in a tertiary care setting or in consultation with an obstetrician or family physician who is experienced in the management of high-risk pregnancies.4 During labor, the management goals are to prevent seizures and control hypertension.4 Magnesium sulfate is the medication of choice for the prevention of eclamptic seizures in women with severe preeclampsia and for the treatment of women with eclamptic seizures.1,21 One commonly used regimen is a 6-g loading dose of magnesium sulfate followed by a continuous infusion at a rate of 2 g per hour.1Magnesium sulfate has been shown to be superior to phenytoin (Dilantin) and diazepam (Valium) for the treatment of eclamptic seizures.1 Although magnesium sulfate commonly is used in women with preeclampsia, studies to date have been inadequate to show that it prevents progression of the disorder.22,23 Antihypertensive drug therapy is recommended for pregnant women with systolic blood pressures of 160 to 180 mm Hg or higher24 and diastolic blood pressures of 105 to 110 mm Hg or higher4,5,25 The treatment goal is to lower systolic pressure to 140 to 155 mm Hg and diastolic pressure to 90 to 105 mm Hg. To avoid hypotension, blood pressure should be lowered gradually.5

Although evidence about the potential adverse effects of most antihypertensive drugs has been poorly quantified, use of many of these agents is contraindicated during pregnancy.7 Hydralazine (Apresoline) and labetalol (Normodyne, Trandate) are the antihypertensive drugs most commonly used in women with severe preeclampsia (Table 5).15 Nifedipine (Procardia) and sodium nitroprusside (Nitropress) are potential alternatives, but significant risks are associated with their use.5 Note that labetalol therapy should not be used in women with asthma or congestive heart failure.5 Use of angiotensin-converting enzyme inhibitors is contraindicated in pregnant women. TABLE 5 Antihypertensive Drugs Commonly Used in the Treatment of Severe Preeclampsia Hydralazine (Apresoline)* Initial dose: 5 mg IV or 10 mg IM When blood pressure is controlled, repeat initial dose as needed (usually about every 3 hours; maximum, 400 mg per day). If blood pressure is not controlled in 20 minutes, repeat initial dose every 20 minutes until maximum dosage is reached, or go immediately to next step. If blood pressure is not controlled with a total of 20 mg IV or 30 mg IM, consider using a different antihypertensive drug (labetalol, nifedipine [Procardia], sodium nitroprusside [Nitropress]). Labetalol (Normodyne, Trandate)* Initial dose: 20 mg in IV bolus If blood pressure is not controlled, give 40 mg 10 minutes after initial dose and then 80 mg every 10 minutes for two additional doses (maximum: 220 mg). If blood pressure is not controlled, use a different antihypertensive drug (hydralazine, nifedipine, sodium nitroprusside). IV = intravenous; IM = intramuscular. *In managing hypertensive emergencies, IV administration is safer than IM or oral administration because it is easier to combat inadvertent hypotension by stopping an IV injection or infusion. Labetalol should not be used in women with asthma or congestive heart failure. Adapted from National High Blood Pressure Education Program. Working Group on High Blood Pressure in Pregnancy. Working group report on high blood pressure in pregnancy. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 2000; NIH publication no. 00-3029. Accessed online November 8, 2004, athttp://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_preg.pdf. In women with preeclampsia, blood pressure usually normalizes within a few hours after delivery but may remain elevated for two to four weeks.26 As previously noted, a diagnosis of chronic hypertension is made if blood pressure remains elevated at 12 weeks postpartum.5

Women with preeclampsia should be counseled about future pregnancies. In nulliparous women with preeclampsia before 30 weeks of gestation, the recurrence rate for the disorder may be as high as 40 percent in future pregnancies.5 Multiparous women have even higher rates of recurrence.5 Prevention There currently are no well-established measures for preventing preeclampsia.4,8 Both low-dose aspirin therapy and daily calcium supplementation have been studied as preventive measures but have not been shown to be beneficial in the general pregnant population and are not recommended for primary prevention of preeclampsia.4,5 Some evidence does support the use of low-dose aspirin therapy and daily calcium supplementation in certain high-risk women. Calcium supplementation has been shown to produce modest blood pressure reductions in pregnant women who are at above-average risk for hypertensive disorders of pregnancy and in pregnant women with low dietary calcium intake.27 An optimum calcium dosage for these women has not been established.27 Low-dose aspirin therapy (100 mg per day or less) has been shown to reduce the incidence of preeclampsia in women who were found to have an abnormal uterine artery on Doppler ultrasound examination performed in the second trimester.28 Research on the use of antioxidants in the prevention of preeclampsia is promising.29 However, further study is needed, and antioxidant therapy currently is not recommended.4,5,29 Although preeclampsia is not preventable, many deaths from the disorder can be prevented. Women who do not receive prenatal care are seven times more likely to die from complications related to preeclampsiaeclampsia than women who receive some level of prenatal care.3 Some studies indicate that preeclampsiarelated fatalities occur three times more often in black women than in white women.3Although the precise reasons for the racial differences remain elusive, the differences may be indicative of disparities in health status, as well as access to, and quality of, prenatal care.3 To decrease preeclampsia-related mortality, appropriate prenatal care must be available to all women. Early detection, careful monitoring, and treatment of preeclampsia are crucial in preventing mortality related to this disorder.3,8