Preeclampsia - Management and Prognosis UpToDate

3/4/2015
Preeclampsia:Managementandprognosis
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Authors
ErrolRNorwitz,MD,PhD
JohnTRepke,MD
SectionEditor
CharlesJLockwood,MD,MHCM
DeputyEditor
VanessaABarss,MD,FACOG
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Mar2015.|Thistopiclastupdated:Mar05,2015.
INTRODUCTIONPreeclampsiareferstothenewonsetofhypertensionandeitherproteinuriaorendorgan
dysfunctionafter20weeksofgestationinapreviouslynormotensivewoman(table1).Itisamultisystem,
progressivedisorderwithadiseasespectrumthatrangesfrommildtosevere.Progressiontoseveredisease
(table2)maybegradualorrapid.Deliveryresultsinresolutionofthedisease.
GENERALPRINCIPLESAkeyaspectofroutineprenatalcareismonitoringpregnanciesforsignsand
symptomsofpreeclampsia.Ifthediagnosisismade,thedefinitivetreatmentisdeliverytopreventdevelopmentof
maternalorfetalcomplicationsfromdiseaseprogression.(See"Preeclampsia:Clinicalfeaturesanddiagnosis",
sectionon'Burdenofdisease'.)Whentoinitiatedeliveryisbasedupongestationalage,theseverityofthe
disease,andmaternalandfetalcondition.Patientswithpreeclampsiaat37weeksofgestationaredelivered
however,beforeterm,therisksofserioussequelaefromdiseaseprogressionneedtobebalancedwiththerisksof
pretermbirth.Evidenceofseriousmaternalendorgandysfunctionorindeterminatetestsoffetalwellbeingmaybe
indicationsforpromptdeliveryatanygestationalage.Ontheotherhand,whenmotherandfetusarestableand
withoutfindingsofseriousendorgandysfunction,aconservativeapproachwithclosemonitoringforevidenceof
progressiontoseverefeaturesofthedisease(table2)isreasonableinordertoachievefurtherfetalgrowthand
maturity.
APPROACHBASEDONDISEASESEVERITY
PreeclampsiawithfeaturesofseverediseasePreeclampsiawithfeaturesofseveredisease(alsocalled
severepreeclampsia)(table2)isgenerallyregardedasanindicationfordeliveryinthefollowingsettings:
Beforefetalviability
At340/7thsweeksofgestation
Whenthematernalorfetalconditionisunstable,regardlessofgestationalage
Deliveryminimizestheriskofdevelopmentofseriousmaternalandfetalcomplications(eg,cerebralhemorrhage,
hepaticrupture,renalfailure,pulmonaryedema,seizure,bleedingrelatedtothrombocytopenia,fetalgrowth
restriction,abruptioplacentae)[14].Withtheexceptionoffetalgrowthrestriction,anyoftheseadverseevents
canoccursuddenlyinawomanwithseveredisease.Afterfetalviabilityandbefore34weeksofgestation,when
themotherandfetusarestable,prolongationofpregnancyinatertiarycaresettingorinconsultationwitha
maternalfetalmedicinespecialistisreasonabletoreducemorbidityfrompretermbirth.Candidatesforthis
approachandmanagementofthesepregnanciesarediscussedseparately.(See"Expectantmanagementof
preeclampsiawithseverefeatures".)
Observationaldatasuggestthatthedecisiontoexpeditedeliveryinthesettingofseverepreeclampsiadoesnot
mandateimmediatecesareanbirth[46].Cervicalripeningagentscanbeusedpriortoinductionifthecervixisnot
favorable[7].However,wefeelthataprolongedinductionandinductionswithalowlikelihoodofsuccessarebest
avoided.Cesareandeliveryisreasonableforwomenwithseverepreeclampsia/eclampsiawhoareunderabout32
weeksofgestationandhavealowBishopscore,giventhehighfrequencyofindeterminatefetalheartrate
tracingsandfailureofthecervixtodilateinthissetting[79].Lessthanonethirdofpreterminductionsinthis
settingresultinvaginalbirth.
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PreeclampsiawithoutfeaturesofseverediseaseExpertsconsistentlyrecommenddeliveryofwomenwith
preeclampsiaat37weeksofgestation,evenintheabsenceoffeaturesofseveredisease(previouslycalledmild
preeclampsia)[3,4,1012].Cervicalripeningagentsshouldbeusedinwomenwithunfavorablecervices.
Thebenefitsoflaborinductionat37weeksofgestationwereillustratedinamulticentertrial(HYPITAT)that
randomlyassigned756womenwithmildpreeclampsiaorgestationalhypertension>360/7weekstoinduction
oflabororexpectantmanagementwithmaternal/fetalmonitoring[13].Routineinductionwasassociatedwith
asignificantreductionincompositeadversematernaloutcome(RR0.71,95%CI0.590.86absoluterisk
reduction12.76percent),whichwasprimarilydrivenbyareductioninpatientswhodevelopedsevere
hypertensionandwasnotsignificantforwomenat360to366weeks.Theinducedgroupdelivered,on
average,1.2weeksearlierthanthecontrolgroupandhadasignificantlylowerrateofcesareandelivery(14
versus19percent).Therewerenosignificantdifferencesbetweengroupsinneonataloutcome.
Thistrialshowedthatpreeclampticwomenbenefitedfromearlyintervention,withoutincurringanincreased
riskofoperativedeliveryorneonatalmorbidity.Thetrialwasnotlargeenoughtodeterminewhethersmall
differencesinnewbornoutcomesorinductionbetween36and37weeksmightbestatisticallysignificant.A
followupeconomicanalysisofthistrialconcludedinductionwasalsolesscostlyoverallthanexpectant
managementwithmonitoring[14].Anotherfollowupanalysisshowedthatanunfavorablecervixwasnota
reasontoavoidinduction[15].
Theoptimummanagementforwomenwithpreeclampsiawithoutfeaturesofseverediseaseandstablematernal
andfetalconditionsat340/7to360/7weeksremainsuncertainnorandomizedtrialshavebeenperformedinthis
population.Thesepregnanciesaregenerallymanagedexpectantlytoenablefurtherfetalgrowthandmaturation.
Progressionofthediseaseisgenerallyslowandobservationaldatashowthatmanypatientswithlateonset
diseasewillreachtermwithoutprogressiontoseveredisease.Forpatientsmanagedexpectantly,deliveryis
indicatedassoonastheydevelopsignsorsymptomsofseverepreeclampsia/eclampsia(table2)orat37weeks
ofgestationifthediseasedoesnotprogresstotheseverestage.
Priorto340/7weeks,guidelinesfrommajormedicalorganizationsgenerallyrecommendexpectantmanagementof
preeclampsiawithoutfeaturesofseveredisease,basedonexpertopinion,giventhehighriskofcomplicationsof
prematurity[3,4,12].(See"Shorttermcomplicationsoftheprematureinfant"and"Longtermcomplicationsofthe
prematureinfant"and"Incidenceandmortalityoftheprematureinfant".)
EXPECTANTANTEPARTUMMANAGEMENTOFPREECLAMPSIAWITHOUTFEATURESOFSEVERE
DISEASEWomenwithpreterm(<37weeksofgestation)preeclampsiawithoutfeaturesofseverediseaseare
managedexpectantly,withclosematernalandfetalmonitoringandwithoutantihypertensivetherapy.
InpatientversusoutpatientcareClosematernalmonitoringupondiagnosisofpreeclampsiaisimportantto
establishdiseaseseverityandtherateofprogression.Hospitalizationisusefulformakingtheseassessmentsand
facilitatesrapidinterventionintheeventofrapidprogression.Aftertheinitialdiagnosticevaluation,outpatientcare
isacosteffectiveoptionforwomenwithstablenonseverepreeclampsia[1620].Outpatientcarecanbeprovided
inthepatientshomeor,whereavailable,atanantenataldaycareunit[21].
Therearelimiteddataonoutcomeofoutpatientmanagementofpreeclampticwomen.Anobservationalstudyand
arandomizedtrialreportedgoodoutcomes,butthesestudieshadtoofewsubjectstodetectclinicallysignificant
differencesinoutcomebetweeninpatientandoutpatientmanagement[17,18].Asystematicreviewofthreetrials
withatotalof504womenwithvariouscomplicationsofpregnancyobservednomajordifferencesinclinical
outcomesformothersorbabiesbetweenantenataldayunitsorhospitaladmission[21].
Patientsofferedoutpatientmonitoringshouldbeabletocomplywithfrequentmaternalandfetalevaluations(every
onetothreedays)andshouldhavereadyaccesstomedicalcare.Restrictedactivitymayberecommendedsince
bloodpressureislowerinrestedpatientshowever,thereisnoevidencethatbedrestimprovespregnancy
outcomeordelaysprogressionofdisease[22].Furthermore,bedrestinthehospitalincreasestheriskofvenous
thromboembolism[23].Restintheleftlateraldecubituspositioncanaugmentuteroplacentalflow,whichmay
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benefitsomepregnancies.Avoidingthesupinesleeppositionisprudent[24].Ifsignsorsymptomsofdisease
progressionarenoted,hospitalizationformoreintensivemonitoringandpossibledeliveryisindicated.
Outpatientsshouldbeawareofthesignsandsymptomsofpreeclampsiaandtheyshouldmonitorfetal
movementsdaily[4].Theyshouldbetoldtocalltheirhealthcareproviderimmediatelyiftheydevelopsevereor
persistentheadache,visualchanges,shortnessofbreath,orrightupperquadrantorepigastricpain.Aswithany
pregnancy,decreasedfetalmovement,vaginalbleeding,abdominalpain,ruptureofmembranes,oruterine
contractionsshouldbereportedimmediately,aswell.
LaboratoryfollowupTheminimumlaboratoryevaluationshouldincludeplateletcount,serumcreatinine,and
liverenzymes.Thesetestsshouldberepeatedatleastweeklyinwomenwithnonseverepreeclampsiatoassess
fordiseaseprogression,andmoreoftenifclinicalsignsandsymptomssuggestworseningdisease[4].
Thevalueofothertestsislessclearlydefined.Arisinghematocritcanbeusefultolookforhemoconcentration,
whichsuggestscontractionofintravascularvolumeandprogressiontomoreseveredisease,whileafalling
hematocritmaybeasignofhemolysis.Anelevatedserumindirectbilirubinconcentrationisabettersignof
hemolysis,althoughanelevatedLDHmayalsobeamarkerofseverediseaseorHELLPsyndrome.Hemolysis
canbeconfirmedbyobservationofschistocytesandhelmetcellsonabloodsmear(picture1AB).(See"HELLP
syndrome".)
Sinceseveralclinicalstudieshaveshownthatneithertherateofincreasenortheamountofproteinuriaaffects
maternalorperinataloutcomeinthesettingofpreeclampsia[2528],repeated24hoururinaryproteinestimations
arenotusefuloncethethresholdof300mg/24hoursorprotein/creatinineratio0.3mg/dL/mg/dLforthediagnosis
ofpreeclampsiahasbeenexceeded.Serumcreatininealonecanbeusedtomonitorrenalfunction.(See
"Expectantmanagementofpreeclampsiawithseverefeatures".)
TreatmentofhypertensionBloodpressureshouldbeassessedatleasttwiceweekly.Theuseof
antihypertensivedrugstocontrolmildhypertensioninthesettingofpreeclampsiadoesnotalterthecourseofthe
diseaseordiminishperinatalmorbidityormortality,andshouldbeavoidedinmostpatients.Theindicationsfor
startingantihypertensivetherapy,thechoiceofdrug,andbloodpressuregoalsarediscussedseparately.(See
"Managementofhypertensioninpregnantandpostpartumwomen",sectionon'Preeclampsia'.)
Sodiumrestrictionbelowtherecommendeddailyintakeanddiureticshavenoroleinroutinetherapy[2931].
Althoughintravascularvascularvolumeisreduced,arandomizedtrialshowedthatplasmavolumeexpansiondid
notimprovematernalorfetaloutcome[32].
AssessmentoffetalwellbeingTherearenodatafromrandomizedtrialsonwhichtobaserecommendations
fortheoptimaltypeandfrequencyoffetalbiophysicalmonitoring.Wesuggestdailyfetalmovementcountsand
twiceweeklyfetalnonstresstestingwithassessmentofamnioticfluidvolume,ortwiceweeklybiophysical
profiles.Testingisrepeatedimmediatelyifthereisanabruptchangeinmaternalcondition.(See"Nonstresstest
andcontractionstresstest"and"Thefetalbiophysicalprofile".)
EvaluationofumbilicalarteryDopplerindicesisalsouseful,astheresultshelpinoptimaltimingofdelivery.Ina
metaanalysisof16randomizedtrialsinhighriskpregnancies,knowledgeofumbilicalarteryDopplervelocimetry
resultswasassociatedwitha29percentreductioninperinataldeath(RR0.71,95%CI0.520.98,10,225babies,
1.2versus1.7percentnumberneededtotreat203,95%CI1034352),primarilyinpregnanciescomplicatedby
preeclampsiaand/orgrowthrestriction.Thefrequencyofassessmentdependsonthefindingsweekly
assessmentisreasonablewhenDopplerindicesarenormal.(See"Dopplerultrasoundoftheumbilicalarteryfor
fetalsurveillance",sectionon'Clinicaleffectiveness'and"Dopplerultrasoundoftheumbilicalarteryforfetal
surveillance",sectionon'Guidelinesforclinicalpractice'.)
AssessmentoffetalgrowthEarlyfetalgrowthrestrictionmaybethefirstmanifestationofpreeclampsiaandis
asignofsevereuteroplacentalinsufficiency.Wesuggestperformingsonographicestimationoffetalweightto
evaluateforgrowthrestrictionandoligohydramniosatthetimeofdiagnosisofpreeclampsia.Iftheinitial
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examinationisnormal,werepeattheultrasoundexaminationeverythreeweeks.Managementofthegrowth
restrictedfetusisreviewedseparately.(See"Fetalgrowthrestriction:Evaluationandmanagement",sectionon
'Serialfetalweightassessment'and"Dopplerultrasoundoftheumbilicalarteryforfetalsurveillance".)
AntenatalcorticosteroidsAlthoughpreeclampsiamayacceleratefetallungmaturation,neonatalrespiratory
distressremainscommoninprematureneonatesofpreeclampticpregnancies[33,34].Antenatalcorticosteroids
(betamethasone)topromotefetallungmaturityshouldbeadministeredtowomen<34weeksofgestationsince
theyareatincreasedriskofprogressiontoseverediseaseandpretermdelivery.(See"Antenatalcorticosteroid
therapyforreductionofneonatalmorbidityandmortalityfrompretermdelivery".)
INTRAPARTUMMANAGEMENT
IntrapartummonitoringContinuousmaternalfetalmonitoringisindicatedintrapartumtoidentifyworsening
hypertension,deterioratingmaternalhepatic,renal,cardiopulmonary,neurological,orhematologicfunction,aswell
asabruptioplacentaeoranabnormalorindeterminatefetalheartratetracing.Therearenoevidencebased
standardsfortheoptimalapproach.
FluidsFluidbalanceshouldbemonitoredcloselytoavoidexcessiveadministration,sincewomenwithsevere
diseaseareatriskofpulmonaryedemaandsignificantthirdspacing.Maintenancefluidsof80mL/hourareoften
adequateintheabsenceofongoingfluidloss,suchasbleeding.Oliguriathatdoesnotrespondtoamodesttrialof
increasedfluidsshouldbetolerated.Diureticsareonlyindicatedfortreatmentofpulmonaryedema.
ManagementofhypertensionSeverehypertensioninlaborshouldbetreatedwithintravenouslabetalolor
hydralazineororalnifedipinetopreventstroke.Antihypertensivemedicationsdonotpreventeclampsia.(See
"Managementofhypertensioninpregnantandpostpartumwomen",sectionon'Acutetherapy'.)
AnesthesiaNeuraxialtechniquesaregenerallysafeandeffectiveinpreeclampticwomen[4,35].In
preeclampsia,thetwomajoranesthesiarelatedconcernswithuseofneuraxialtechniquesare(1)thepotentialfor
alargedropinbloodpressureduetodepletedintravascularvolumeandsympatheticblockadeand(2)peridural
hematomainwomenwithseverethrombocytopenia.Theformercanbeminimizedbyappropriateadjustmentsin
prehydration,drugchoice,drugdosing,anddrugdeliverybytheanesthesiologisthowever,alowplateletcount
mayprecludeneuraxialanesthesia.(See"Adverseeffectsofneuraxialanalgesiaandanesthesiaforobstetrics",
sectionon'Hypotension'and"Adverseeffectsofneuraxialanalgesiaandanesthesiaforobstetrics",sectionon
'Neuraxialanalgesiaandlowplatelets'.)
Themajorconcernsassociatedwithgeneralanesthesia(forcesareandelivery)areatransientspikeinblood
pressureduringintubation(responsetonoxiousstimuli),hypotension(fromreductionincardiacoutputand
systemicvascularresistance),anddifficultorfailedintubationbecauseoforopharyngealedema.(See"Airway
managementofthepregnantpatientatdelivery".)
Giventheseissues,earlypatientassessmentbytheanesthesiateamisdesirable.
InvasivehemodynamicmonitoringAlthoughnotroutinelyrecommendedeveninthesettingofsevere
preeclampsia[4],invasivehemodynamicmonitoringcanbeusefulincomplicatedpatients,suchasthosewith
severecardiacdisease,severerenaldisease,severeoliguria,refractoryhypertension,orpulmonaryedema.
However,mostwomencanbemanagedwithoutthesetoolsandshouldnotbeexposedtotherisksassociated
witharterialandcentralvenouscatheterization.Randomizedtrialshavenotbeenperformed[36].(See"Pulmonary
arterycatheterization:Indicationsandcomplications"and"Complicationsofcentralvenouscathetersandtheir
prevention".)
SeizureprophylaxisBasedupondatafromrandomizedtrials,weadministerintrapartumandpostpartum
magnesiumsulfateseizureprophylaxistoallwomenwithpreeclampsia.Althoughseizureanddeatharerare
outcomeswhenmagnesiumsulfateisomittedinwomenwhodonothaveseverehypertensionorpreeclampsia
symptoms,wefeelthebenefitoftreatmentisjustifiablegiventhelowcostandtoxicityofmagnesiumsulfateand
therelativelylownumberofpatientsthatneedtobetreatedtopreventoneseizure.Inarandomizedplacebo
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controlledtrialincluding10,000women(MAGPIE[magnesiumsulfateforpreventionofeclampsiatrial]),about100
womenwithmildpreeclampsiaandabout60womenwithseverepreeclampsiawouldneedtobetreatedtoprevent
oneseizure[37].Thisrecommendationisincontrasttothe2013AmericanCollegeofObstetriciansand
Gynecologistsrecommendations,whichstatethatforwomenwithpreeclampsiawithsystolicbloodpressureof
lessthan160mmHgandadiastolicbloodpressurelessthan110mmHgandnomaternalsymptoms,itis
suggestedthatmagnesiumsulfatenotbeadministereduniversallyforthepreventionofeclampsia[4].
Itisimportanttoemphasizethatseizureprophylaxisdoesnotpreventprogressionofdiseaseunrelatedto
convulsions.Approximately10to15percentofwomeninlaborwithnonseverepreeclampsiawilldevelopsignsof
severepreeclampsia(eg,severehypertension,severeheadache,visualdisturbance,epigastricpain,laboratory
abnormalities)orabruptioplacenta,whetherornottheyreceivemagnesiumtherapy[38,39].
Wedonotadministerseizureprophylaxistowomenwithonlygestationalhypertension(pregnancyrelated
hypertensionwithoutproteinuriaorendorgandysfunction),astheseizureriskinthelattergroupislessthan0.1
percent[40].(See"Gestationalhypertension".)
MagnesiumsulfateversusotheranticonvulsantsMajormedicalorganizationsworldwideconsistently
recommendmagnesiumsulfateasthedrugofchoiceforthepreventionofeclampsia[4,12,41].Inrandomized
trials[37,42,43]andlargeobservationalseries[44],magnesiumsulfatewasmoreeffectiveforpreventionofafirst
seizurethanphenytoin[42]oranantihypertensivedrugalone(nimodipine)[43]orplacebo[44].Asanexample,a
trialthatrandomlyassigned2138preeclampticpatientsadmittedtoLaborandDeliveryatParklandHospitalto
seizureprophylaxiswithmagnesiumsulfateorphenytoinreportedeclampticseizuresin10of1089women
assignedtophenytoincomparedtononeof1049womenassignedtomagnesiumsulfate[42].Maternaland
neonataloutcomesweresimilarinbothgroups.
Inmetaanalysesofrandomizedtrialsineclampticwomen,magnesiumsulfatewassaferandmoreeffectivefor
preventionofrecurrentseizuresthanphenytoin,diazepam,orlyticcocktail(ie,chlorpromazine,promethazine,and
pethidine).Thesedataprovideadditionalindirectevidenceofitseffectivenessinpreeclampsia.(See"Eclampsia",
sectionon'Preventionofrecurrentseizures'.)
MagnesiumregimenandmonitoringThereisnoconsensusontheoptimalmagnesiumregimen,whenit
shouldbestartedandterminated,orrouteofadministration[45].Thedrugisusuallyinitiatedattheonsetoflabor
orinduction,orpriortoacesareandelivery[4,46,47].Itisusuallynotgiventostableantepartumpatientsoffthe
laborunit,butissometimesusedinwomenwithseverepreeclampsiabeingconsideredforexpectant
management.Prolongedantepartumtherapy(morethanfivetosevendays)inwomenwithpretermlaborhasbeen
associatedwithadverseeffectsonfetalbones[48].(See"Expectantmanagementofpreeclampsiawithsevere
features".)
DosingAlthoughpublisheddosageregimensformagnesiumsulfatevarywidely(loadingdoseof4to6
gramsintravenouslyandmaintenancedoseof1to3gramsperhour),themostcommonregimen,andtheonethat
weuse,isaloadingdoseof6gramsintravenouslyover15to20minutesfollowedby2gramsperhourasa
continuousinfusion[4,39,44,47].Analternativeregimenis5gramsintramuscularlyintoeachbuttock(totalof10
grams)followedby5gramsintramuscularlyeveryfourhours.However,thismethodisassociatedwithmoreside
effects,particularlypainattheinjectionsite.
Theredoesnotappeartobeaclearthresholdconcentrationforinsuringthepreventionofconvulsions,althougha
therapeuticrangeof4.8to8.4mg/dL(2.0to3.5mmol/L)hasbeenrecommendedbasedonretrospectivedata[49].
Loadingdoseslessthan6gramsaremorelikelytoresultinsubtherapeuticmagnesiumlevels(lessthan4.5
mg/dL)[44,50].
Sincemagnesiumsulfateisexcretedbythekidneys,dosingshouldbeadjustedinwomenwithrenalinsufficiency
(definedasaserumcreatininegreaterthan1.0mg/dL).Suchwomenshouldreceiveastandardloadingdose
(sincetheirvolumeofdistributionisnotaltered),butareducedmaintenancedose(1gramperhourorno
maintenancedoseiftheserumcreatinineisgreaterthan2.5mg/dL)andclosemonitoringoftheirserum
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magnesiumleveleverysixhoursorbyclinicalassessmenteveryonetotwohours.
Themaintenancephaseisgivenonlyifapatellarreflexispresent(lossofreflexesbeingthefirstmanifestationof
symptomatichypermagnesemia),respirationsexceed12perminute,andtheurineoutputexceeds100mLperfour
hours.(See"Symptomsofhypermagnesemia".)Followingserummagnesiumlevelsisnotrequiredifthewoman's
clinicalstatusiscloselymonitoredforevidenceofpotentialmagnesiumtoxicity(see'Complicationsandside
effects'below).Themaintenancedoseshouldbedecreasedifthereisclinicalevidenceofmagnesiumtoxicity.
DurationoftherapyMagnesiumsulfateisusuallycontinuedfor24hourspostpartum[47].Timingof
drugdiscontinuationhasbeenarbitrarytherearenohighqualitydatatoguidetherapy.Inwomenwhohave
nonseverepreeclampsia,discontinuationoftherapyafter12hoursmaybesafe[51].Inwomenwithsevere
preeclampsiaoreclampsia,seizureprophylaxisisgenerallycontinuedfor24to48hourspostpartum,afterwhich
theriskofrecurrentseizuresislow.
Itisprobablyreasonabletoextendthedurationofmagnesiumsulfatetherapyinwomenwhosediseasehasnot
beguntoimprovepostpartumandshortenthedurationoftherapyinwomenwhoareclearlyimprovingclinically
(eg,diuresisof100mL/hourfortwoconsecutivehours,absenceofsymptoms[headache,visualchanges,
epigastricpain],andabsenceofseverehypertension)[5255].Diuresis(greaterthan4L/day)isbelievedtobethe
mostaccurateclinicalindicatorofresolutionofpreeclampsia/eclampsia,butisnotaguaranteeagainstthe
developmentofseizures[56].Inwomenwithpersistentrenalimpairmentpostpartum,itisimportanttobecautious
whenadministeringaprolongedmagnesiumsulfateinfusiontopreventtheoccurrenceofmagnesiumtoxicity.
ComplicationsandsideeffectsRapidinfusionofmagnesiumsulfatecausesdiaphoresis,flushing,and
warmth,probablyrelatedtoperipheralvasodilationandadropinbloodpressure.Nausea,vomiting,headache,
muscleweakness,visualdisturbances,andpalpitationscanalsooccur.Dyspneaorchestpainmaybesymptoms
ofpulmonaryedema,whichisararesideeffect.(See"Symptomsofhypermagnesemia".)
Magnesiumtoxicityisuncommoninwomenwithgoodrenalfunction[57].Toxicityisrelatedtoserummagnesium
concentration:lossofdeeptendonreflexesoccursat7to10mEq/L(8.5to12mg/dLor3.5to5.0mmol/L),
respiratoryparalysisat10to13mEq/L(12to16mg/dLor5.0to6.5mmol/L),cardiacconductionisalteredat>15
mEq/L(>18mg/dLor>7.5mmol/L),andcardiacarrestoccursat>25mEq/L(>30mg/dLor>12.5mmol/L)[58].
Calciumgluconate(1gramintravenouslyover5to10minutes)shouldbeadministeredonlytocounteractlife
threateningsymptomsofmagnesiumtoxicity(suchascardiorespiratorycompromise).
Magnesiumsulfateiscontraindicatedinwomenwithmyastheniagravissinceitcanprecipitateasevere
myastheniccrisis(see"Managementofmyastheniagravisinpregnancy").Neuromuscularblockadeand
hypotensionduetoconcurrentuseofmagnesiumsulfateandcalciumchannelblockershavebeendescribedin
casereports,buttheriskappearstobeminimal[59].
Althoughmagnesiumsulfateisaweaktocolytic,labordurationdoesnotappeartobeaffectedbymagnesium
sulfateadministration[60].Theriskofpostpartumhemorrhage,possiblyrelatedtouterineatonyfrommagnesium's
tocolyticeffects,wasslightlyincreasedinonetrial[43].
Magnesiumfreelycrossestheplacentaasaresult,thecordbloodconcentrationapproximatesthematernal
serumconcentration.Maternaltherapycausesadecreaseinbaselinefetalheartrate,whichgenerallyremains
withinthenormalrange,andadecreaseinfetalheartratevariability,whichmaybeabsentorminimal[61].
Antenatalfetalassessmenttestresults(eg,biophysicalprofilescoreandnonstresstestreactivity)arenot
significantlyaltered[62].
Magnesiumtherapyresultsinatransientreductionoftotalandionizedserumcalciumconcentrationduetorapid
suppressionofparathyroidhormonerelease[63].Rarely,hypocalcemiabecomessymptomatic(myoclonus,
delirium,ECGabnormalities).(See"Symptomsofhypermagnesemia",sectionon'Hypocalcemia'.)Cessationof
magnesiumtherapywillrestorenormalserumcalciumlevels.However,calciumadministrationmayberequiredif
symptomsarepresent(calciumgluconate1gramintravenouslyover5to10minutes).(See"Causesand
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treatmentofhypermagnesemia".)
MechanismofanticonvulsantactionThemechanismfortheanticonvulsanteffectsofmagnesium
sulfatehasnotbeenclearlydefined.Theprimaryeffectisthoughttobecentral.Hypothesesincluderaisingthe
seizurethresholdbyitsactionatthenmethyldaspartate(NMDA)receptor,membranestabilizationinthecentral
nervoussystemsecondarytoitsactionsasanonspecificcalciumchannelblocker,aswellasdecreasing
acetylcholineinmotornerveterminals[64,65].Anothertheoryisthatitpromotesvasodilatationofconstricted
cerebralvesselsbyopposingcalciumdependentarterialvasospasm,therebyreducingcerebralbarotrauma[66].
POSTPARTUMMANAGEMENTNonsteroidalantiinflammatorydrugs(NSAIDs)forpaincontrolshouldbe
avoidedinwomenwithpoorlycontrolledhypertension,oliguria,renalinsufficiency,orthrombocytopenia.(See
"NonselectiveNSAIDs:Overviewofadverseeffects".)
Therearenoevidencebasedstandardsfortheoptimalapproachtopostpartummonitoringandfollowup.We
monitorvitalsignseverytwohourswhilethepatientremainsonmagnesiumsulfateandwerepeatlaboratorytests
untiltwoconsecutivesetsofdataarenormal.
Severehypertensionshouldbetreatedsomepatientswillhavetobedischargedonantihypertensivemedications,
whicharediscontinuedwhenbloodpressurereturnstonormal.(See"Managementofhypertensioninpregnantand
postpartumwomen",sectionon'Postpartumhypertension'.)
Patientsshouldbefollowedcloselyasoutpatients.TheAmericanCollegeofObstetriciansandGynecologists
suggestsmonitoringbloodpressureinhospitalorathomeforthefirst72hourspostpartumandagain7to10days
postdelivery[4].Somepatientswillrequirelongermonitoringcontinuedfollowupisneededuntilallofthesigns
andsymptomsofpreeclampsiahaveresolved.Alternativediagnosesshouldbesoughtinthosewithpersistent
abnormalfindingsafterthreetosixmonths[67].(See"Overviewofhypertensioninadults".)
PostpartumonsetofpreeclampsiaInwomenwhoareinitiallydiagnosedwithpreeclampsiaafterdelivery,
magnesiumsulfateshouldbeadministeredtothoseatincreasedriskofdevelopingseizures[4]:
Womenwithnewonsethypertensionandheadacheorblurredvision,or
Womenwithseverehypertension
Antihypertensivetherapyshouldalsobeinitiated.TheAmericanCollegeofObstetriciansandGynecologists
suggeststreatmentofsystolicbloodpressure150mmHgordiastolicbloodpressure100mmHgontwo
occasionsfourtosixhoursapart[4].Treatmentshouldbeinitiatedwithinonehourifsystolicbloodpressureis
160mmHgordiastolicbloodpressureis110mmHg.
GUIDELINESFROMSELECTEDORGANIZATIONSAnumberofmedicalorganizationshavepublished
guidelinesformanagementofpreeclampsia.Theseguidelinesaregenerallyconsistentwiththerecommendations
inthistopicreview.
AmericanCollegeofObstetriciansandGynecologists(ACOG).HypertensioninPregnancy[4]
NationalInstituteforHealthandClinicalExcellence(NICE).Hypertensioninpregnancy:Themanagementof
hypertensivedisordersduringpregnancy[3]
SocietyofObstetriciansandGynaecologistsofCanada(SOGC).Diagnosis,evaluation,andmanagementof
thehypertensivedisordersofpregnancy[12]
PROGNOSISPrognosticissuesincludetheriskofrecurrentpreeclampsiaandrelatedcomplicationsin
subsequentpregnanciesandlongtermmaternalhealthrisks.
RecurrenceA2015metaanalysisofindividualpatientdatafromover75,000womenwithpreeclampsiawho
becamepregnantagainfoundthat20percentdevelopedhypertensioninasubsequentpregnancyand16percent
developedrecurrentpreeclampsia[68].
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Therecurrenceriskvarieswiththeseverityandtimeofonsetoftheacuteepisode[69].Womenwithearlyonset,
severepreeclampsiaareatgreatestriskofrecurrence(ashighas25to65percent)[7072].Theriskismuch
lower(5to7percent)inwomenwhohadnonseverepreeclampsiaduringthefirstpregnancy,versuslessthan1
percentinwomenwhohadanormotensivefirstpregnancy(doesnotapplytoabortions)[70,7378].Inaseriesof
125womenwithseveresecondtrimesterpreeclampsiafollowedforfiveyears,65percentdevelopedrecurrent
preeclampsiaand35percentwerenormotensiveintheirsubsequentpregnancy[70].Ofthepreeclampticgroup,
approximatelyonethirddevelopedthediseaseat27weeks,onethirdat28to36weeks,andonethirdat37
weeks.Thus,21percentofsubsequentpregnancieswerecomplicatedbyseverepreeclampsiainthesecond
trimester.
Recurrentpreeclampsiaismorelikelyfollowingapreeclampticsingletonpregnancythanapreeclamptictwin
pregnancy[79].TherecurrenceriskinwomenwithHELLPsyndrome(whomaydevelopeitherHELLPor
preeclampsiainasubsequentpregnancy)isdiscussedseparately.(See"HELLPsyndrome",sectionon
'Recurrenceinsubsequentpregnancies'.)
PreventionPreventivetherapy(lowdoseaspirin)isreviewedelsewhere.(See"Preeclampsia:Prevention".)
RiskofrelatedobstetricalcomplicationsPreeclampsia,growthrestriction,pretermdelivery,abruptio
placentae,andstillbirthcanallbesequelaeofimpairedplacentalfunction.Womenwithpregnanciescomplicated
byoneofthesedisordersareatincreasedriskofdevelopingoneoftheotherdisordersinfuturepregnancies.Early
onsetpreeclampsiaismorelikelytobeassociatedwithoneoftheseadverseeventsinasubsequentpregnancy,
evenifnormotensive,thanlateonsetpreeclampsia[80,81].
Longtermmaternalrisks
CardiovasculardiseaseCasecontrolandcohortstudiesconsistentlyreportthatpreeclampsiaispredictive
offuturecardiovascularandcerebrovasculardisease.Thisriskwassummarizedintwosystematicreviewsof
controlledstudiesthatevaluatedtheriskoflatecardiovasculareventsinwomenwithandwithoutahistoryof
preeclampsia[82,83]:
Comparedwithwomenwithnohistoryofthedisease,womenwithpreeclampsiawereatincreasedriskof
developinghypertension(RR3.70,95%CI2.705.05atmeanfollowupof14years),ischemicheartdisease
(RR2.16,95%CI1.862.52atmeanfollowupof11.7years),stroke(RR1.81,95%CI1.452.27atmean
followupof10.4years),andvenousthromboembolism(RR1.79,95%CI1.372.33atmeanfollowupof4.7
years)[82].Theabsoluteriskthatawomanwithorwithoutahistoryofpreeclampsiawoulddeveloponeof
thesecardiovasculareventsatage50to59yearswasestimatedtobe17.8and8.3percent,respectively.
Inaddition,agradedrelationshipwasobservedbetweenseverityofpreeclampsiaandriskoffuturecardiac
disease(mildpreeclampsiaRR2.00,95%CI1.832.19moderatepreeclampsiaRR2.99,95%CI2.513.58
severepreeclampsiaRR5.36,95%CI3.967.27),aswellasacorrelationbetweenpreeclampsiaandfuture
peripheralarterydisease(RR1.87,95%CI0.943.73)[83].Theauthorsdefinedpreeclampsiaas'mild'ifthe
pregnancyhadanuncomplicatedcourse,'moderate'ifpreeclampsiawascomplicatedbyfetalgrowth
restrictionormaternalseizuresand'severe'ifpreeclampsiawascomplicatedbypretermdeliveryorfetal
demise.
Prospectivecohortstudiespublishedafterthesereviewshavereportedsimilarfindings[8487].
Thefutureriskofcardiovascularmorbidityandmortalityappearstoberelatedtoboththeseverityofpreeclampsia
andthenumberofepisodesofpreeclampsia[88].Womenwithearlyonset/severepreeclampsiawithpreterm
deliveryareathighestriskofcardiovasculardiseaselaterinlife,includingduringthepremenopausalperiod(table
3).Intwolargestudies,thesewomenhadaneighttoninefoldincreasedriskofdeathfromcardiovascularcauses
comparedwithwomenwithoutahistoryofpreeclampsia[86,89].Incontrast,mildpreeclampsiaoccurringlatein
gestationdoesnotappeartobeassociatedwithahighriskofremotecardiovasculardisease[90].Thestronger
associationbetweencardiovasculardiseaseandpretermpreeclampsiasuggeststhatthepathogenesisofearly
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versuslatepreeclampsiamaybedifferent.
Severalstudieshavedemonstratedthatwomenwithahistoryofpreeclampsiaorsevereearlyonsetfetalgrowth
restrictionexhibitimpairedendothelialfunctionandvasodilatationremotefrompregnancy[9194].Womenwitha
historyofhypertensivedisordersinpregnancyhavehigherlevelsofglucose,insulin,andunfavorablelipidsthan
womenwithahistoryofnormotensivepregnancy[95].Datafromsomeepidemiologicstudiessuggestthatthe
increasedriskoflatecardiovascularmorbidityinpreviouslypreeclampticwomenreflectsanunderlying
predispositioninthesewomenforbothdisorders(geneticfactors,sharedriskfactors),butitisalsopossiblethat
preeclampsiaresultsinpermanentarterialchangesleadingtolatecardiovasculardisease[9699].Some
investigatorshavehypothesizedthatincreasedinsulinresistance,sympatheticoveractivity,proinflammatory
activity,endothelialdysfunction,andtheabnormallipidprofileinpreeclampticwomenconstituteanearly
manifestationofmetabolicsyndromeandthatthesechangespersistafterpregnancy,therebyputtingaffected
womanatincreasedriskofcardiovasculardisease[100104].Onegroupestimatedthatlifestyleinterventionsafter
preeclampsiawoulddecreasecardiovasculardiseaseriskby4to13percent[105].
DiabetesmellitusInapopulationbasedretrospectivecohortstudyincludingoveronemillionwomen,
preeclampsiaorgestationalhypertensionintheabsenceofgestationaldiabetesmellitus(GDM)wasassociated
withatwofoldincreaseintheincidenceofdiabetesduring16.5yearsofpostdeliveryfollowup,aftercontrolling
forseveralconfoundingvariables(butnotobesity)[106].Inwomenwhohadpreeclampsiaorgestational
hypertensionandGDM,theriskoffuturediabeteswasincreased16to18fold,whichwasabovethealready
elevated13foldincreaseinriskassociatedwithGDMalone.Thesefindings,andthosefrompreviousreports
[107109],suggestthatcliniciansshouldinformwomenwithahistoryofpreeclampsiaorgestationalhypertension
thattheymaybeatincreasedriskofdevelopingdiabeteshowever,theavailableevidencedoesnotsupporta
changeinstandardscreeningguidelines.(See"Screeningfortype2diabetesmellitus",sectionon'Screening
recommendationsbyexpertgroups'.)
EndstagerenaldiseaseWomenwithpreeclampsiamaybeatincreasedriskofdevelopingendstagerenal
disease(ESRD)laterinlife,buttheabsoluteriskissmall.Astudythatlinkedfourdecadesofdatafromthe
NorwegiannationalbirthandESRDregistriesfoundthatwomenwithpreeclampsiaintheirfirstpregnancyhada
fourfoldincreaseinriskofESRDcomparedwithwomenwithoutpreeclampsia(RR4.7,95%CI3.66.1)after
adjustingforknownconfounders,buttheabsoluteriskofESRDwaslessthan1percentwithin20years[110].
Similarly,astudyusingclaimsdatafromtheTaiwanNationalHealthInsuranceProgramnotedthatwomenwith
preeclampsia/eclampsiawereatsignificantlyhigherriskofdevelopingESRDovertimethanwomenwithout
hypertensivedisordersduringpregnancy(incidence5.33versus0.34per10,000personyears)[111].
AlthoughwomenwhowentontodevelopESRDmayhavehadsubclinicalrenaldiseaseduringpregnancy,itis
alsopossiblethatasyetundefinedriskfactorspredisposedthesewomentobothpreeclampsiaandESRD.Itis
lesslikelythatpreeclampsiadamagesthekidney,therebyinitiatingaprocessofchronicdeterioration.
SubclinicalhypothyroidismAnestedcasecontrolstudyfoundthatnulliparouswomenwhodeveloped
preeclampsiaweretwiceaslikelytodevelopsubclinicalhypothyroidismduringpregnancyandlongafterdelivery
thanmatchednormotensivecontrols[112].Theriskwasstrongestinwomenwithrecurrentpreeclampsiaand
withoutthyroidperoxidaseantibodies,suggestingthatanautoimmunemediatedmechanismofhypothyroidism
wasnotinvolved.Inastudyincluding25,000pregnantwomen,womenwithsubclinicalhypothyroidismidentified
duringpregnancywereatincreasedriskofdevelopingseverepreeclampsiacomparedwitheuthyroidwomen(OR
1.6,95%CI1.12.4),afteradjustmentforriskfactorsforpreeclampsia[113].Abnormallevelsofthyroidhormones
appeartodamageendothelialcells,potentiallyleadingtopreeclampsiaandlongtermcardiovascularsequelae.
OtherAsystematicreviewfoundnosignificantassociationbetweenpreeclampsiaandlaterdevelopmentof
cancer[82].ObservationalstudiesfromtheUnitedStates,Sweden,andNorwayreportedthatwomenwith
preeclampsiawereatreducedriskorhadnoexcessriskofcancerwhenfollowed13to19yearspostpartum
[89,114119].Incontrast,astudyfromIsraelreportedanincreasedriskofcancerinsuchwomen(hazardratio
1.27,95%CI1.031.57)withamedianfollowupof29years[120,121].Sitespecificincreaseswerenotedfor
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cancerofthestomach,lungorlarynx,breast,andovary.Thediscordantresultsmaybeexplainedbyanumberof
factors,includingdifferencesinpatientpopulations,absenceoforinsufficientadjustmentforconfounders,
differencesinlengthoffollowup,andincompleteascertainment.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Preeclampsia(TheBasics)"and"Patientinformation:Highblood
pressureandpregnancy(TheBasics)"and"Patientinformation:HELLPsyndrome(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Preeclampsia(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Thedefinitivetreatmentofpreeclampsiaisdeliverytopreventdevelopmentofmaternalorfetalcomplications
fromdiseaseprogression.Timingofdeliveryisbasedupongestationalage,theseverityofpreeclampsia,
andmaternalandfetalcondition.(See'Generalprinciples'above.)
Preeclampsiawithfeaturesofseveredisease(table2)isgenerallyregardedasanindicationfordelivery,
regardlessofgestationalage,giventhehighriskofseriousmaternalmorbidity.However,prolonged
antepartummanagementinatertiarycaresettingorinconsultationwithamaternalfetalmedicinespecialist
isanoptionforselectedwomenremotefromterm(<34weeksofgestation).(See'Preeclampsiawith
featuresofseveredisease'above.)
Forwomenwithpreeclampsiawithoutfeaturesofseveredisease,wesuggestexpectantmanagementwith
deliveryat37weeksofgestation(Grade2B).(See'Preeclampsiawithoutfeaturesofseveredisease'
above.)
Expectantmanagementofwomenwithpreeclampsiawithoutfeaturesofseverediseaseconsistsoffrequent
laboratorymonitoring(plateletcount,liverandrenalfunctiontests),assessmentofmaternalbloodpressure
andsymptoms,andevaluationoffetalgrowthandwellbeing.Inmostpatients,antihypertensivetherapyis
notindicatedforsystolicbloodpressure<160mmHgordiastolicbloodpressure<110mmHg.(See
'Expectantantepartummanagementofpreeclampsiawithoutfeaturesofseveredisease'above.)
Forwomenwithaviablefetusandpreeclampsia<34weeksofgestation,werecommendacourseof
antenatalglucocorticoids(betamethasone)(Grade1A).(See"Antenatalcorticosteroidtherapyforreductionof
neonatalmorbidityandmortalityfrompretermdelivery".)
Forwomenwithpreeclampsiaandfeaturesofseveredisease,werecommendintrapartumandpostpartum
seizureprophylaxis(Grade1A).Thebenefitofseizureprophylaxisislessclearinwomenwithoutsevere
hypertensionorpreeclampsiasymptomshowever,wealsosuggestintrapartumandpostpartumprophylaxis
forthesewomen(Grade2B).Werecommendtheuseofmagnesiumsulfateasafirstlineagentforseizure
prophylaxisinpreeclampsia(Grade1A).(See'Seizureprophylaxis'above.)
Wegivealoadingdoseof6gramsmagnesiumsulfateintravenouslyover15to20minutesfollowedby2
gramsperhourasacontinuousinfusion.Themaintenancedose(butnottheloadingdose)shouldbe
adjustedinwomenwithrenalinsufficiency.(See'Magnesiumregimenandmonitoring'above.)
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=p
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Magnesiumtoxicityisuncommoninwomenwithgoodrenalfunction.Toxicityisrelatedtoserummagnesium
concentration:lossofdeeptendonreflexesoccursat7to10mEq/L(8.5to12mg/dLor3.5to5.0mmol/L),
respiratoryparalysisat10to13mEq/L(12to16mg/dLor5.0to6.5mmol/L),cardiacconductionisalteredat
>15mEq/L(>18mg/dLor>7.5mmol/L),andcardiacarrestoccursat>25mEq/L(>30mg/dLor>12.5
mmol/L).Calciumgluconate(1gramintravenouslyover5to10minutes)shouldbeadministeredto
counteractlifethreateningsymptomsofmagnesiumtoxicity.(See'Complicationsandsideeffects'above.)
Thereisanincreasedriskofpreeclampsiarecurrenceinsubsequentpregnanciesandpossiblelongterm
risksofcardiovasculardiseaseandprematuredeath.Earlyonsetpreeclampsiawithseverefeatureshasa
higherriskofrecurrencethanmilderdiseasewithonsetatterm.(See'Prognosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic6825Version58.0
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GRAPHICS
Criteriaforthediagnosisofpreeclampsia
Systolicbloodpressure140mmHgordiastolicbloodpressure90mmHgontwooccasionsat
leastfourhoursapartafter20weeksofgestationinapreviouslynormotensivepatient
Ifsystolicbloodpressureis160mmHgordiastolicbloodpressureis110mmHg,confirmation
withinminutesissufficient
and
Proteinuria0.3gramsina24hoururinespecimenorprotein(mg/dL)/creatinine(mg/dL)ratio
0.3
Dipstick1+ifaquantitativemeasurementisunavailable
Inpatientswithnewonsethypertensionwithoutproteinuria,thenewonsetofanyof
thefollowingisdiagnosticofpreeclampsia:
Plateletcount<100,000/microliter
Serumcreatinine>1.1mg/dLordoublingofserumcreatinineintheabsenceofotherrenal
disease
Livertransaminasesatleasttwicethenormalconcentrations
Pulmonaryedema
Cerebralorvisualsymptoms
Adaptedfrom:Hypertensioninpregnancy:ReportoftheAmericanCollegeofObstetriciansand
Gynecologists'TaskForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.
Graphic79977Version9.0
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Thepresenceofoneormoreofthefollowingindicatesadiagnosisof
"preeclampsiawithseverefeatures"
Symptomsofcentralnervoussystemdysfunction:
Newonsetcerebralorvisualdisturbance,suchas:
Photopsia,scotomata,corticalblindness,retinalvasospasm
Severeheadache(ie,incapacitating,"theworstheadacheI'veeverhad")orheadachethatpersists
andprogressesdespiteanalgesictherapy
Alteredmentalstatus
Hepaticabnormality:
Severepersistentrightupperquadrantorepigastricpainunresponsivetomedicationandnotaccounted
forbyanalternativediagnosisorserumtransaminaseconcentrationtwicenormal,orboth
Severebloodpressureelevation:
Systolicbloodpressure160mmHgordiastolicbloodpressure110mmHgontwooccasionsatleast
fourhoursapartwhilethepatientisonbedrest(unlessthepatientisonantihypertensivetherapy)
Thrombocytopenia:
<100,000platelets/microL
Renalabnormality:
Progressiverenalinsufficiency(serumcreatinine>1.1mg/dLordoublingofserumcreatinine
concentrationintheabsenceofotherrenaldisease)
Pulmonaryedema
Incontrasttooldercriteria,the2013criteriadonotincludeproteinuria>5grams/24hours
andfetalgrowthrestrictionasfeaturesofseveredisease.
Adaptedfrom:Hypertensioninpregnancy:ReportoftheAmericanCollegeofObstetriciansand
Gynecologists'TaskForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.
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Peripheralsmearinmicroangiopathichemolytic
anemiashowingpresenceofschistocytes
Peripheralbloodsmearfromapatientwithamicroangiopathic
hemolyticanemiawithmarkedredcellfragmentation.Thesmear
showsmultiplehelmetcells(smallblackarrows),otherfragmented
redcells(largeblackarrow)microspherocytesarealsoseen(blue
arrows).Theplateletnumberisreducedthelargeplateletinthe
center(redarrow)suggeststhatthethrombocytopeniaisdueto
enhanceddestruction.
CourtesyofCarolavonKapff,SH(ASCP).
Normalperipheralbloodsmear
Highpowerviewofanormalperipheralbloodsmear.Several
platelets(blackarrows)andanormallymphocyte(bluearrow)can
alsobeseen.Theredcellsareofrelativelyuniformsizeand
shape.Thediameterofthenormalredcellshouldapproximatethat
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ofthenucleusofthesmalllymphocytecentralpallor(redarrow)
shouldequalonethirdofitsdiameter.
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Helmetcellsinmicroangiopathichemolyticanemia
Peripheralsmearsfromtwopatientswithmicroangiopathichemolytic
anemia,showinganumberofredcellfragments(ie,schistocytes),
someofwhichtaketheformofcombat(redarrow),bicycle(thickblack
arrow),orfootball(bluearrow)"helmets."Microspherocytesarealso
seen(thinblackarrows),alongwithanucleatedredcell(greenarrow).
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Deathsfromcardiovascularcauses
Relativehazardrate(95percentconfidence
interval)
Population
Nonpreeclamptic,term
delivery
Nonpreeclamptic,preterm
delivery
2.95(2.12to4.11)
Preeclamptic,termdelivery
1.65(1.01to2.70)
Preeclamptic,pretermdelivery
8.12(4.31to15.33)
Datafrom:Irgens,HU,Reisaeter,L,Irgens,LM,Lie,RT.BMJ2001323:1213.
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Disclosures
Disclosures:ErrolRNorwitz,MD,PhDConsultant/AdvisoryBoards:Hologic[Pretermbirth(Fetalfibronectintesttopredictpretermbirth)]Natera
preeclampsia(Useofurinaryangiogenicfactorstopredictpreeclampsia)].JohnTRepke,MDNothingtodisclose.CharlesJLockwood,MD,MHC
EquityOwnership/StockOptions:Celula[Aneuploidyscreening(PrenatalandcancerDNAscreeningtestsindevelopment)].VanessaA
Barss,MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevel
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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