Preeclampsia: 3 preemptive tactics
A strategy to prevent preeclampsia or minimize severity—starting before conception if possible—is the best way to reduce adverse outcomes.
TABLE 3
Diagnostic criteria
| GESTATIONAL HYPERTENSION IN HEALTHY WOMEN | |
| Blood pressure <160 mm Hg diastolic and <110 mm Hg systolic | |
| Proteinuria <300 mg/24-hour collection | |
| Platelet count >100,000/mm3 | |
| Normal liver enzymes | |
| No maternal symptoms | |
| No intrauterine growth restriction or oligohydraminos by ultrasound | |
| PREECLAMPSIA IN WOMEN WITH PREEXISTING MEDICAL CONDITIONS | |
| Condition | Criteria |
| Hypertension only | Proteinuria >500 mg/24-hours or thrombocytopenia |
| Proteinuria only | New onset hypertension plus symptoms or thrombocytopenia or elevated liver enzymes |
| Hypertension plus proteinuria (renal disease or class F diabetes) | Worsening severe hypertension and/or new onset of symptoms, thrombocytopenia, elevated liver enzymes |
FIGURE Whether preeclampsia will develop depends on when gestational hypertension begins
Adapted from Barton JR, et al. Am J Obstet Gynecol. 2001;184:979-983.
Step 3Consider how to balance risk to mother and fetus
Once a diagnosis is made, promptly evaluate mother and fetus, continue close surveillance, select those who will benefit from hospitalization, and identify indications for delivery (TABLE 4).
Delivery will always reduce the risks for the mother, but in certain situations, it might not be the best option for an extremely premature fetus. Sometimes delivery is best for both mother and fetus.
The best strategy takes into consideration:
- maternal and fetal status at initial evaluation,
- preexisting medical conditions that could affect pregnancy outcome,
- fetal gestational age at time of diagnosis,
- labor or rupture of fetal membranes (both could affect management), and
- maternal choice of available options.
Women who remain undelivered require close maternal and fetal evaluation. In otherwise healthy women, management depends on whether the preeclampsia is mild or severe, and, if there are other medical conditions, on the status of those conditions, as well.
TABLE 4
Indications for delivery
| Consider delivery in gravidas with 1 or more indications |
|---|
| Gestational age ≥38 weeks for mild disease |
| Gestational age ≥34 weeks for severe disease |
| 33-34 weeks with severe disease after steroids |
| Onset of labor and/or membrane rupture ≥34 weeks |
| Eclampsia or pulmonary edema (any gestational age) |
| HELLP syndrome (any gestational age) |
| Severe cerebral symptoms or epigastric pain |
| Acute renal insufficiency (serum creatinine >1.2 mg/dl) |
| Persistent thrombocytopenia (platelet count <100,000) |
| Maternal desire for delivery |
| Severe oligohydraminos or IUGR < 5th percentile |
| Nonreassuring fetal testing |
Chronic hypertension
- Underlies 30% of cases of hypertension during pregnancy.
- Begins before pregnancy or before 20 weeks’ gestation.
Gestational hypertension
- The most common form of hypertension during pregnancy.
- Acute onset beyond 20 weeks’ gestation in a woman known to be normotensive before pregnancy or prior to 20 weeks’ gestation.
Preeclampsia
- Can superimpose upon chronic hypertension, renal disease, or connective tissue disease, or develop in women with gestational hypertension.
- Preeclampsia in healthy nulliparous women: hypertension and proteinuria after 20 weeks’ gestation.
- Preeclampsia in women with preexisting chronic hypertension and absent proteinuria: an exacerbation of hypertension and new onset proteinuria.
Eclampsia
- Development of convulsions in women with hypertensive disorders of pregnancy.
“HELLP syndrome”
- Hemolysis,
- Elevated liver enzymes, and
- Low platelet count
Suspected or confirmed preeclampsia in a woman who has documented evidence of hemolysis (abnormal peripheral smear, or elevated bilirubin, or anemia, or low heptoglobin levels), plus elevated liver enzymes (AST or ALT), and thrombocytopenia (platelet count below 100,000).
The author reports no financial relationships relevant to this article.
