The authors report no financial relationships relevant to this article.
CASE: At risk, or just very pregnant?
At her first prenatal visit, a 31-year-old gravida has blood pressure (BP) of 100/60 mm Hg, no proteinuria, and normal weight for her gestational age. As she enters the third trimester, however, her BP rises to 138/86 mm Hg, she now has proteinuria of 1+, and she has gained 10 lb in the past 2 weeks.
Does she have preeclampsia, or do these findings reflect normal development in the last trimester?
These findings, in and of themselves, may not indicate preeclampsia—but they do suggest a serious risk of developing the disease.
Preeclampsia complicates approximately 3% to 7% of nulliparous pregnancies in the United States, and about 0.8% to 5% of multiparous pregnancies.
Although severe preeclampsia represents only a fraction of those amounts, and eclampsia an even lower percentage, they are potentially catastrophic complications of pregnancy and one of the leading causes of maternal death. They also are responsible for a large percentage of infants born prematurely as a result of a worsening maternal or fetal condition.
Preeclampsia and eclampsia are obstetric diseases, and obstetricians are the group best equipped to diagnose, evaluate, and manage them. In this article, we highlight seven challenges that obstetricians face when managing preeclampsia and eclampsia, and offer useful strategies to help minimize morbidity and mortality in both mother and infant.
CHALLENGE NO. 1: Making the diagnosis
Good prenatal care is a prerequisite
We can’t overemphasize the importance of early and adequate prenatal care! Although the diagnostic criteria for preeclampsia have been widely established—persistent BP elevation above 140/90 mm Hg and proteinuria exceeding 300 mg over a 24-hour collection period—the condition does not always play by the rules. With close monitoring of weight, urine protein, and BP, the clinician can identify and follow potentially worrisome trends.
Earlier diagnostic criteria—which included a rise in systolic BP of 30 mm Hg or a rise in diastolic BP of 15 mm Hg above initial baseline BP, as well as the presence of pathologic edema—may have been revised, but it remains important for clinicians to put all pieces of clinical information together at each visit. For example, given her rising BP, proteinuria, and weight gain, the patient in the opening case must be considered at risk for preeclampsia. Suspicion also is justified if the patient has any of the risk factors for preeclampsia in TABLE 1.
Risk factors for preeclampsia
Early detection is critical
Early identification of preeclampsia may allow for interventions, including delivery, that will lessen the risk of progression to severe preeclampsia and eclampsia and reduce fetal and maternal morbidity and mortality. It is, therefore, essential for the clinician to ask specifically about signs and symptoms of preeclampsia and to listen carefully to the answers.
Signs and symptoms may sometimes be typical:
- weight gain
- increasing edema
- persistent headache
- blurred vision.
- epigastric discomfort
- right upper-quadrant discomfort.
The diagnosis of preeclampsia is based on persistent BP elevation above 140/90 mm Hg and proteinuria exceeding 300 mg over a 24-hour collection period.1 Other criteria have been applied, such as a rise in systolic or diastolic BP above baseline and urine dipstick criteria for proteinuria, but BP above 140/90 mm Hg and proteinuria above 300 mg are most frequently used in medical centers in the United States.2
Gestational hypertension and chronic hypertension do sometimes coexist with superimposed preeclampsia, but should not be confused with preeclampsia or lead to management decisions that should apply only to patients with preeclampsia.3
Before severe preeclampsia can be diagnosed, the initial criteria for preeclampsia should have been fulfilled, along with one or more of the findings listed in TABLE 2.