Preeclampsia

Preeclampsia is one of the most common causes of perinatal morbidity and mortality. The etiology for preeclampsia remains unknown. However, placental dysfunction may initiate systemic vasospasm, ischemia, and thrombosis that eventually damages maternal organs and causes placental infarction, IUGR, and death. Preeclampsia complicates 5% to10% of all pregnancies. It occurs at both extremes of reproductive age but is greatest in women younger than 20. Risk factors for preeclampsia include extremes of maternal age, nulliparity, African American race, multiple gestation, molar pregnancy, preexisting medical conditions (hypertension, diabetes, renal disease, connective tissue disorders, vascular disease), and prior or family history of preeclampsia or eclampsia.

The disorder is typically suspected in the presence of hypertension and proteinuria in the pregnant woman without history of preexisting chronic hypertension. Edema is no longer considered a reliable clinical sign and is often seen after the 20th week of gestation without signs of a hypertensive disorder. Historically, mild preeclampsia was diagnosed with a systolic BP rise of 30 mm Hg or diastolic BP rise of 15 mm Hg. Consensus statements now describe mild preeclamp-sia as an absolute reading of 140/90 mm Hg or greater in a pregnant woman with proteinuria greater than 0.3 g in a 24-hour urine collection. Again, nondependent edema is no longer considered a diagnostic criterion. Severe preeclamp-sia consists of a systolic BP greater than 160 mm Hg or diastolic BP greater than 110 mm Hg, complicated by significant proteinuria (>5.0 g/day) and evidence of end-organ damage. Signs and symptoms indicating severe preeclampsia include headache, visual disturbances, confusion, right upper quadrant (RUQ) or epigastric pain, impaired liver function, proteinuria, oliguria (<500 mL/24 hr), pulmonary edema, microangiopathic hemolytic anemia, thrombocytopenia, oligohydramnios, and IUGR.

Pregnant women with hypertension documented before pregnancy may develop preeclampsia. Chronic hypertension with superimposed preeclampsia is responsible for 15% to 30% of hypertensive disease in pregnancy. Treatment for mild preeclampsia involves bed rest and surveillance to assess development of complications. Delivery is carefully delayed until fetal maturity, development of severe preeclampsia, or other complications occur. In most cases, treatment of severe preeclampsia is delivery.

During labor and delivery, women with preeclampsia should receive IV magnesium sulfate for seizure prophylaxis, with a loading dose of 4 g infused over 15 to 20 minutes, then continuous infusion at 2 g/hr, similar to the preterm-labor magnesium therapy protocol (Box 21-7). Blood pressure should be carefully evaluated and treated with IV hydralazine if levels are persistently above 110 mm Hg dia-stolic. Severe preeclamptic women should generally deliver within 24 hours. Postpartum therapy with magnesium sulfate is recommended for 12 to 24 hours depending on degree of severity.

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