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Clincal features, diagnosis, and long term prognosis of pre-cclampsia Anna Witt, MD Up-to-Date November 10, 2009 4 major hypertensive disorders related to pregnancy Preeclampsia – 5 to 8% of pregnancies affected o Syndrome characterized by the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman Chronic hypertension – 3% of pregnancies affected o Defined as systolic pressure ≥140 mmHg, diastolic pressure ≥90 mmHg, or both, that antedates pregnancy, is present before the 20th week of pregnancy, or persists longer than 12 weeks postpartum. Preeclampsia superimposed upon chronic hypertension o Diagnosed when a woman with preexisting hypertension develops new onset proteinuria after 20 weeks of gestation. Women with both preexisting hypertension and proteinuria are considered preeclamptic if there is an exacerbation of blood pressure to the severe range (systolic ≥160 mmHg or diastolic ≥110 mmHg) in the last half of pregnancy, especially if accompanied by symptoms or increased liver enzymes or thrombocytopenia. Gestational hypertension – 6% of pregnancies affected o Hypertension without proteinuria (or other signs of preeclampsia) developing in the latter part of pregnancy Clinical features may be explained as maternal responses to generalized endothelial dysfunction. Disturbed endothelial control of vascular tone causes hypertension, increased vascular permeability results in edema and proteinuria, and abnormal endothelial expression of procoagulants leads to coagulopathy. These changes also cause ischemia of target organs, such as the liver, kidney, and placenta, sometimes with life- threatening results. Hypertension (systolic pressure ≥140 mmHg, diastolic pressure ≥90 mmHg, or both) is generally the earliest clinical finding of preeclampsia and is the most common clinical clue to the presence of the disease. Systolic blood pressure of ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg on two occasions at least six hours apart upstages the diagnosis from mild to severe preeclampsia. Proteinuria (≥0.3 g protein in a 24-hour urine specimen or persistent 1+ on dipstick) must be present to make a diagnosis of preeclampsia. The presence of ≥5 grams of protein in 24-hour urine collection upstages the diagnosis from mild to severe preeclampsia. Urine output of <500 mL/24 hours upstages the diagnosis from mild to severe preeclampsia. Edema is no longer part of the diagnostic criteria. However, sudden and rapid weight gain (eg, >5 pounds/week) and facial edema may occur in women who develop preeclampsia, thus, these findings warrant evaluation for other clinical manifestations of preeclampsia. In the absence of pulmonary edema, diuretics should be avoided because intravascular volume is lower than in normotensive pregnancy. Presence of pulmonary edema upstages the diagnosis from mild to severe preeclampsia. Thrombocytopenia is the most common coagulation abnormality in due to formation of microthrombi. The prothrombin time, partial thromboplastin time, and fibrinogen concentration are not affected unless there are additional complications, such as abruptio placentae or severe liver involvement. A platelet count less than 100,000 upstages the diagnosis from mild to severe preeclampsia. Liver involvement might include clinical manifestations of right upper quadrant or epigastric pain, elevated transaminases and, in the most severe cases, subcapsular hemorrhage or hepatic rupture, which may represent HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets). Nausea and vomiting may occur. Hepatitic changes upstage the diagnosis from mild to severe preeclampsia. Central nervous system manifestations of preeclampsia include headache, blurred vision, scotomata, and, rarely, cortical blindness; their presence upstage the diagnosis from mild to severe preeclampsia. Seizures in a preeclamptic woman signify a change in diagnosis to eclampsia. Clincal features, diagnosis, and long term prognosis of pre-cclampsia Anna Witt, MD Up-to-Date November 10, 2009 Headache location can be temporal, frontal, occipital, or diffuse. Quality is usually a throbbing/pounding pain, but piercing pain can occur. Headache may persist despite administration of over-the-counter analgesics and it can progress to become severe (ie, incapacitating, "the worst headache of my life"). Cardiac. Preeclampsia does not directly affect the myocardium and is not associated with elevated troponin levels in the absence of cardiac disease. Decrements in left ventricular performance can occur and reflect a physiologically appropriate response to increased afterload, which can cause cardiac strain, which is reflected by four-fold higher concentrations of natriuretic peptides Fetal consequences of chronic placental hypoperfusion are fetal growth restriction and oligohydramnios. Fetal growth restriction upstages the diagnosis from mild to severe preeclampsia These women with gestational hypertension should be treated as though they have preeclampsia (or HELLP syndrome), even in the absence of proteinuria, because they are at high risk of maternal and/or fetal morbidity 1. Remote from term — As many as 50 percent of women with gestational hypertension go on to develop preeclampsia, with the highest risk in women who develop gestational hypertension before 30 weeks 2. Development of severe hypertension with signs of preeclampsia — If severe hypertension, persistent headache, visual changes, growth restriction, oligohydramnios, epigastric or right upper abdominal pain, thrombocytopenia, or liver function abnormalities, occur in a woman diagnosed with gestational hypertension Occurrence of signs and symptoms of preeclampsia before 20 weeks of gestation is unusual. When present, they are suggestive of an underlying molar pregnancy or the antiphospholipid antibody syndrome. The possibility of illicit drug use or withdrawal or chromosomal aneuploidy in the fetus should also be considered. Prognostic issues: risk of recurrent preeclampsia in subsequent pregnancies and long-term maternal health risks. Women with early, severe preeclampsia are at greatest risk of recurrence (25-65%), the incidence is much lower (5-7%) in women who had mild preeclampsia during the first pregnancy, versus < 1% in women who had a normotensive first pregnancy Women with early onset/severe preeclampsia, recurrent preeclampsia, gestational hypertension, or preeclampsia with onset as a multipara appear to be at highest risk of cardiovascular disease later in life. Mild preeclampsia occurring late in gestation in primigravid women and followed by a normotensive pregnancy does not appear to be associated with increased remote cardiovascular risk Women with preeclampsia appear to be at increased risk of developing end-stage renal disease (ESRD) later in life, but the absolute risk is small. No significant association between preeclampsia and later development of cancer Women who smoke cigarettes have a lower risk of preeclampsia than nonsmokers.
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