Obstetrics and Gynaecology

at a Glance

Fourth Edition
Errol R. Norwitz, John O. Schorge

CaseStudies
Case10:Preeclampsia

Ahealthy29yearoldG2P0101isadmittedtolaboranddeliveryat28weeksgestationcomplainingofasevereheadacheand
blurredvision.HerBPis200/110mmHgwith2+proteinuriaonurinalysis.RepeatBPafewhourslateris160/110mmHg.
Laboratorystudiesshowedanormalhematocrit,plateletcount,andlivertransaminaselevels.

1.Howispreeclampsiadefined?

Correctanswer:Preeclampsia(gestationalproteinurichypertension)isdefinedasnewonsetsignificanthypertensionandproteinuriaafter20weeksgestation.
Thecorrecttechniquetomeasurebloodpressure(BP)inpregnancyisinthesittingpositionatrestforatleast5minutesusinganappropriatesizeBPcuffplaced
ontheupperarmattheleveloftheheartandusingthefifthKorotkoffsound(disappearance)todesignatethediastolicBP.Significanthypertensionreferstoa
sustainedelevationinBPof140mmHgsystolicand/or90mmHgdiastolicinapreviouslynormotensiveparturient.Ofnote,anincreaseoverthepregnancyin
systolicBPof30mmHgand/ordiastolicBPof30mmHgand15mmHg,respectively,isnolongersufficienttomakethediagnosis.Significantproteinuria
referstoanewfindingof1+proteinonurinedipstickor,moreobjectively,300mgproteinina24hoururinecollection.
Theoriginaldefinitionofpreeclampsiaincludednondependentedema(ie,swellingofthehandsandface),butthisisnolongeraprerequisiteforthediagnosis.
Thediagnosisofpreeclampsiashouldbemadeonlyafter20weeksgestation.Evidenceofgestationalproteinurichypertensionbefore20weeksgestation
shouldraisethepossibilityofanunderlyingmolarpregnancy,drugwithdrawal,antiphospholipidantibodysyndrome,or(rarely)achromosomalabnormalityinthe
fetus.

2.Her24hoururinalysisreveals1.2gprotein.Thispatientmeetscriteriaforthe
diagnosisofpreeclampsia.Whattypeofpreeclampsiadoesshehave?

Correctanswer:Onceadiagnosisofpreeclampsiahasbeenmade,thepatientshouldbeallocatedtooneoftwocategories:mildorseverepreeclampsia.
Thereisnocategoryofmoderatepreeclampsia.Mildpreeclampsiaincludesallwomenwithadiagnosisofpreeclampsia,butwithoutfeaturesofsevere
disease.Severepreeclampsiareferstowomenwhomeetthediagnosticcriteriaforpreeclampsiaandhaveoneormoreofthecriterialistedbelow.Notethat
onlyoneofthelistedcriteriaisrequiredforthepatienttobeassignedtotheseverecategory.
Featuresofseverepreeclampsia
Symptoms
Symptomsofcentralnervoussystemdysfunction(blurredvision,scotomas,alteredmentalstatus,and/orsevere
headache)
Symptomsoflivercapsuledistention(rightupperquadrantand/orepigastricpain)
Signs
SevereBPelevation(definedasBP160/110mmHgontwooccasionsatleast6hoursapart)
Pulmonaryedema
Eclampsia(generalizedseizuresand/orunexplainedcoma)
Cerebrovascularaccident(stroke)
Fetalintrauterinegrowthrestriction(IUGR)
Laboratoryfindings
Proteinuria(>5g/24h)

Renalfailureoroliguria(<500mL/24h)
Hepatocellularinjury(serumtransaminaselevelstwoormoretimesnormal)
Thrombocytopenia(<100,000platelets/mm3)
Coagulopathy
HELLP(hemolysis,elevatedliverenzymes,lowplatelets)syndrome

3.Whatcausespreeclampsia?

Correctanswer:Preeclampsiaisamultisystemdisorderspecifictohumanpregnancyandthepuerperium.Itdoesnotoccurnaturallyinanyotheranimal
species.Moreprecisely,itisadiseaseoftheplacentabecauseithasalsobeendescribedinpregnancieswherethereistrophoblastbutnofetaltissue(complete
molarpregnancies).Itcomplicates57%ofallpregnancies.
Thepathophysiologyofpreeclampsiaremainsunclear.Atleastsixhypotheseshavebeenproposed,including:
(1)geneticimprinting
(2)immunemaladaptation
(3)placentalischemia
(4)generalizedendothelialdysfunction
(5)defectivefreefattyacid,lipoprotein,and/orlipidperoxidasemetabolism
(6)animbalanceinproandantiangiogenicfactorexpression.
Theprimarydefectappearstobeacompleteorpartialfailureofthesecondwaveoftrophoblastinvasion,whichisresponsibleforremodelingofthematernal
spiralarteriolesandestablishmentofthedefinitiveuteroplacentalcirculation.Thisprocessistypicallycompleteby1618weeksgestation.Ifthisprocessis
deficient(socalledshallowendovascularinvasionoftheplacenta),thespiralarteriolesareunabletodilateadequatelytomeetthedemandsofthegrowing
fetoplacentalunit.Thisleads,inturn,toplacentalischemiawiththereleaseofatoxemicfactorthatdamagesthevasculaturethroughoutthematernalcirculation,
resultinginwidespreadvasospasmandendothelialinjury,whichmanifestsclinicallyaspreeclampsia.Theblueprintforthedevelopmentofpreeclampsiais
thereforelaiddownearlyingestation,althoughtheclinicalmanifestationsappearonlyinthelatterhalfofpregnancy.

4.Arethereriskfactorsforthedevelopmentofpreeclampsia?Canweaccurately
predictandpreventpreeclampsia?

Correctanswer:Anumberofriskfactorsforpreeclampsiahavebeendescribed(listedbelow).Thatsaid,itisnotpossibletoaccuratelypredictwhetherornotan
individualwilldeveloppreeclampsiainagivenpregnancy.Moreover,preeclampsiacannotbeeffectivelyprevented.Despitepromisingearlystudies,lowdose
aspirin,dietarysupplementationwithelementalcalcium,bedrest,sodiumrestriction,and/orvitaminCandEsupplementationdoesnotappeartopreventpre
eclampsiaineitherhighorlowriskpopulations.
Riskfactorsforpreeclampsia
Riskfactor

Relativerisk

Nulliparity

AfricanAmericanorigin

15

Extremesofage(<18or>40years)

Multiplegestation

Familyhistoryofpreeclampsia(firstdegreerelativeonthematernalorpaternalside)

Priorhistoryofpreeclampsia

1014

Chronichypertension

10

Chronicrenaldisease

20

Antiphospholipidantibodysyndrome

10

Diabetesmellitus

Collagenvasculardisease(suchassystemiclupuserythematosus)

23

Obesity

AngiotensinogengeneT235
homozygous

20

heterozygous

5.ThispatienthasseverepreeclampsiabysymptomsandBPcriteria.Sheisonly28
weeksgestation.Shouldshebedeliveredorcanshebemanagedexpectantly?

Correctanswer:Deliveryistheonlyeffectivetreatmentforpreeclampsia.Itshouldbeconsideredinallwomenwithmildpreeclampsiaonceafavorable
gestationalagehasbeenreached(usuallyregardedas3637weeks).Deliveryisalsorecommendedforallwomenwithseverepreeclampsiaregardlessof
gestationalage,withthreepossibleexceptions:
Severepreeclampsiabyproteinuriaalone(becausetheamountofproteinintheurinedoesnotcorrelatewithmaternalorperinataloutcome)
SeverepreeclampsiabyIUGRaloneremotefromtermwithgoodfetaltesting(althoughsuchwomenshouldbekeptinhospitalwithdailyfetaltesting)
SeverepreeclampsiabyBPcriteriaalone<32weeksgestation(anumberofstudieshavesuggestedthatitmaybebothreasonableandsafetocontinue
thepregnancyinthissettingwithcarefulBPcontrolanddeliveryat34weeks).
ThemagnitudeofBPelevationisnotpredictiveofeclampsia(definedastheoccurrenceofoneormoregeneralizedconvulsionsand/orcomainthesettingof
preeclampsiaandintheabsenceofotherneurologicconditions).Althoughroutineuseofantihypertensivemedicationsdoesnotchangethecourseofpre
eclampsiaforeitherthemotherorthefetus,BPcontrolisimportanttopreventmaternalcerebrovascularaccident(stroke),whichisusuallyassociatedwithaBP
170/120mmHg.Forthisreason,antihypertensivemedicationscanbeusedwhileaffectingdeliverytomaintainBP<160/110mmHg.
Oncethedecisionhasbeenmadetoproceedwithdelivery,thepatientshouldbegivenmagnesiumsulfateseizureprophylaxisduringlaborandfor2448hours
postpartum.Ifcircumstancespermit,antenatalcorticosteroidsshouldbeadministeredanddeliverydelayedfor2448hourstoallowthemtoexerttheirprotective
effectonthefetus.

6.Thedecisionhasbeenmadetoproceedwithdelivery.Bimanualexaminationshows
hercervixtobelongandclosed.Doesthismeanthatthepatienthastohaveacesarean
sectiondelivery?

Correctanswer:Oncethedecisionhasbeenmadetoproceedwithdelivery,thereisgenerallynoprovenbenefittoacesareansection,andattemptedvaginal
deliveryisareasonableoption.Thatsaid,however,thechanceofaffectingasuccessfulvaginaldeliveryinawomanwithseverepreeclampsia,remotefromterm
withanunfavorablecervicalexamination,isonly1420%.Everyeffortshouldbemadetoavoidprolongedinductionoflabor.Ifthereisnoresponsetocervical
ripeningafter12hours,cesareansectiondeliveryshouldbeconsidered.
Preeclampsiaanditscomplicationstypicallyresolvewithinafewdaysofdelivery(withthenotedexceptionofstroke).Diuresis(>4L/day)isthemostaccurate
clinicalindicatorofresolution.Fetalprognosisdependslargelyongestationalageatdeliveryandthepresenceorabsenceofcomplicationsofprematurity(such
asrespiratorydistresssyndrome,necrotizingenterocolitis,intraventricularhemorrhage,andchroniclungdisease).

SeeChapter44.

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