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37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
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37454656 preeclampsia-atypical-sibai

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Preeclampsia atípica por Baha Sibai

Preeclampsia atípica por Baha Sibai

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  • 1. Clinical Opinion www. AJOG.orgOBSTETRICSDiagnosis and managementof atypical preeclampsia-eclampsiaBaha M. Sibai, MD; Caroline L. Stella, MDH ypertension is the most common medical disorder during preg-nancy.1,2 The term gestational hyperten- Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets syndrome are major obstetric disorders that are associated with substantial maternal andsion-preeclampsia is used to describe a perinatal morbidities. As a result, it is important that clinicians make timely and accuratewide spectrum of disorders for patients diagnoses to prevent adverse maternal and perinatal outcomes associated with thesewho may have only mild elevation in syndromes. In general, most women will have a classic presentation of preeclampsiablood pressure or severe hypertension (hypertension and proteinuria) at 20 weeks of gestation and/or 48 hours afterwith various organ dysfunctions that in- delivery. However, recent studies have suggested that some women will experienceclude acute gestational hypertension, preeclampsia without 1 of these classic findings and/or outside of these time periods.preeclampsia, eclampsia and hemolysis, Atypical cases are those that develop at 20 weeks of gestation and 48 hours after deliveryelevated liver enzymes, and low platelets and that have some of the signs and symptoms of preeclampsia without the usual hypertension(HELLP) syndrome. There are numer- or proteinuria. The purpose of this review was to increase awareness of the nonclassic andous reports that describe the diagnosis atypical features of preeclampsia-eclampsia. In addition, a stepwise approach toward diagnosisand treatment of women with classic and treatment of patients with these atypical features is described.mild and severe preeclampsia.1-3 There- Key words: atypical preeclampsia, diagnosis, eclampsia, managementfore, in this report, the discussion will fo- Cite this article as: Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-cus on atypical preeclampsia, which re- eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.fers to any of the clinical entities listed inTable 1. of women with eclampsia never demon- tations of preeclampsia (such as the pres-Definition of classic preeclampsia strate the presence of edema.7 ence of signs and symptoms or other lab-The so-called classic triad of preeclamp- Hypertension is defined as systolic oratory abnormalities).5,7-11 We willsia includes hypertension, proteinuria, blood pressure of at least 140 mm Hg and focus on the clinical entities that com- diastolic blood pressure of 90 mm Hg on prise atypical preeclampsia and eclamp-and edema. However, there is now gen- at least 2 occasions; the measurements sia and their respective management.eral agreement that edema should not be should be at least 4 hours (but not 7considered as part of the diagnosis of days) apart.1-3 Hypertension is consid- Gestational hypertensionpreeclampsia.1-6 Indeed, edema is nei- ered severe if the systolic blood pressure without proteinuriather sufficient nor necessary to confirm is at least 160 mm Hg and/or the diastolic The pathophysiologic abnormalities inthe diagnosis of preeclampsia, because pressure is at least 110 mm Hg on 2 oc- preeclampsia are viable and can manifestedema is a common finding in normal casions at least 4 hours apart. Proteinuria as either 1 organ or multiorgan dysfunc-pregnancy, and approximately one-third is defined primarily as a concentration of tion. As a result, the signs and symptoms 30 mg/dL (1 ) in at least 2 random will reflect the organs involved. Protein- urine specimens that were collected at uria in preeclampsia is a manifestation ofFrom the Division of Maternal-Fetal least 4 hours apart (but within a 7-day renal involvement that results from glo-Medicine, Department of Obstetrics and interval) or 0.3 g in a 24-hour period.1,2,4 merulo endothelial injury (altered per-Gynecology, University of Cincinnati The traditional criterion to confirm a meability to proteins) and abnormal tu-College of Medicine, Cincinnati, OH. diagnosis of preeclampsia is the presence bular handling of filtered proteins.Received June 4, 2008; revised, July 2, 2008;accepted July 28, 2008. of proteinuric hypertension (new onset Traditionally, proteinuria was consid-Reprints: Baha M. Sibai, MD, Division of of hypertension and new onset of pro- ered the hallmark for the diagnosis ofMaternal-Fetal Medicine, University of teinuria at 20 weeks of gestation). This preeclampsia, because it usually devel-Cincinnati, 231 Albert Sabin Way, Room 5052, criterion is appropriate to use in most ops after the onset of hypertensionMedical Sciences Building, PO Box 670526, nulliparous women; however, recent and/or onset of symptoms.12 However,Cincinnati, OH 45267-0526. data suggest that, in some women, pre- its onset in clinical practice may be vari-Baha.Sibai@uc.edu. eclampsia and even eclampsia may de- able in onset in relation to hypertension0002-9378/$36.00 velop in the absence of either hyperten- and/or other end-organ effects. There-© 2009 Mosby, Inc. All rights reserved.doi: 10.1016/j.ajog.2008.07.048 sion or proteinuria. In many of these fore, its presence should not be consid- women, there are usually other manifes- ered mandatory to establish the clinical MAY 2009 American Journal of Obstetrics & Gynecology 481.e1
  • 2. Clinical Opinion Obstetrics www.AJOG.org of data from 2 multicenter trials, preg- TABLE 1 nancy outcomes in women with severe TABLE 2 Atypical preeclampsia gestational hypertension were compared Signs and symptoms and Gestational hypertension plus 1 of the with the outcomes of women with mild laboratory test results consistent following items: .................................................................................................. or severe preeclampsia.4,15 This analysis with preeclampsia Symptoms of preeclampsia revealed that severe gestational hyper- Signs and symptoms .................................................................................................. .................................................................................................. Hemolysis tension is associated with higher mater- Right upper quadrant pain .................................................................................................. .................................................................................................. Thrombocytopenia ( 100,000/mm ) 3 nal and perinatal morbidities than those Epigastric pain .................................................................................................. found in mild preeclampsia.4,15 The re- .................................................................................................. Elevated liver enzymes (2 times the Retrosternal chest pain sults of these studies also revealed that .................................................................................................. upper limit of the normal value for Nausea and vomiting aspartate aminotransferase or alanine women with severe gestational hyper- .................................................................................................. aminotransferase) tension had adverse maternal or perina- Shortness of breath/congestive heart ........................................................................................................... tal outcomes that were similar to those failure Gestational proteinuria plus 1 of the .................................................................................................. following items: seen in women with severe preeclampsia Headaches (not responsive to .................................................................................................. (Table 3).4,15 However, these 2 studies analgesics) Symptoms of preeclampsia .................................................................................................. .................................................................................................. included only a total of 56 subjects; more Visual changes Hemolysis data are needed. Nevertheless, women .................................................................................................. .................................................................................................. Altered mental status Thrombocytopenia .................................................................................................. with uncontrollable severe gestational .................................................................................................. hypertension or women with signs and Bleeding from mucosal membranes Elevated liver enzymes .................................................................................................. ........................................................................................................... symptoms of end-organ disease with any Jaundice Early signs and symptoms of ........................................................................................................... preeclampsia-eclampsia at 20 weeks hypertension should be treated as if they Laboratory tests .................................................................................................. of gestation had severe preeclampsia. Furthermore, ........................................................................................................... Persistent proteinuria Late postpartum preeclampsia-eclampsia we recommend hospital admission until ( 300 mg/24 h) ( 48 hours after delivery) hypertension is well controlled without .................................................................................................. 3 Platelet count ( 100,000/mm ) ........................................................................................................... symptoms and delivery at 34 weeks of .................................................................................................. Sibai. Diagnosis and management of a typical Liver enzymes (aspartate preeclampsia-eclampsia. Am J Obstet Gynecol 2009. gestation if severe hypertension or symp- toms persist, or earlier if indicated.17 aminotransferase or alanine aminotransferase) 2 times the upper limit of normaldiagnosis of preeclampsia or eclamp- Capillary leak syndrome: facial .................................................................................................. Serum creatinine ( 1.2 mg/dL)sia.2,5,9,10 In the absence of proteinuria, edema, ascites and pulmonary ..................................................................................................the syndrome of preeclampsia should be edema, gestational proteinuria Lactic dehydrogenase 2 times theconsidered when gestational hyperten- Hypertension is considered to be the upper limit of normal ...........................................................................................................sion is present in association with persis- hallmark for the diagnosis of preeclamp- Sibai. Diagnosis and management of a typicaltent symptoms or with abnormal labora- sia; however, recent evidence suggests preeclampsia-eclampsia. Am J Obstet Gynecol 2009.tory tests (Table 2).2,5,7-11 It is also that, in some patients with preeclampsia,important to note that 25-50% of the disease may manifest itself in thewomen with mild gestational hyperten- form of either a capillary leak (protein- tests should be considered to havesion will progress to preeclampsia.13-15 uria, ascites, pulmonary edema), exces- preeclampsia.5,8-10The rate of progression depends on ges- sive weight gain, or a spectrum of ab-tational age at onset of hypertension (ie, normal hemostasis with multiorgan Gestational proteinuriathe rate approaches 50% when gesta- dysfunction (Figure 1).5,8,18 These pa- Gestational proteinuria is defined astional hypertension develops before 32 tients usually experience clinical mani- urinary protein excretion of 300 mg/weeks of gestation).14,15 In most of these festations of atypical preeclampsia (ie, 24-hour timed collection or persistentwomen, the progression will result in proteinuria with or without facial proteinuria ( 1 on dipstick on atpreterm delivery and/or fetal growth re- edema, excessive weight gain [ 5 lb/ least 2 occasions at least 4 hours apartstriction.14-16 Therefore, such women wk], ascites, or pulmonary edema in as- but no more than 1 week apart).19,20require close observation for early detec- sociation with abnormalities in labora- The exact incidence of gestational pro-tion of preeclampsia (frequent prenatal tory values or presence of symptoms) teinuria is unknown. Two prospectivevisits and serial evaluation of platelets but without hypertension.5,7-11,18 There- studies in healthy nulliparous womenand liver enzymes) and/or fetal growth fore, we recommend that women with found that approximately 4% of(serial ultrasound). capillary leak syndrome with or without women who remained normotensive Preeclampsia should also be consid- hypertension be evaluated for platelet, had gestational proteinuria; however,ered when gestational hypertension is se- liver enzyme, or renal abnormalities. Ad- neither of these studies reported thevere, because of the associated adverse ditionally, they should be questioned percentage of women who had new on-maternal-perinatal outcome reported in about symptoms of preeclampsia. Those set gestational proteinuria and later ex-such women.4,16 In a secondary analysis with symptoms and/or abnormal blood perienced preeclampsia.19,20481.e2 American Journal of Obstetrics & Gynecology MAY 2009
  • 3. www.AJOG.org Obstetrics Clinical Opinion TABLE 3 Adverse pregnancy outcomes in severe gestational hypertension and in mild and severe preeclampsia Buchbinder et al16 Hauth et al4 Severe Mild Severe Severe Mild Severe hypertension preeclampsia preeclampsia hypertension preeclampsia preeclampsia Outcome (n 24) (n 62) (n 45) (n 32) (n 217) (n 109) Mean gestational age 35.8 37.8 34.8 38 39.2 37 at delivery (wk) ................................................................................................................................................................................................................................................................................................................................................................................ Preterm delivery (%) 25 9.7 35.6 3.1 1.9 18.5 ................................................................................................................................................................................................................................................................................................................................................................................ Mean birthweight (g) 2637 3196 2490 2967 3212 2642 ................................................................................................................................................................................................................................................................................................................................................................................ Weight 10th 20.8 4.8 11.4 9.7 10.2 18.5 percentile (%) ................................................................................................................................................................................................................................................................................................................................................................................ Abruptio placenta (%) 4.2 3.2 6.7 3.1 0.5 3.7 ................................................................................................................................................................................................................................................................................................................................................................................ Respiratory distress 6.5 3.2 16.7 12.5 4.8 15.7 syndrome (%) ................................................................................................................................................................................................................................................................................................................................................................................ Perinatal death (%) 0 0 3 3.1 0.5 0.9 ................................................................................................................................................................................................................................................................................................................................................................................ Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009. Women with new onset gestational eration of the placenta with or without a teinuria, and abnormal laboratory testsproteinuria only should be monitored coexistent fetus.7-9,25-27 Additionally, al- at 20 weeks of gestation may be due tovery closely for the early detection of pre- though exceedingly rare, preeclampsia- lupus nephritis, hemolytic-uremic syn-eclampsia, because the presence of gesta- eclampsia can occur during the first half drome, antiphospholipid antibody syn-tional proteinuria alone may herald the of pregnancy without molar degenera- drome, or thrombotic thrombocytope-early manifestation of an impending tion of the placenta.9,28-30 On the other nic purpura.31 Therefore, such womenpreeclampsia.21-23 There are no prospec- hand, the presence of hypertension, pro- should be evaluated to rule out the pres-tive studies that have evaluated the riskof the development of preeclampsia inpatients with gestational proteinuria. In FIGURE 1addition, such women should be evalu- Overlapping role of hypertension, capillary leak, maternal symptoms,ated for potential preexisting renal dis- and fibrinolysis/hemolysis in the spectrum of atypical preeclampsiaease (such as chronic pyelonephritis,lupus nephritis, immunoglobulin A ne-phropathy, and other nephropathies).24Evaluation for lupus nephritis is ex-tremely important, because this is a po- Blood Capillarytentially treatable cause of proteinuria Pressure Leakduring pregnancy. If proteinuria persistsfor 8 weeks after delivery, thesewomen should be evaluated for underly-ing renal disease. Some of these patientsmay require renal biopsy.24 Moreover, Symptomswomen with proteinuria with cardiore-spiratory symptoms, ascites, or pulmo-nary edema should be evaluated for Fibrinolysispotential cardiac disease (such as con- Hemolysisgestive heart failure or peripartumcardiomyopathy).Preeclampsia-eclampsiaat < 20 weeks of gestationPreeclampsia and/or eclampsia that oc-curs at 20 weeks of gestation has been Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009.reported with molar or hydropic degen- MAY 2009 American Journal of Obstetrics & Gynecology 481.e3
  • 4. Clinical Opinion Obstetrics www.AJOG.org from 87-96%.32,33 In the absence of FIGURE 2 TABLE 5 other disease, the treatment of choice for Sonographic findings of a fetus Differential diagnosis such pregnancies is parenteral magne- with triploidy (69 XXX) of eclampsia sium sulfate to control and prevent con- vulsions, antihypertensive drugs, and Cerebrovascular accidents .................................................................................................. termination of the pregnancy as a defin- Hemorrhage .................................................................................................. itive cure. Ruptured aneurysm .................................................................................................. Late postpartum preeclampsia- Arterial embolism or thrombosis .................................................................................................. eclampsia and HELLP syndrome Cerebral venous thrombosis .................................................................................................. Late postpartum preeclampsia-eclamp- Hypoxic ischemic encephalopathy .................................................................................................. sia is defined as the development of signs Angiomas and symptoms of preeclampsia-eclamp- ........................................................................................................... sia for the first time at 48 hours but Hypertensive encephalopathy ...........................................................................................................Courtesy John Barton, MD, from Central Baptist 4 weeks after delivery.34,35 Historically, Seizure disorder ...........................................................................................................Hospital, Lexington, KY. preeclampsia and eclampsia were be- Previously undiagnosed brain tumors ...........................................................................................................Sibai. Diagnosis and management of a typical lieved to occur only 48 hours from de- Metastatic gestational trophoblasticpreeclampsia-eclampsia. Am J Obstet Gynecol 2009. livery. However, several reports have disease confirmed the existence of late postpar- ........................................................................................................... Metabolic diseases tum preeclampsia-eclampsia.7,34-41 Ta- ...........................................................................................................ence of these disorders. In the absence of ble 4 provides a summary of the inci- Reversible posterior leukoencephalopathyother disease, the patient should be dence of postpartum eclampsia in the syndrome ...........................................................................................................treated for severe preeclampsia. In addi- last 2 decades. Catastrophic antiphospholipid syndrome ...........................................................................................................tion, women in whom convulsions de- Based on our experience and review of Thrombotic thrombocytopenic purpura ...........................................................................................................velop in association with hypertension literature, we recommend that, after de- Postdural puncture syndromeand proteinuria during the first half of livery, any woman with a history of con- ...........................................................................................................pregnancy should be considered to have vulsions at 48 hours after delivery who Cerebral vasculitis ...........................................................................................................eclampsia until proved otherwise.9 is hypertensive and has either protein- Sibai. Diagnosis and management of a typicalThese women should have ultrasound uria or symptoms of preeclampsia preeclampsia-eclampsia. Am J Obstet Gynecol 2009.examination of the uterus to rule out should be considered eclamptic whilemolar pregnancy and/or hydropic or other causes are being ruled out.7 The drome (Figure 3). In the presence ofcystic degeneration of the placenta (Fig- differential diagnosis is listed in Table 5. unexplained blindness or other neuro-ure 2). A diagnostic modality that is also Patients who do not improve rapidly af- logic deficits, another differential diagno-considered is the measurement of uter- ter control of seizures and control of sis is spontaneous reversible vasculopa-ine artery Doppler velocimetry that hypertension and women who have lo- thy syndrome or cerebral angiopathy.43shows the classic “notching” characteris- calizing findings on neurologic examina- This can be diagnosed by magnetic reso-tic of increased resistance in the placenta tion should be evaluated aggressively nance angiograph or traditional cerebralof patients with preeclampsia. The sensi- with neurodiagnostic tests.9,42 The clas- angiography (Figure 4).tivity of this test in patients with estab- sic finding in preeclampsia-eclampsia is Approximately 20-30% of womenlished early onset preeclampsia ranges posterior reversible encephalopathy syn- with HELLP syndrome experience the manifestations for the first time at 48 hours after delivery.8,18 In most cases, TABLE 4 delivery is the ultimate cure for women Incidence of late postpartum eclampsia with preeclampsia/ HELLP syndrome; in Eclampsia Late postpartum some patients, the syndrome of pre- Year Country Study (n) eclampsia (%) eclampsia may get worse after deliv- 1994 United Kingdom Douglas and Redman37 383 5 ery.8,18 Therefore, women who experi- .............................................................................................................................................................................................................................................. 1998 Colombia Conde-Agudelo and 164 12 ence signs and symptoms that are Kafury-Goeta38 consistent with HELLP syndrome for the .............................................................................................................................................................................................................................................. 2000 United States Katz et al 39 53 6 first time after delivery should have .............................................................................................................................................................................................................................................. 2000 United States Mattar and Sibai 7 399 17 prompt medical evaluation that includes .............................................................................................................................................................................................................................................. 40 laboratory testing to rule out or confirm 2002 United States Chames et al 89 26 .............................................................................................................................................................................................................................................. the presence of severe preeclampsia or 41 2003 Singapore Chen et al 62 3 HELLP syndrome. The differential diag- .............................................................................................................................................................................................................................................. Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009. nosis in such women should include thrombotic thrombocytopenic purpura,481.e4 American Journal of Obstetrics & Gynecology MAY 2009
  • 5. www.AJOG.org Obstetrics Clinical Opinion venous dexamethasone in patients with FIGURE 3 FIGURE 4 antepartum and postpartum HELLP syn- Posterior reversible Cerebral vasculitis drome revealed no improvement in ma- encephalopathy syndrome ternal laboratory findings, maternal mor- bidities, or length of hospital stay.44,45 However, both of these randomized trials had a limited number of patients with platelet count of 50,000/mm3 (total of 67 patients randomized in both trials).44,45 More data are needed to answer this ques- tion in such patients. Until then, the use of intravenous dexamethasone to improve maternal outcome in these women re- mains experimental.47 Comment Preeclampsia is a syndrome that is char- Angiogram shows multifocal narrowing and di- acterized by heterogenous clinical andA T2-weighted brain magnetic resonance imag- lation of cortical branches of the right anterior laboratory findings for which the patho-ing shows hyperintense cortical and subcortical cerebral artery, specifically the right internal genesis can differ. The traditional teach-signal in the occipital lobes that is consistent parietal cortical branch. ing states that preeclampsia is defined aswith posterior reversible encephalopathy syn- Sibai. Diagnosis and management of a typical hypertension plus proteinuria that de- preeclampsia-eclampsia. Am J Obstet Gynecol 2009.drome. The arrows indicate cerebral edema in velops at 20 weeks of gestation and/orthe occipital lobes. within 48 hours after delivery. However,Sibai. Diagnosis and management of a typicalpreeclampsia-eclampsia. Am J Obstet Gynecol 2009. based on our experience and review of highly suggestive of preeclampsia. A literature, we suggest that the aforemen- complete blood count, liver panel, lac- tioned criteria for defining preeclampsia tate dehydrogenase, and a disintegrin-hemolytic uremic syndrome, or exacer- should be revisited, because preeclamp- like and metalloprotease with throm-bated systemic lupus erythematosus.18,31 sia, like many other syndromes in medi- bospondin should be considered to rule Corticosteroids generally are recom- cine, can have atypical presentations. out thrombotic thrombocytopenic pur-mended to enhance fetal lung maturity Therefore, we recommend that health pura.48 An antinuclear antibody screen,in patients with severe preeclampsia at care providers in obstetric practice antimitochondrial antibodies, serum se-34 weeks of gestation.17 In addition, should have a high index of suspicion for rology, and serum biochemistry shouldsome authors recommend corticoste- the potential atypical clinical manifesta- be done to exclude the diagnosis of sys-roids, particularly dexamethasone, as a tions of preeclampsia (Figure 1), irre- temic lupus erythematosus. Addition-treatment for patients with partial or spective of gestational age at the time of ally, anticardiolipin antibody and lupuscomplete HELLP syndrome in the ante- onset or the number of days after anticoagulant should be performed topartum and immediate postpartum pe- delivery. rule out antiphospholipid antibody syn-riods in an attempt to improve maternal Treatment of patients with atypical drome. Urinalysis, a 24-hour urine col-laboratory findings and/or to reduce ma- manifestations of preeclampsia-eclamp- lection, and renal tests should be per-ternal hospital stay. An exhaustive re- sia require a well-formulated plan that formed to rule out the possibility ofview of the benefits of steroids is de- takes the following items into consider- undiagnosed renal disease.12scribed by Martin et al.18 The use of ation: maternal risk factors; clinical, lab- Gestational hypertension or gesta-corticosteroids antepartum actually may oratory, and imaging findings; the time tional proteinuria alone may be the firstdelay the onset of HELLP syndrome un- of onset in relation to gestational age, sign for subsequent development of pre-til the postpartum period.8,18 and delivery. eclampsia. In women with gestational The use of intravenous dexamethasone For pregnancies that are complicated hypertension, the risk of progression toto improve maternal outcome in women with hypertension and proteinuria that preeclampsia is related inversely to ges-with HELLP syndrome in the postpartum occur at 20 weeks gestation, an ultra- tational age at onset.13,14 Thus, theseperiod remains controversial.8,18,44-46 Al- sound scan must be performed to ex- women should have close antenatal fol-most all studies that have reported such clude the diagnosis of molar or partial low-up evaluations, with attention tobenefit were retrospective in design or they molar pregnancy, and uterine artery new onset of symptoms and regular eval-compared treatment to no treatment in a Doppler velocimetry must be performed uation (1-2 times/wk) of platelet countlimited number of subjects.8,18 In contrast, to evaluate uterine artery resistance and and liver enzymes for early detection of2 recent multicenter, double-blind, pla- the presence of a notch.32,33 The pres- preeclampsia. Ancillary studies may in-cebo-controlled trials that evaluated intra- ence of notching in the uterine artery is clude ultrasound scans for the evaluation MAY 2009 American Journal of Obstetrics & Gynecology 481.e5
  • 6. Clinical Opinion Obstetrics www.AJOG.orgof fetal growth and amniotic fluid and In cases with hypertension, symptoms eclampsia. Future investigations shoulduterine artery Doppler velocimetry to of headache or blurred vision, with or address the maternal and perinatal out-evaluate the presence of notching.32,33 without seizures at 48 hours after de- comes in women with atypical pre-Patients with symptoms and/or abnor- livery, magnesium sulfate therapy eclampsia. Additionally, further researchmal laboratory tests or women with ab- should be initiated without delay while should include measurements of serumnormal ultrasound findings should be other possible causes of the aforemen- angiogenic markers and other potentialconsidered to have atypical preeclampsia tioned symptoms are being ruled out.9,42 biomarkers in cases of atypical pre-and be treated. However, the results We recommend a loading dose of 6 g to eclampsia to determine whether thesefrom uterine artery Doppler imaging be administered over 30 minutes, fol- markers can be useful potentially to con-have no prognostic value regarding the lowed by a maintenance dose of 2 g/hour firm the diagnosis in such women. ftiming of delivery.32 Patients with gesta- for at least 24 hours after the last seizuretional proteinuria should be evaluated and that urine output, blood pressure, REFERENCESfor the presence of undiagnosed diabetes and maternal symptoms should be mon- 1. Report of the National High Blood Pressuremellitus (glucose testing) and undiag- itored closely after discontinuation of Education Program Working Group. Report onnosed lupus (serology, antibodies, anti- magnesium sulfate. If the patient has se- high blood pressure in pregnancy. Am J Obstetcardiolipin antibodies, and platelet vere hypertension alone, then antihyper- Gynecol 2000;183:S1-22. tensive therapy should be administered 2. Sibai BM. Diagnosis and management ofcount) and undergo a metabolic profile, gestational hypertension and preeclampsia.complete urine analysis, and 24-hour to stabilize blood pressure to a level of Obstet Gynecol 2003;102:181-92.urine for creatinine clearance and quan- 150/100 mm Hg.42 If the condition does 3. ACOG Committee on Practice Bulletins-Ob-titative proteinuria. Renal biopsy is not not respond to such therapy or the pa- stetrics. Diagnosis and management of pre-indicated during pregnancy, because the tient continues to have seizures despite eclampsia and eclampsia. Obstet Gynecol magnesium sulfate therapy or continues 2001;98:159-67.results will not be helpful in treatment. If 4. Hauth JC, Ewell MG, Levine RL, Esterlitz JR, to have cerebral symptoms, then brainthe results of testing rule out renal dis- Sibai BM, Curet LB. Pregnancy outcomes in imaging with magnetic resonance imag-ease, these patients should be considered healthy nulliparous women who subsequently ing and angiography, if needed, should developed hypertension: calcium for pre-at risk for the subsequent development be performed to rule out the presence of eclampsia prevention study group. Obstet Gy-of preeclampsia. Management should other cerebral disease.42,43 necol 2000;95:24-8.include frequent prenatal visits (1-2 5. Brown MA, Hague WM, Higgins J, et al. The Patients who complain of persistenttimes/wk) for evaluation of blood pres- detection, investigation, and management of nausea, vomiting, epigastric pain, or hypertension in pregnancy: full consensussure, symptoms, and changes in blood mucosal bleeding with or without hyper- statement of recommendations from the Coun-tests. tension at 48 hours after delivery cil of Australian Society of the study of hyper- Recently, several circulating angio- tension in pregnancy. Aust N Z J Obstet Gynae- should also be evaluated for possiblegenic markers have been proposed to ei- HELLP syndrome. These women should col 2000;40:139.ther predict or confirm the diagnosis of have platelet counts, liver enzyme tests, 6. Brown MA, Lindheimer MD, de Swiet M, Vanpreeclampsia.21,48-51 These markers have Assche A, Moutquin JM. The classification and and coagulation studies as needed to rule diagnosis of the hypertensive disorders of preg-included reduced serum placental out other disease, such as thrombotic nancy: statement of the International Society forgrowth factor, elevated soluble fms-like thrombocytopenic purpura, hemolytic the study of hypertension in pregnancy (ISSHP).tyrosine kinase-1 receptor, and elevated uremic syndrome, and acute fatty liver of Hypertens Pregnancy 2001;20:IX-XIV.serum soluble endoglin levels.48-51 Some pregnancy.8,18 Abdominal imaging stud- 7. Mattar F, Sibai BM. Eclampsia VIII: risk fac- tors for maternal morbidity. Am J Obstet Gy-studies have also found that the magni- ies may be needed on the basis of clinical necol 2000;182:307-12.tude of the imbalance between these an- and laboratory findings.8 8. Sibai BM. Diagnosis, controversies and man-giogenic markers correlates with disease In summary, it is important to widen agement of the HELLP syndrome. Obstet Gy-severity and with early onset of pre- the spectrum of the definition of pre- necol 2004;103:981-91.eclampsia.48,49 In addition, some au- 9. Sibai BM. Diagnosis, differential diagnosis eclampsia to cases that manifest as hy- and management of eclampsia. Obstet Gy-thors have found that these markers may pertension without proteinuria and necol 2005;105:402-10.be useful clinically to rule out the diag- vice versa. Alternately, one must be 10. Brown MA, Buddle ML. 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Barton JR, O’Brien JM, Bergauer NK,nant women with atypical clinical and geted laboratory tests, as needed, to Jacques DL, Sibai BM. Mild gestational hyper-laboratory findings. confirm the diagnosis of atypical pre- tension remote from term: progression and out-481.e6 American Journal of Obstetrics & Gynecology MAY 2009
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