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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

Gestational hypertension

  • Blood pressure of ≥ 140/90 mm Hg systolic or > 90 mm Hg diastolic after 20 weeks’ gestation.

Preeclampsia

  • Blood pressure of ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic after 20 weeks’ gestation.

  • Proteinuria of ≥ 0.3 g in 24 hours.

Preeclampsia with severe features

  • Blood pressure of ≥ 160 mm Hg systolic or ≥ 110 mm Hg diastolic.

  • Progressive kidney injury.

  • Thrombocytopenia.

  • Hemolysis, elevated liver enzymes, low platelets (HELLP).

  • Pulmonary edema.

  • Vision changes or headache.

  • When hypertension is present with severe features of preeclampsia, seizure prophylaxis could be beneficial.

Eclampsia

  • Seizures in a patient with evidence of preeclampsia.

GENERAL CONSIDERATIONS

Preeclampsia is defined as the presence of newly elevated blood pressure and proteinuria during pregnancy. Eclampsia is diagnosed when seizures develop in a patient with evidence of preeclampsia. Historically, three elements were required for the diagnosis of preeclampsia: hypertension, proteinuria, and edema. Edema was difficult to objectively quantify and is no longer a required element. In addition, proteinuria may not always be present in preeclampsia with severe features.

Preeclampsia-eclampsia most commonly occurs in the third trimester but can occur any time after 20 weeks’ gestation and up to 6 weeks postpartum.

Risk factors for early preeclampsia-eclampsia are maternal comorbid conditions, such as hypertension, kidney disease, and SLE.

Preeclampsia-eclampsia is a disease unique to pregnancy, with the only cure being delivery of the fetus and placenta. Preeclampsia develops in approximately 7% of pregnant women in the United States; of those, eclampsia will develop in 5% (0.04% of pregnant women). Primiparas are most frequently affected; however, the incidence of preeclampsia-eclampsia is increased with multifetal gestations, preeclampsia in a previous pregnancy, and comorbid diseases such as chronic hypertension, pregestational diabetes, gestational diabetes, thrombophilia, kidney disease, SLE, prepregnancy BMI above 30, antiphospholipid antibody syndrome, maternal age 35 years or older, assisted reproductive technology, and obstructive sleep apnea. Eclampsia is a significant cause of maternal death.

The cause of preeclampsia-eclampsia is not known, but it is likely a multifactorial, two-stage process. The first stage is thought to be a disturbance in placental implantation involving the spiral arteries very early in gestation. The abnormal placental perfusion that results leads to the formation of noxious free radicals. The second stage is characterized by excessive inflammation causing endothelial damage, vasospasm, and finally clinical signs and symptoms. An immunologic component to preeclampsia-eclampsia has been proposed, citing the increased incidence in primigravidas. This entire process is likely enhanced by environmental factors, genetic predisposition, and preexisting maternal disease.

CLINICAL FINDINGS

The severity of preeclampsia-eclampsia is based on its effect on six major target areas: the CNS, the kidneys, the liver, the hematologic system, the vascular system, and the fetal-placental unit. By evaluating each of these areas for the presence of mild to severe ...

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