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Definition
Description
The most common classification used to define hypertensive disorders of pregnancy is the
one recommended by the American College of Obstetricians and Gynecologists (ACOG) and
endorsed by the NIH Working Group on High Blood Pressure:
For purposes of accuracy and standardization, health professionals should take blood
pressure measurements in pregnant women with the patient seated rather than lying on her
side, because substantial differences exist between the blood pressures in the upper and
lower arms when the patient is lying on her side. In addition, the National Institutes of
Health (NIH) recommends that the diastolic pressure reading should be taken at Korotkoff
5, with the disappearance of sound—not at Korotkoff 4, when sound becomes muffled. To
meet strict criteria for hypertension, the patient's readings must be elevated on at least two
separate occasions at least six hours apart.
A liver condition related to hypertension in pregnancy is called the HELLP syndrome, which
occurs in about 1:150 births. HELLP stands for hemolysis, elevated liver enzymes,
and lowplatelet count. Normal liver functioning is altered in the HELLP syndrome as a result
of vascular damage related to preeclampsia. Researchers believe that the fetus and mother
share a defect in processing fatty acids that leads to destruction of red blood cells,
inflammation of the liver, and decreased platelet count. HELLP syndrome is associated with
disseminated intravascular coagulation (DIC); placental abruption (sudden tearing);
acute renal failure; and pulmonary edema. About 30% of pregnancy-related cases of HELLP
develop in the postpartum period.
Preeclampsia and eclampsia may also be associated with the serious condition known as
disseminated intravascular coagulation, or DIC. DIC is a disorder characterized by both
bleeding and thrombosis (the formation of intravascular clots). Maternal hemorrhage is a
risk in patients with preeclampsia who develop DIC. About 15% of hypertension-related
deaths in pregnancy are associated with DIC.
Diagnosis
The diagnosis of preeclampsia is complicated by the fact that the signs of hypertension in
pregnancy can be easily confused with the symptoms of chronic
hypertension, gallbladderand pancreatic diseases, and other disorders. Since prevention of
maternal and fetal morbidity and mortality is of the utmost priority, however, the NIH
recommends overdiagnosis of preeclampsia rather than underdiagnosis to ensure careful
management. Pregnant women should have their weight, blood pressure, urine checked at
every prenatal visit. Regular prenatal visits are extremely important, as the early symptoms
of preeclampsia cause no discomfort. The NIH guidelines suggest that women who develop
an increase of 30 mmHg systolic or 15 mmHg diastolic over their prenatal baseline
measurements should be closely monitored, especially if their protein or uric acid levels are
elevated. Early detection of preeclampsia allows for proper management of the condition.
Treatment
Pre-delivery management
Delivery is the definitive treatment of preeclampsia. Even mild preeclampsia that develops
at 36 weeks of gestation or later is managed by delivery. Prior to 36 weeks, severe
preeclampsia requires delivery of the fetus. Mild to moderate preeclampsia between 20 and
36 weeks is treated with bed rest. Rest increases central blood flow to the patient's heart,
kidneys, placenta, and other organs. Bed rest at home is an option for some patients with
mild preeclampsia and stable home situations. Patients with severe eclampsia or unstable
family situations require hospitalization. Monitoring of fetal heart rate and lung maturity is
an important part of the management of preeclampsia.
Medications
Medication for preeclampsia is usually directed toward preventing convulsions rather than
controlling blood pressure. Magnesium sulfate is the drug of choice for controlling seizures
during pregnancy. Prophylactic magnesium sulfate administration may continue into the
postpartum period.
Emergency care
Vaginal delivery is preferred to caesarean delivery in order to avoid the additional stress of
surgery on the patient's organ systems. The NIH recommends a trial of labor induction,
regardless of the condition of the patient's cervix. Magnesium sulfate may be given as an
anticonvulsant. Antihypertensive medication is restricted to use for sudden elevations of
blood pressure, or if the patient's diastolic pressure reaches 105 to 110 mm Hg.
Prognosis
Risks to the fetus from preeclampsia include intrauterine growth retardation and low birth
weight, placental abruption, and stillbirth. The fetus may be delivered prematurely if the
condition of the mother deteriorates. Risks to the mother include vascular organ damage;
the additional risks of eclampsia include convulsions and accompanying oxygen deprivation,
hemorrhage in the brain, temporary blindness, permanent neurological damage, liver or
kidney damage, cerebrovascular and cardiovascular complications, and even death. The
prognoses for both the fetus and mother are excellent in mild preeclampsia. If blood
pressure readings are within normal limits after several weeks postpartum, the mother may
still be at increased risk of hypertension later in life, and should have her blood pressure
checked yearly.
The long-term prognosis for children born to preeclamptic mothers is not yet known. These
individuals do, however, appear to be at increased risk of chronic disease in adult life.
Prevention
Since the cause of preeclampsia is unclear, prevention focuses on early detection and
management to avoid progression. Bed rest improves blood flow to the placenta and to
maternal organs. Lying on the side increases sodium excretion and decreases fluid retention
through increased diuresis. Magnesium sulfate may be given to lessen the risk of
convulsions.
Recent clinical trials appear to indicate that some preventive strategies do not benefit most
patients at risk for preeclampsia. These strategies include the prophylactic administration of
heparin, calcium, or aspirin; and supplemental doses of fatty acids.
KEY TERMS
Cyanosis—A bluish color to the skin that indicates poor circulation and poor oxygenation of
the blood and tissues.
Oliguria—Minimal urine output, usually defined as 500 ml or less over a 24-hour period.