Premaclam

Preeclampsia
The following section is entitled “Preeclampsia”. This section familiarizes the medical provider with the diagnostic features and medical management of preeclampsia. The section begins with a learner handout with space for the learner to make their own notes. The learner handout is followed by the teaching script for the educator. Relevant cases for discussion and a bibliography of articles related to preeclampsia and chronic hypertension in pregnancy can be found at the end of this section.

PREECLAMPSIA

PREECLAMPSIA / PREGNANCY INDUCED HYPERTENSION

Incidence
• Preeclampsia complicates at lease 10% of first pregnancies

Etiology
• The etiology of preeclampsia is unknown but may be related to abnormal placentation.

Obstetric Medicine Curriculum Learner Handout Preeclampsia (Page 1)

PREECLAMPSIA

Pathophysiology
• • Preeclampsia most commonly presents in the second half of pregnancy. It is a multisystem disease associated with diffuse vasospasm and endothelial damage.

Pathophysiology
• Pathology demonstrates areas of endothelial swelling, edema, micro-infarctions and microhemorrhages in effected organs.

Risk Factors
• first pregnancy • new mailings • younger than 18 and older than 35 • prior history • family history
Obstetric Medicine Curriculum Learner Handout Preeclampsia (Page 2)

• multiple gestations • hydatidiform mole • hydrops • triploidy

PREECLAMPSIA

Risk Factors
• • • • • chronic hypertension diabetes renal disease SLE thrombophilias (especially APLA) • obesity

Diagnosis
• Though important manifestations of the disease, hypertension, proteinuria, and edema are not essential to the diagnosis of preeclampsia. • The likelihood of preeclampsia increases when more elements of the disease are present.

Symptoms • • • • headache visual disturbances epigastric or RUQ discomfort edema/rapid weight gain

Obstetric Medicine Curriculum Learner Handout Preeclampsia (Page 3)

PREECLAMPSIA

Signs
• • •

References: Ananth CV, Savitz DA, Bowes WA, Luther ER. Influence of hypertensive disorders and cigarette smoking on placental abruption and uterine bleeding. British Journal of Obstetrics and Gynecology. 1997;104:572-578 Ananth CV, Bowes WA, Savitz DA, Luther ER. Relationship between pregnancy induced hypertension and placenta previa: a population based study. Am J Obstet Gynecol 1997:997-1002. Ayala DE, Hermida RC, Mojon A, Fernanadez JR, Iglesias M. Circadian blood pressure variability during gestation in healthy and complicated pregnancies. Hypertension 1997; 30(2):603-10 Ayala DE, Hermida RC, Mojon A, Fernanadez JR, Silva I, Ucieda R, Iglesias M. Blood pressure variability during gestation in healthy and complicated pregnancies. Hypertension 1997; 30(2):611-618 Baron JR, Stanziano GJ, Sibai BM. Monitored outpatient management of mild gestational hypertension remote from term. Am J Obstet Gynecol 1994; 170:765-9. Bienarz J, Crottogini JJ et al. Aortocaval compression by the uterus in late human pregnancy . American Journal of Obstetrics and Gynecology. 1968; 100:203-7 Biswas A, Choolani MA, Anandakumar C, Arulkumaran S. Ambulatory blood pressure monitoring in pregnancy induced hypertension. Acta Obstetrica Gynecologica Scandinavica. 1997; 76:829-833. Bhorat IE, Datshana PN, Rout CC, Moodley K. Malignant ventricular arrhythmias in eclampsia: A comparison of labetalol with dihydralazine. M J Obstet Gynecol 1993; 168:1292-6 Caritis,SN, Sibai BM, Hauth J, Lindheimer MD, Klebanoff M, Thom E, VanDorsten P, Landon M, Paul R, Miodovnik M, Meis P, Thurnau G, and the National Institute of Child Health and Human Development Network of Maternal Fetal Medicine Units. Low Dose Aspirin to Prevent Pre-eclampsia in women at High Risk. N Engl J Med 1993; 329:1213-8. Cnattingius S, Mills JL, Yuen J, Erikksson O Ros H. The paradoxical effect of smoking in pre-eclamptic pregnancies: smoking reduces the incidence but increases the rates of perinatal mortality, abruptio placentae and intrauterine growth restriction. Am J Obstet Gynecol 1997; 177:156-61. Cockburn J, Moar VA, Ounsted M and Redman CWG. Final report of study on hypertension during pregnancy: the effects of specific treatment on the growth and development of the children. Lancet 1982; 647-9 Collaborative Low Dose Aspirin Study in Pregnancy collaborative group. CLASP: a randomized trial of low dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. Lancet 1994; 343:619-29 Cousins L. Pregnancy complications among diabetic women : review 1965-1985. Obstet Gynecol Surv 1987; 42:140-149.53 Dotsch J, Hohmann M, Kuhl PG. Neonatal morbidity and mortality associated with maternal hemolysis elevated liver enzymes and low platelets syndrome. Eur J Pediatr 1997; 156:389-91. Obstetric Medicine Curriculum Bibliography Preeclampsia (Page19) Garner PR, D’Alton ME, Dudley DK, Huard P, Hardie M. Pre-eclampsia in diabetic pregnancies. Am J Obstet Gynecol 1990; 163:505-508. Goodlin RC. Pre-eclampsia as the great impostor. Am J Obstet Gynecol 1991; 164:1577-81. Halligan A, Shennan, de Swiet M, Taylor DJ. The use of ambulatory pressure monitoring in the assessment of hypertension in pregnancy. Contemp Rev Obstet Gynecol 1995; 7:83-9. Helewa ME, Burrows RF, Smith J, Williams K, Brain P, Rabkin SW. Report of the Canadian Hypertension Society Consensus Conference: Definitions, evaluation and classification of hypertensive disorders in pregnancy. Can Med Assoc J 1997; 157(6):715-25. Henriksen T. Hypertension in Pregnancy: use of antihypertensive drugs. Act Obstet Gynecol Scand 1997; 76:96-106 Hermida RC, Ayala DE, Iglesias M, Mojon A, Siolva I, Ucieda R, Fernanadez JR. Time dependent effects of low dose aspirin administration on blood pressure in pregnant women. Hypertension 1997; 30(2):589-595. James WH. Coital rate and pregnancy induced hypertension. Human Reproduction. 1997; 12(6):1311-12. Kanayama N, El Maradny E, Kajiwara Y, Kayoko M, Tokunaga N, Terao T. Hypolumbarlordosis: a predisposing factor for pre-eclampsia. European Journal of Obstetrics and Gynecology and reproductive biology. 1997; 75:11521. Khedun SM, Moodley J, Naicker T, Maharaj B. Drug Management of Hypertensive Disorders of Pregnancy. Pharmacol. Ther. 1997; 74(2):221-58 Khong TY, De Wolf F, Robertson WB, Brosens I. Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by small for gestation al age infants. British Journal of Obstetrics and Gynecology. 1986; 93:1049-59. Kirby JC, Jaindl JJ. Cerebral CT findings in toxemia of pregnancy. Radiology 1984; 151:114. Kramer RL, Izquierdo LA, Gilson GJ, Curet LB, Qualls CR. Pre-eclamptic labs for evaluating hypertension in pregnancy. Journal of reproductive medicine. 1997; 42:223-28 Lind T, Godfrey KA, Otun H, Philips PR. Changes in serum uric acid concentrations during normal pregnancy. British Journal of Obstetrics and Gynecology 1984; 91:128-32. Lubarsky SL, Barton JR, Friedman SA, Nasreddine S, Ramadan MK, Sibai BM. Late postpartum eclampsia revisited. Obstetrics and Gynecology 1994; 83:502-5. Lucas MJ, Leveno KJ, Cunninghm FG. A comparison of magnesium sulfate with phenytoin for the prevention of eclampsia. N Engl J Med 1995; 333:201-5. Levine RJ, Hauth JC, Curet LB, et al: Trial of calcium to prevent preeclampsia, N Engl. J Med 1997; 337: 69-76. Levine RJ, Hauth C, Curet LB, Sibai BM, Catalano PM, Morris CD, DerSimonian R, Esterlitz JH, Raymond EG, Bild DE, Clemens JD, Cutler JA. Trial of calcium to prevent pre-eclampsia. N Engl J Med 1997; 337(2):69-76. Obstetric Medicine Curriculum Bibliography Preeclampsia (Page20) Lewis R, Sibai B. Recent advances in the management of pre-eclampsia. The Journal of Maternal Fetal Medicine. 1997; 6:6-15. Loebstein R, Lalkin A, Koren G. Pharmacokinetic changes during pregnancy and their clinical relevance. Clin Pharmacokinet. 1997; 33(5):328-343. Lovestam-Adrian M, Agardh CD, Aberg A, Agardh E. Pre-eclampsia is a potent risk factor for deterioration of retinopathy during pregnancy in type 1 diabetics. Diabet Med 1997; 14:1059-1065. Lucas MJ, DePalma RT, Peters MT, Leveno KJ, Person D, Cunningham FG. A simplified phenytoin regimen for pre-eclampsia. American Journal of Perinatology 1994; 11(2):153-156. Mabie WC, Gonzalez AR, Sibai BM: A comparative trail of labetalol and hydralazine in the acute management of severe hypertension complicating pregnancy. Obstet Gynecol 1987;70:328/. Marcoux S, et al. The effect of cigarette smoking on the risk of pre-eclampsia and gestational hypertension. Am J Epidemiol 1989; 130:950-957. Misra DP, Kiely JL. The association between nulliparity and gestational hypertension. J Clin Epidemiol. 1997; 50(7):851-55. Moore LG, Hershey DW, Jahnigen D, Bowes W. The incidence of pregnancy induced hypertension is increased among Colorado residents at high altitude. Am J Obstet Gynecol 1982; 144:423-29. Moutquin J, Garner PR, Burrows RF, Rey E, Helewa ME, Lange IR, Rabkin SW. Report of the Canadian Hypertension Society Consensus Conference: Nonpharmacologic management and prevention of hypertensive disorders in pregnancy. Can Med Assoc J 1997; 157(7):907. National High Blood Pressure Education Program. National high blood pressure education program working group report on high blood pressure in pregnancy. American Journal of Obstetrics and Gynecology 1990; 163:1691-1712. Neerhof MG. Pregnancy in the chronically hypertensive patient. Clinics in Perinatology. 1997; 24(2):391-406. Newcombe DS. The hyperuricemia of pre-eclampsia and eclampsia. Obstetric and Gynecologic Survey 1972; 27(2):543-50. Perry IJ, Stewart BA et al. Recording diastolic blood pressure in pregnancy. British Medical Journal 1990; 301:11983. Porapakkham S. An epidemiologic study of eclampsia. Obstetrics and gynecology 1979; 54:26-30. Pryde PG, Sedman AB, Nugent CE, Barr M. Angiotensin converting enzyme fetopathy. J Am Soc Nephrol 1993; 3:1575-82. Rajkovic A, Catalano PM, Malinow MR. Elevated homocyst(e)ine levels with preeclampsia. Obstetrics and Gynecology 1997; 90:168-171. Redman CWG, Beilin LJ, Bonnar J, Ounsted MK. Fetal outcome in trial of antihypertensive treatment of pregnancy . The Lancet 1976; 2(7989):753-756. Obstetric Medicine Curriculum Bibliography Preeclampsia (Page21) Report of the Canadian Hypertension Society Consensus Conference: Pharmacologic management of hypertensive disorders in pregnancy. Can Med Assoc J 1997; 157(7):907. Rey E. Pre-eclampsia and neonatal outcomes in chronic hypertension: comparison between white and black women. Ethnicity and Disease 1997; 7:5-11. Rijhsinghani A, Yankowitz J, Strauss RA, Kuller JA, Shivanand P, Williamson RA. Risk of pre-ecalmpsia in second trimester triploid pregnancies. Obstetrics and Gynecology 1997; 90:884-8. Royburt M, Seidman DS, Serr DM, Mashiach S. Neurologic Involvement in Hypertensive Disease of Pregnancy. Obstetrical and Gynecological Survey. 1991; 46(10):656-63. Sanders TG, Calyman DA, Sanchez, Ramos L, Vines FS and Russo L. Brain in eclampsia: MRI imaging with clinical correlation. Radiology 1991; 180:475-8. *Sibai BM. Treatment of hypertension in pregnant women N. Engl J Med. 1996; 335(4):257-65. Sibai BM, Barton JR, Sherif A, Sarinoglu C, Mercer BM. A randomized prospective comparison of nifedipine and bed rest versus bed rest alone in the management of pre-eclampsia remote from term. Am J Obstet Gynecol 1992; 167:879-84. Sibai BM Gonzalez AR, Mabie WC, Moretti M. A comparison of labetalol plus hospitalization alone in the management of pre-eclampsia remote from term. Obstet Gynecol 1987; 70:323-27. Sibai BM, Mabie WC, Shansa F, Villar MA, Anderson GD. A comparison of no medication versus methyldopa or labetalol in chronic hypertension during pregnancy. AM J Obstet Gynecol 1990; 162:960-7. Sibai BM, McCubbin JH, Anderson GD, Lipshitz J & Dilts PV. Eclampsia. I. Observations from 67 recent cases. Obstetrics and Gynecology 1981; 58:6089-13. Sibai BM, Mercer B, Sarinoglu C. Severe pre-eclampsia in the second trimester: recurrence risk and long term prognosis. Am J Obstet Gynecol 1991; 165:1408-12. Sibai BM, Ramadan MK, Usta I: Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169(4):1000-6. Smith GN, Walker M, Tessier JL, Millar KG. Increase incidence of pre-eclampsia in women conceiving by intrauterine insemination with donor versus partner sperm for treatment of primary infertility. Am J Obstet Gynecol 1997; 177:455-8. Usta IM, Sibai BM. Emergent management of puerperal eclampsia. Obstetrics and Gynecology Clinics of North America 1995; 22(2):315-35. Wergeland E, Strand K. Working conditions and prevalence of pre-eclampsia, Norway 1989. International Journal of Gynecology and Obstetrics. 1997; 58:189-96. Williams MA, Liberman E, Mittendorf R, Monson RR, Schoenbaum SC. Risk factors for abruptio placentae. Am J Epidemiol 1991; 134:965-72. Obstetric Medicine Curriculum Bibliography Preeclampsia (Page22) Witlin AG, Sibai BM. Hypertension in Pregnancy: Current concepts of pre-eclampsia. Annu. Rev Med. 1997; 48:115-27. Obstetric Medicine Curriculum Bibliography Preeclampsia (Page23)