Preeclampsia pdf articles

In the United States, however, the classification scheme as per the ACOG in comprising four categories remains unchanged In , the Society of Obstetricians and Gynecologists of Canada released revised recommendations on hypertension in pregnancy on the basis of literature reviews and criteria from the Canadian Task Force on Preventative Health Care The National Institute for Health and Care Excellence in the United Kingdom in introduced evidence-based guidelines on the diagnosis and management of hypertension during pregnancy, birth, and the postnatal period www.

The Society of Obstetric Medicine of Australia and New Zealand has expanded its definition of chronic hypertension Finally, the International Society for the Study of Hypertension in Pregnancy submitted a revised statement in that includes the categories of chronic hypertension, gestational hypertension, preeclampsia de novo or superimposed on chronic hypertension , and white coat hypertension The main categories from each society have been summarized in Table 1.

Treatment targets for BP, although similar, may also be slightly different between societies and may depend on the presence of end organ damage or comorbidities. We have summarized the treatment goals in Table 2. In being more aggressive with BP treatments, we are somewhat reassured by the results of the recent multicenter, randomized, controlled study: the Control of Hypertension in Pregnancy Study This study showed that a tighter target of diastolic BP of 85 mmHg had nonsignificant maternal and fetal outcomes compared with a less tight control level of mmHg.

The less tight control group, however, had a higher incidence of severe hypertension, thrombocytopenia, elevated liver enzymes with symptoms, and a trend toward a higher incidence of hemolysis, elevated liver enzymes, and low platelets syndrome. Thus, it seems that tighter control of BP is not only safe for the fetus but potentially beneficial to the mother.

However, one must be realistic and mindful of the evidence of treating mild to moderate hypertension in pregnancy. Abalos et al. The care of the woman at risk for preeclampsia starts with preconception counseling followed by prevention, treatment, and appropriate postpartum follow-up. An extensive review of this topic is beyond the scope of this paper. However, we would like to highlight a few salient points. The ACOG recommends that women who had preeclampsia in a prior pregnancy seek preconception counseling and assessment.

We agree with preconception counseling in high-risk individuals; however, we do not recommend against the use of angiotensin—converting enzyme inhibitors and angiotensin receptor blockers in women with comorbidities, such as diabetes, proteinuria, or CKD, because of the weak evidence of congenital malformations in the first trimester 95 , We do recommend that these agents be discontinued after pregnancy has been confirmed.

We have also summarized important therapies in the prevention and treatment of preeclampsia and eclampsia in Table 3. First—line antihypertensive agents are presented in Table 4. Postpartum surveillance, as per the ACOG guidelines, includes obtaining a cardiovascular profile, including yearly assessment of BP, lipids, fasting blood glucose, and body mass index, in women with a history of preterm preeclampsia or recurrent preeclampsia It is recognized that the evidence behind these recommendations is low and thus, health care providers must individualize their decisions on the basis of the value of this information versus convenience and cost.

In summary, with our ever-expanding insight into the pathogenesis of preeclampsia and now, a revised definition of preeclampsia, we hope to more accurately diagnose and treat these patients. Furthermore, the recognition of the long-term consequences of this entity will hopefully enhance our care for these women during pregnancy and for decades afterward. Published online ahead of print. Publication date available at www.

National Center for Biotechnology Information , U. Clin J Am Soc Nephrol. Published online Apr Author information Copyright and License information Disclaimer. Corresponding author. Correspondence: Dr.

Email: moc. This article has been cited by other articles in PMC. Abstract Preeclampsia is becoming an increasingly common diagnosis in the developed world and remains a high cause of maternal and fetal morbidity and mortality in the developing world. Introduction Preeclampsia has been dubbed a disease of theories. Pathogenesis The pathogenesis of preeclampsia is not fully elucidated but much progress has been made in the last decades.

Open in a separate window. Figure 1. Angiogenic Factors In , Maynard et al. Heme Oxygenase Pathway Most recent studies have focused on the proximal pathways of sFlt-1 induction.

Hydrogen Sulfide Pathway The hydrogen sulfide H 2 S —generating system has also been implicated in the pathogenesis of preeclampsia. Oxidative Stress From early pregnancy on, the placenta assumes a state of oxidative stress arising from increased placental mitochondrial activity and production of reactive oxygen species ROS , mainly superoxide anion 50 , Angiotensin Receptor 1 Autoantibodies Turning to immune mechanisms, there have been many studies to show the link between autoantibodies to angiotensin receptor 1 AT1-AAs and preeclampsia.

Misfolded Proteins Preeclamptic placentas have been shown to accumulate clusters of misfolded protein, which may contribute to the pathophysiology of the disease Subtypes of Preeclampsia Ness and Roberts 63 in had proposed to distinguish preeclampsia into two broad categories: placental and maternal. Maternal Outcomes Multiple clinical studies of women with preeclampsia show an increased risk of developing cardiovascular diseases later in life Guidelines The classification schema of hypertensive disorders in pregnancy in general and the definition of preeclampsia in particular have been variably modified in recent years.

Table 1. Comparison of definitions among different societies. Comparison of Guidelines from International Societies Although there may be myriad societal guidelines, we chose to review those that have been most impactful and used. BP Targets Treatment targets for BP, although similar, may also be slightly different between societies and may depend on the presence of end organ damage or comorbidities. Table 2. BP targets. Preconception Counseling, Prevention, Treatment, and Postpartum Care in Preeclampsia The care of the woman at risk for preeclampsia starts with preconception counseling followed by prevention, treatment, and appropriate postpartum follow-up.

Table 3. Table 4. First—line medication choices in treatment of hypertension of pregnancy. PO, oral; IV, intravenous. Disclosures None. Eclampsia is generally considered an indication for emergency cesarean section. Although delivery is the only effective treatment for pre- eclampsia, and despite the fact that clinical symptoms and laboratory abnormalities usually regress in the hours afterwards, the risk of complications persists for some time following delivery.

Hemodynamic, neurological, and laboratory monitoring is necessary following delivery for patients with severe preeclampsia. Neurological monitoring consists of checking for signs of imminent eclampsia, including headaches, phosphene signals, tinnitus, and brisk tendon reflexes. Clinical monitoring must be done several times daily during the week after delivery, a period considered at high risk for complications.

If necessary, monitoring can be performed in an intensive care unit. Laboratory monitoring should be done several times daily in the first 72 hours after delivery and thereafter adapted according to progress of the indices.

It must include a complete blood count, liver function tests, and measurement of lactate dehydrogenase. The risk of recurrence of pre-eclampsia during a subsequent pregnancy has to be considered.

The relative risk is 15 if pre-eclampsia occurs at 20—33 weeks, 10 at 33—36 weeks, and 8 after 37 weeks. Such screening is intended to check for normalization of blood pressure values and disappearance of proteinuria, and if abnormalities persist, a referral should be made to a nephrologist or a hypertension expert to determine the cause. This examination is important because pre-eclampsia may unmask previously undiagnosed systemic or kidney disease or thrombophilia. It should include a specific set of questions, blood pressure measurement, a clinical examination looking for signs of autoimmune conditions, and a urinary dipstick test.

Testing for antiphospholipid antibodies is recommended after severe pre-eclampsia. The search for hereditary thrombophilia by assays for protein C and S, antithrombin III, and a test for resistance to activated protein C is recommended in the case of a personal or family history of venous thromboembolic disease, early pre-eclampsia, or pre-eclampsia with any intrauterine growth retardation, abruptio placentae, or in utero death. Patients who have had severe pre-eclampsia may share predispositions with nonpregnant patients who have cardiovascular risk factors.

Primary prevention of pre-eclampsia is based on the detection of modifiable risk factors. The literature is plentiful regarding the risk factors for pre-eclampsia, but should be interpreted with caution.

Although the search for these risk factors is important, they may not effectively predict this pre-eclampsia by themselves. However, accurate prediction of pre-eclampsia would enable early and optimal management of women at high risk. Several predictive tests are being assessed currently. These include clinical tests, such as blood pressure measurement during the second trimester or hour ambulatory blood pressure monitoring, but these lack sensitivity and specificity. Frequent monitoring of women with elevated levels could be useful, but these tests may not be carried out for screening purposes due to their low negative predictive value.

Imaging tests have been evaluated, including uterine artery Doppler ultra-sound. The combination of a uterine artery Doppler examination during the first trimester and a three-dimensional ultrasound assessing placental volume may predict the risk of pre-eclampsia as early as the first trimester. In clinical practice, because no single marker effectively predicts the risk of pre-eclampsia, the current trend is to test a combination of markers.

The most commonly used combination of markers assesses sFlt-1, placental growth factor, endoglin, and vascular endothelial growth factor during the first or second trimester. Increased vascular endothelial growth factor and endoglin levels, combined with increased sFlt-1 and decreased placental growth factor during the first trimester, is associated with a significantly increased risk of pre-eclampsia.

Improved prediction of pre-eclampsia has been noticed when serum markers are combined with Doppler indices. In a recent nested case-control study, second trimester maternal serum cystatin C, C-reactive protein, and uterine artery mean resistance index were observed to be independent predictors of pre-eclampsia. However, aspirin should be initiated as early as possible, ie, before 12—14 weeks, which corresponds to the beginning of the first phase of trophoblast invasion.

The efficacy of aspirin has been shown only in women with previous pre-eclampsia associated with intrauterine growth retardation and without thrombophilia. Low molecular weight heparin is indicated only in cases of complicated thrombophilia history of thromboembolic complications or of pre-eclampsia.

Pre-eclampsia is a rare pregnancy-related disease with an unpredictable course that can have serious consequences for both the mother and the fetus.

The treatment is simple, ie, delivery. Nonetheless, induced preterm delivery requires careful weighing of both maternal and fetal risk— benefit.

Accordingly, identifying delivery criteria in case of pre- eclampsia is crucial to optimal management. Current research focuses on the prediction of onset of pre-eclampsia or even severe pre-eclampsia so as to allow early management and improve the morbidity and mortality associated with this disease. Specific tools for secondary prevention must also be developed for recurrent pre-eclampsia.

National Center for Biotechnology Information , U. Vasc Health Risk Manag. Published online Jul Author information Copyright and License information Disclaimer. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. This article has been cited by other articles in PMC. Keywords: pre-eclampsia, epidemiology, pathophysiology, therapeutic management.

Introduction The criteria that define pre-eclampsia have not changed over the past decade. Open in a separate window. Surveillance and Diagnosis of Complications Currently, there is no established consensus regarding the optimal monitoring of the foetus in preeclamptic pregnancies. Table 2 Routine recommendations for foetal surveillance in preeclampsia without severe features.

If normal, do not routinely repeat unless indicated. Not recommended At diagnosis and every two weeks. At diagnosis and every two weeks. Not recommended At diagnosis and every two to three weeks.

At diagnosis and every two to three weeks. If CTG is non-reactive. At diagnosis, then at least once weekly. Adjunct if there is evidence of foetal growth restriction. At diagnosis and every three to four weeks. Not recommended Recommended, however timing not specified. Recommended, however timing not specified. Timing not specified. Management Interventions for the management and prevention of foetal complications of preeclampsia are limited.

Long-Term Impact on the Offspring There is growing evidence that there are long-term cardiovascular sequelae in the mother following hypertensive pregnancies [ , , ] and in the offspring Figure 1 from in utero exposure to hypertensive disorders of pregnancy, which are independent from other coexisting pregnancy complications.

Figure 1. Conclusions Hypertensive disorders of pregnancy now affect around one in 10 pregnancies worldwide [ 1 ]. Author Contributions Conceptualization, A. Conflicts of Interest The authors declare no conflict of interest.

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Management of preeclampsia The management of preeclampsia has not changed significantly over time, possibly as a result of the poor progress being made in our understanding of the condition. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. The classification and definition of the hypertensive disorders of pregnancy.

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