The importance of urinary protein excretion during conservative management of severe preeclampsia

Hypertension in pregnancy

The hypertensive diseases of pregnancy commonly refer to a group of disorders whose definitions have changed over time within and among professional organizations. Pre-eclampsia, either mild or severe, is managed best with a policy of delivery at or beyond 37 and 34 weeks' gestation, respectively. Similarly, chronic hypertension,gestational hypertension, and chronic hypertension with superimposed pre-eclampsia are conditions wherein it is difficult to justify expectant management beyond 37 weeks' gestation. The approach to management before these gestational ages is subject to interpretation of a limited body of literature.

Facteurs de risque d’éclampsie : étude cas-témoins

OBJECTIVE

Our purpose was to characterize the risk factors of eclampsia in women with preeclampsia.

PATIENTS AND METHODS

A case-control study was conducted at Monastir hospital to investigate risk factors for eclampsia between 1st January 1995 and 30th June 2000. Cases were matched to preeclamptic controls on a 2:1 ratio. Univariate analysis was used to determine which of the independent variables were significantly different between the groups. Those with significant differences were then entered into multiple logistic regression analysis to determine the characteristics that were independently related to eclampsia.

RESULT

A total of 41 cases of eclampsia were ascertained from deliveries. The ratio of eclampsia cases to number of deliveries over the study period was 1.87 per 1000. The first seizures occurred at home in 59% of the cases. Univariate analysis revealed statistical significance for the following variables associated with eclampsia: systolic hypertension > or =160 mmHg and diastolic > or =110 mmHg, headache, visual symptoms, vivid deep tendon reflexes, proteinuria >3+ or >3 g d(-1), uric acid concentration > or =350 micromol l(-1), serum creatinine concentration >100 micromol l(-1) and aminotransferase aspartate >30 IU l(-1). A history of abortion appears to be the protective factor against eclampsia. However, with subsequent multivariate analysis, only vivid deep tendon reflexes and elevated uric acid concentration remained significant.

CONCLUSION

These data indicate a need for improved prenatal care and medical attention focused on prodroms of eclampsia as well as the detection of preeclampsia to reduce the incidence of eclampsia.

Perinatal outcomes in preeclampsia that is complicated by massive proteinuria

OBJECTIVE

Current treatment of preeclampsia no longer mandates delivery for proteinuria of >5 g per 24 hours. We sought to determine whether delayed delivery of preeclampsia with massive proteinuria (>10 g/24 h) increased maternal or neonatal morbidity.

STUDY DESIGN

Records of all women with preeclampsia who were delivered at <37 weeks of gestation between January 1, 1997, and June 30, 2001, were reviewed. Patients with underlying renal disease or multiple gestation were excluded. Patients were characterized as having mild (<5 g/24 h), severe (5-9.9 g/24 h), or massive (>10 g/24 h) proteinuria. Outcomes were compared using the chi(2) test, one-way analysis of variance, or Fisher exact test.

RESULTS

Two hundred nine patients met the inclusion criteria: 125 patients had mild proteinuria, 43 patients had severe proteinuria, and 41 patients had massive proteinuria. No significant differences in maternal morbidity were seen. Massive proteinuria was associated with earlier onset of preeclampsia, earlier gestational age at delivery, and higher rates of prematurity complications. After correction for prematurity, massive proteinuria has no significant effect on neonatal outcomes.

CONCLUSION

Women with preeclampsia and massive proteinuria did not have increased maternal morbidity compared with women with severe or mild proteinuria. Massive proteinuria appears to be a marker for early-onset disease and progression to severe preeclampsia. Neonatal morbidity appears to be a function of prematurity rather than of massive proteinuria itself.

Urinary protein excretion and expectant management of early onset, severe pre-eclampsia

OBJECTIVE

To evaluate the importance of proteinuria in the expectant management of early onset, severe pre-eclampsia.

METHODS

In this prospective series of 340 women, 24-h urine collections were performed and monitored twice weekly in a high-care ward.

RESULTS

Seventy-four women with at least two 24-h urine collections were grouped into women with a proteinuria increase of > or =2 g (n=29) and with women whose proteinuria decreased, or increased by <2 g (n=45). Major maternal complications, prolongation of gestation, and perinatal outcomes were comparable. Fifty-six (75%) women experienced an increase in proteinuria. When patients with heavy proteinuria (n=83) were compared to those with moderate proteinuria (n=257), maternal and perinatal outcomes were comparable. More days were gained before delivery in the heavy proteinuria group than in the moderate (12 vs. 9; P<0.001).

CONCLUSION

Most patients experienced increased proteinuria. Neither the rate of increase nor the amount of proteinuria affected maternal and perinatal outcomes.

Management and monitoring of severe preeclampsia

Preeclampsia is associated with increased maternal and perinatal morbidity and mortality. Preeclampsia is more than pregnancy-induced hypertension. The hypertension is only one manifestation of an underlying multifactorial, multisystem disorder, initiated early in pregnancy. In established severe disease there is volume contraction, reduced cardiac output, enhanced vascular reactivity, increased vascular permeability and platelet consumption. Medical treatment of severe hypertension in pregnancy is required. The more controversial issues are the role of pharmacological treatment in conservative management of severe preeclampsia aiming at prolongation of pregnancy, the ability of such therapy to modify the course of the underlying systemic disorder and the effects on fetal and maternal outcome. This paper presents an overview concerning the current developments in management and monitoring of severe preeclampsia. Controversial topics such as the role of plasma volume expansion in preeclampsia, expectant versus aggressive management of severe preeclampsia remote from term, and pharmacological interventions in the management of eclampsia and the HELLP syndrome are addressed.

Pre-eclampsia

Pre-eclampsia is associated with significant morbidity and mortality for mother and baby, but it resolves completely post partum. Despite a steady reduction in maternal mortality from the disorder in more developed countries, it remains one of the most common reasons for a woman to die during pregnancy. The disorder starts with a placental trigger followed by a maternal systemic response. Because both this systemic response and the woman's reaction to it are inconsistent, the clinical presentation varies in time and substance, with many different organ systems affected. With the increasing understanding of the disease process, there have been advances in management, such as antihypertensive therapy, magnesium sulphate, and fluid restriction.

Hypertension in pregnancy: new recommendations for management

Hypertension in pregnancy is a frequent complication that has substantial adverse perinatal outcomes. Hypertension may be preexisting (chronic) essential or secondary hypertension; a second entity is pregnancy induced (gestational hypertension, preeclampsia). Recent advances have identified newer markers for pregnancy hypertension: several potential candidate genes may explain the apparent family inheritance of preeclampsia, and some thrombophilic markers have been associated with the condition. Management options for mild to moderate hypertension include a short hospital stay to exclude ongoing severe hypertension and to ascertain fetal well-being. Outpatient care with appropriate maternal and fetal surveillance, including umbilical artery doppler velocimetry, is recommended for better perinatal outcomes. Acute care for severe hypertension includes the use of magnesium sulfate to prevent eclampsia and antihypertensive medication. Expeditious delivery is recommended when the maternal or fetal states cannot be stabilized. Follow-up after delivery allows the uncovering of any other coexisting hypertensive or cardiovascular disorder.

Treatment of severe preeclampsia remote from term: a clinical dilemma

Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. Women with severe preeclampsia are usually delivered without delay. In recent years, a new approach in the treatment of women with severe preeclampsia remote from term has been advocated by several investigators worldwide. This approach advocates conservative management in a selected group of women with severe preeclampsia remote from term with the aim of improving perinatal outcome without compromising maternal safety. In most studies, patients who were candidates for conservative management had a blood pressure of more than 160/110, whereas in some studies, women with heavy proteinuria were also considered suitable. Only very few studies have supported conservative management in patients with signs and symptoms of HELLP syndrome. It is imperative to carefully balance maternal and fetal risks before choosing conservative management in severe preeclampsia remote from term.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to understand which patients are most likely to benefit from conservative management of severe preeclampsia remote from term, what the conservative management of severe preeclampsia remote from term entails, and what are the benefits of conservative management of preeclampsia remote form term.

Expectant management of severe preeclampsia remote from term

Traditionally, preeclamptic women who meet accepted criteria for severe disease are delivered expeditiously, regardless of gestational age. Although delivery is always appropriate therapy for the mother, it may not be optimal for the fetus remote from term. Several recent randomized clinical trials support expectant management of severe preeclampsia remote from term in well-selected patients. We have described our rationale and guidelines for management, which we believe should be performed only at tertiary perinatal centers.

Management of hypertension in pregnancy

Hypertension in pregnancy is generally defined as either an absolute BP > 140/90 mm Hg or a rise in systolic BP > or = 25 mm Hg and/or diastolic BP > or = 15 mm Hg from pre-conception or 1st trimester BP. Hypertension in pregnancy is classified as: a) Chronic--essential or secondary hypertension, b) De novo--pre-eclampsia or gestational hypertension, and c) Pre-eclampsia superimposed on chronic hypertension. Pre-eclampsia is a multisystem disorder in which hypertension is but one sign. The major maternal abnormalities occur in kidneys, liver, brain and coagulation systems. Impaired uteroplacental blood flow causes fetal growth retardation or intrauterine death. There is general agreement that BP > or = 170/110 mm Hg should be lowered rapidly to protect the mother against risk of stroke or eclampsia. There is dispute concerning the level at which lesser degrees of hypertension should be treated, and lowering BP is treating only one aspect of pre-eclampsia. Delivery remains the definitive management.

Risk factors for abruptio placentae and eclampsia: analysis of 445 consecutively managed women with severe preeclampsia and eclampsia

OBJECTIVE

Our purpose was to characterize the clinical presentation or laboratory variables predictive of either abruptio placentae or eclampsia in women with severe preeclampsia.

STUDY DESIGN

Prospective collection of perinatal data from 445 consecutively managed women with severe preeclampsia and eclampsia. Univariate analysis was used to determine which of the independent variables were significantly different between the groups (abruptio placentae vs no abruptio placentae; eclampsia vs no eclampsia). Those with significant differences were then entered into multiple logistic regression analysis to determine those characteristics that were independently related to the outcome variable (abruptio placentae or eclampsia). Before multivariate analysis, the independent variables with an interval scale of measurement were converted to a dichotomous scale, with the receiver-operator characteristic curve used to determine a cutoff level.

RESULTS

Univariate analysis revealed statistical significance for the following variables associated with eclampsia: uric acid concentration, > 8.1 mg/dL; proteinuria (>3+); headache; visual symptoms; deep tendon reflexes >3+; serum albumin concentration, <3 mg/dL; and serum creatinine concentration, >1.3 mg/dL. However, with subsequent multivariate analysis, only headache and deep tendon reflexes >3+ remained significant. Univariate analysis for variables associated with abruptio placentae revealed an association between bleeding and platelet count <60,000/mm3. There was no association between abruptio placentae and eclampsia and systolic, diastolic, or mean arterial pressure, quantitative proteinuria, epigastric pain, bleeding, gestational age at delivery, history of preeclampsia, or chronic hypertension.

CONCLUSION

Quantitative proteinuria and degree of blood pressure elevation were not predictive of either abruptio placentae or eclampsia, as has previously been suggested. The greatest morbidity associated with eclampsia occurred in women with preterm gestations not receiving medical attention.

Management of complicated preeclampsia

The complicated preeclamptic patient represents a challenge for the clinician faced with her antepartum or postpartum care. The most serious sequelae of preeclampsia account for a significant portion of maternal morbidity and mortality. Severe preeclampsia also results in an appreciable portion of perinatal morbidity and mortality. In this review, developing trends in the treatment of severe preeclampsia are discussed. Expectant treatment of the patient remote from term, anesthesia choices, and delivery route are reviewed. Developing trends in the pharmacological approach to complicated preeclampsia are discussed. New concepts in the treatment of cerebrovascular preeclampsia and hepatic rupture are outlined and reviewed.