Expectant management of severe preeclampsia remote from term

Expectant Versus Interventionist Care in the Management of Severe Preeclampsia Remote from Term: A Systematic Review

OBJECTIVE

 To compare the effects of expectant versus interventionist care in the management of pregnant women with severe preeclampsia remote from term.

DATA SOURCES

 An electronic search was conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS, for its Spanish acronym), World Health Organization's International Clinical Trials Registry Platform (WHO-ICTRP), and OpenGrey databases. The International Federation of Gynecology and Obstetrics (FIGO, for its French acronym), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and Colombian Journal of Obstetrics and Gynecology (CJOG) websites were searched for conference proceedings, without language restrictions, up to March 25, 2020.

SELECTION OF STUDIES

 Randomized clinical trials (RCTs), and non-randomized controlled studies (NRSs) were included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of the evidence.

DATA COLLECTION

 Studies were independently assessed for inclusion criteria, data extraction, and risk of bias. Disagreements were resolved by consensus.

DATA SYNTHESIS

 Four RCTs and six NRS were included. Low-quality evidence from the RCTs showed that expectant care may result in a lower incidence of appearance, pulse, grimace, activity, and respiration (Apgar) scores < 7 at 5 minutes (risk ratio [RR]: 0.48; 95% confidence interval [95%CI]: 0.23%to 0.99) and a higher average birth weight (mean difference [MD]: 254.7 g; 95%CI: 98.5 g to 410.9 g). Very low quality evidence from the NRSs suggested that expectant care might decrease the rates of neonatal death (RR: 0.42; 95%CI 0.22 to 0.80), hyaline membrane disease (RR: 0.59; 95%CI: 0.40 to 0.87), and admission to neonatal care (RR: 0.73; 95%CI: 0.54 to 0.99). No maternal or fetal differences were found for other perinatal outcomes.

CONCLUSION

 Compared with interventionist management, expectant care may improve neonatal outcomes without increasing maternal morbidity and mortality.

Endothelin receptor antagonism during preeclampsia: a matter of timing?

Preeclampsia (PE) is a pregnancy complication, featuring elevated blood pressure and proteinuria, with no appropriate treatment. Activation of the endothelin system has emerged as an important pathway in PE pathophysiology based on experimental PE models where endothelin receptor antagonists (ERAs) prevented or attenuated hypertension and proteinuria. Hence, ERAs have been suggested as potential therapy for PE. However, developmental toxicity studies in animals have shown severe teratogenic effects of ERAs, particularly craniofacial malformations. Nonetheless, sporadic cases of pregnancy in women using ERAs to treat pulmonary hypertension have been described. In this review we give an overview of cases describing ERA use in pregnancy and critically address their possible teratogenic effects. A systematic search in literature yielded 18 articles describing 39 cases with ERA exposure during human pregnancy. In most cases there was only exposure in the first trimester, but exposure later or throughout pregnancy was reported in five cases. Elective termination of pregnancy was performed in 12 pregnancies (31%), two ended in a spontaneous miscarriage (5%) and no fetal congenital abnormalities have been described in the remaining cases. These preliminary findings support the idea that ERA treatment for severe, early onset PE might be an option if applied later in pregnancy, when organogenesis is completed to avoid teratogenic risks. However, third trimester toxicology studies are warranted to evaluate drug safety. Subsequently, it remains to be established whether ERA treatment is effective for alleviating maternal symptoms, as demonstrated in preclinical PE models, allowing pregnancy prolongation without leading to adverse neonatal outcomes.

Reduction in the severity of early onset severe preeclampsia during gestation may be associated with changes in endothelial cell activation: A pathological case report

Early severe preeclampsia with changes consistent with the Hemolysis elevated liver enzymes low platelet count (HELLP) variant and severe fetal growth restriction rarely resolves prior to delivery. Established clinical disease is preceded by endothelial dysfunction and inflammation. Endothelial activation is reported in vitro to be raised in the presence of necrotic trophoblastic debris which is deported into the maternal circulation in preeclampsia. We report on an early severe preeclamptic patient admitted at 24 weeks gestation. Maternal serum was taken at day 2, 16, 30 of admission and 45 days postpartum. 20% maternal serum or trophoblastic debris from first trimester placental explants that had been cultured with 10% maternal serum was exposed to endothelial cells. Endothelial cell activation was quantified by the cell surface ICAM-1 expression and U937 monocyte adhesion assay. The clinical condition of this patient improved including the blood pressure, liver function, and platelet count by the 3rd day after antihypertensive treatment and remained normal until delivery at 37 weeks. ICAM-1 expression and U937 moncyte adhesion assay of endothelial cells was significantly increased following exposure of the endothelial cells to the maternal serum or trophoblastic debris from placentae treated with maternal serum drawn on day 2. However, ICAM-1 expression and the monocyte adhesion assay were significantly reduced following exposure of endothelial cells to maternal serum or trophoblastic debris from placenta treated with maternal serum drawn on day 16 or 30. Our data suggest unknown factor(s) in the maternal serum triggered endothelial cell activation when the clinical symptoms were present. The improvement in the clinical condition occurred along with the changes in endothelial cell activation.

The emerging role of endothelin-1 in the pathogenesis of pre-eclampsia

Pre-eclampsia (PE) is the most frequently encountered medical complication during pregnancy. It is characterized by a rise in systemic vascular resistance with a relatively low cardiac output and hypovolemia, combined with severe proteinuria. Despite the hypovolemia, renin-angiotensin system (RAS) activity is suppressed and aldosterone levels are decreased to the same degree as renin. This suggests that the RAS is not the cause of the hypertension in PE, but rather that its suppression is the consequence of the rise in blood pressure. Abnormal placentation early in pregnancy is widely assumed to be an important initial event in the onset of PE. Eventually, this results in the release of anti-angiogenic factors [in particular, soluble Fms-like tyrosine kinase-1 (sFlt-1)] and cytokines, leading to generalized vascular dysfunction. Elevated sFlt-1 levels bind and inactivate vascular endothelial growth factor (VEGF). Of interest, VEGF inhibition with drugs like sunitinib, applied in cancer patients, results in a PE-like syndrome, characterized by hypertension, proteinuria and renal toxicity. Both in cancer patients treated with sunitinib and in pregnant women with PE, significant rises in endothelin-1 occur. Multiple regression analysis revealed that endothelin-1 is an independent determinant of the hypertension and proteinuria in PE, and additionally a renin suppressor. Moreover, studies in animal models representative of PE, have shown that endothelin receptor blockers prevent the development of this disease. Similarly, endothelin receptor blockers are protective during sunitinib treatment. Taken together, activation of the endothelin system emerges as an important pathway causing the clinical manifestations of PE. This paper critically addresses this concept, taking into consideration both clinical and preclinical data, and simultaneously discusses the therapeutic consequences of this observation.

Hypertension in pregnancy

Hypertensive disorders of pregnancy represent the second commonest cause of direct maternal death and complicate an estimated 5-10 % of pregnancies. Classification systems aim to separate hypertension similar to that seen outside pregnancy (chronic and gestational hypertension) from the potentially fatal pregnancy-specific conditions. Preeclampsia, HELLP syndrome, and eclampsia represent increasing severities of this disease spectrum. The American College of Obstetricians and Gynecologists' 2013 guidelines no longer require proteinuria as a diagnostic criterion, because of its variable appearance in the disease spectrum. The cause involves inadequate cytotrophoblastic invasion of the myometrium, resulting in placental hypoperfusion and diffuse maternal endothelial dysfunction. Changes in angiogenic and antiangiogentic peptide profiles precede the onset of clinical preeclampsia. Women with preeclampsia should be closely monitored and receive magnesium sulfate intravenously if severe features, HELLP syndrome, or eclampsia occur. Definitive therapy is delivery of the fetus. Hypertension in pregnancy increases future maternal risk of hypertension and cardiovascular disorders.

Hypertension in pregnancy

Hypertension in pregnancy is diagnosed on systolic blood pressure greater than or equal to 140 mm Hg and/or diastolic greater than or equal to 90 mm Hg. The classification systems separate chronic and gestational hypertension from preeclampsia. Significant uncertainty regarding optimal management is reflected in the differing major international society recommendations. Blood pressure treatment is designed to minimize maternal end-organ damage. Methyldopa, labetalol, hydralazine, and nifedipine are oral options; angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are contraindicated. Women with preeclampsia should be closely monitored and receive intravenous magnesium sulfate.

Psychoneuroimmunology in pregnancy: immune pathways linking stress with maternal health, adverse birth outcomes, and fetal development

It is well-established that psychological stress promotes immune dysregulation in nonpregnant humans and animals. Stress promotes inflammation, impairs antibody responses to vaccination, slows wound healing, and suppresses cell-mediated immune function. Importantly, the immune system changes substantially to support healthy pregnancy, with attenuation of inflammatory responses and impairment of cell-mediated immunity. This adaptation is postulated to protect the fetus from rejection by the maternal immune system. Thus, stress-induced immune dysregulation during pregnancy has unique implications for both maternal and fetal health, particularly preterm birth. However, very limited research has examined stress-immune relationships in pregnancy. The application of psychoneuroimmunology research models to the perinatal period holds great promise for elucidating biological pathways by which stress may affect adverse pregnancy outcomes, maternal health, and fetal development.

Development and Use of Quality of Care Indicators for Obstetric Care in Women with Preeclampsia, Severe Preeclampsia, and Severe Morbidity

OBJECTIVE

To develop indicators for evaluating the quality of care in managing preeclampsia.

METHODS

An expert group helped to develop and validate the following indicators for evaluating quality of care: availability of intensive care; completeness of laboratory tests; appropriateness of drug treatment at admission and before delivery (antihypertensive drugs, anticonvulsants, and dexamethasone); gestational age at which pregnancy should be interrupted; and type of delivery. By using these indicators, it was possible to evaluate the quality of care in 432 patients with preeclampsia.

RESULTS

A significant percentage of patients with preeclampsia and "near misses" received low quality of care, regardless of disease severity.

CONCLUSION

A number of interventions are needed to increase the quality of care to help avert maternal deaths in patients with preeclampsia.

Severe, early-onset hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome episode with spontaneous remission during pregnancy

A case of a severe HELLP syndrome episode at 21 + 0 weeks of gestation is reported. Expectant management resulted in rapid improvement of all HELLP parameters. Subsequently preeclampsia developed and uteroplacental dysfunction deteriorated. Intrauterine fetal death occured at 22 + 3 weeks of gestation.

Pre-eclampsia

Pre-eclampsia is a major cause of maternal mortality (15-20% in developed countries) and morbidities (acute and long-term), perinatal deaths, preterm birth, and intrauterine growth restriction. Key findings support a causal or pathogenetic model of superficial placentation driven by immune maladaptation, with subsequently reduced concentrations of angiogenic growth factors and increased placental debris in the maternal circulation resulting in a (mainly hypertensive) maternal inflammatory response. The final phenotype, maternal pre-eclamptic syndrome, is further modulated by pre-existing maternal cardiovascular or metabolic fitness. Currently, women at risk are identified on the basis of epidemiological and clinical risk factors, but the diagnostic criteria of pre-eclampsia remain unclear, with no known biomarkers. Treatment is still prenatal care, timely diagnosis, proper management, and timely delivery. Many interventions to lengthen pregnancy (eg, treatment for mild hypertension, plasma-volume expansion, and corticosteroid use) have a poor evidence base. We review findings on the diagnosis, risk factors, and pathogenesis of pre-eclampsia and the present status of its prediction, prevention, and management.

Symptomatic hypocalcemia after tocolytic therapy with magnesium sulfate and nifedipine

OBJECTIVES

In this study, we presented 2 cases and evaluated the evidence for symptomatic hypocalcemia after treatment with magnesium sulfate alone or combined with use of nifedipine.

STUDY DESIGN

Case reports, such as the one that follows, and literature review were used. A 25-year-old gravida presented at 33 weeks' gestation with advanced preterm labor. She received magnesium sulfate followed by nifedipine and experienced bilateral hand contractures 12 hours after discontinuation of magnesium sulfate. Total serum calcium was 5.4 mg/dL. A 35-year-old gravida presented at 26 weeks' gestation with ruptured membranes and received magnesium sulfate until it was discontinued prematurely because of pulmonary edema. Twenty hours later she experienced bilateral hand contractures; total serum calcium was 5.9 m/dL. Symptoms for both patients resolved with calcium gluconate therapy.

RESULTS

Hypocalcemia is a well-recognized complication of magnesium sulfate infusion. These are the fifth and sixth symptomatic case reports, as identified by Medline Search. Our first case is the only report in which the subsequent use of nifedipine may have been a factor. Little has been reported on the possible toxicity associated with the combined or sequential use of magnesium sulfate and nifedipine.

CONCLUSION

Marked hypocalcemia is clearly associated with magnesium sulfate infusion, is likely dose related, and may appear after discontinuation of magnesium sulfate therapy. Moreover, while the evidence for synergistic toxicity of magnesium sulfate and nifedipine is sparse, caution is advised when these agents are used together.

Post Magpie: how should we be managing severe preeclampsia?

PURPOSE OF REVIEW

Preeclampsia is a common complication of pregnancy and a significant cause of fetal and maternal morbidity and mortality. The purpose of this review is to highlight and discuss aspects of some of the more recent clinical management papers published in the field of preeclampsia and eclampsia. The title explains the clinical nature of this paper and a detailed review of the basic science literature is beyond the scope of this article.

RECENT FINDINGS

Several controversial areas still exist in the current management of severe preeclampsia/eclampsia. We present a number of interesting papers dealing with practical management questions and discuss the optimum treatment regimen for preventing eclampsia. The findings of the MAGPIE study are discussed. Opinions are expressed as to the current management of preterm severe preeclampsia, and we outline a new hypothesis on the etiology of eclampsia.

SUMMARY

Preeclampsia/eclampsia remains a disease without a clear etiology. Despite this, clinical management issues are being addressed and maternal morbidity and mortality continue to fall.

Critical pathways for the management of preeclampsia and severe preeclampsia in institutionalised health care settings

BACKGROUND: Preeclampsia is a complex disease in which several providers should interact continuously and in a coordinated manner to provide proper health care. However, standardizing criteria to treat patients with preeclampsia is problematical and severe flaws have been observed in the management of the disease. This paper describes a set of critical pathways (CPs) designed to provide uniform criteria for clinical decision-making at different levels of care of pregnant patients with preeclampsia or severe preeclampsia. METHODS: Clinicians and researchers from different countries participated in the construction of the CPs. The CPs were developed using the following steps: a) Definition of the conceptual framework; b) Identification of potential users: primary care physicians and maternal and child health nurses in ambulatory settings; ob/gyn and intensive care physicians in secondary and tertiary care levels. c) Structural development. RESULTS: The CPs address the following care processes: 1. Screening for preeclampsia, risk assessment and classification according to the level of risk. 2. Management of preeclampsia at primary care clinics. 3. Evaluation and management of preeclampsia at secondary and tertiary care hospitals: 4. Criteria for clinical decision-making between conservative management and expedited delivery of patients with severe preeclampsia. CONCLUSION: Since preeclampsia continues to be one of the primary causes of maternal deaths and morbidity worldwide, the expected impact of these CPs is the contribution to improving health care quality in both developed and developing countries. The CPs are designed to be applied in a complex health care system, where different physicians and health providers at different levels of care should interact continuously and in a coordinated manner to provide care to all preeclamptic women. Although the CPs were developed using evidence-based criteria, they could require careful evaluation and remodelling according to each system's demands. Additionally, the CPs need to be tested in large-scale, multi-level studies in order to thoroughly examine and evaluate their efficacy and effectiveness.

The evaluation of maternal parameters at diagnosis may predict HELLP syndrome severity

OBJECTIVE

Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, a severe manifestation of pre-eclampsia and/or intrauterine growth restriction (IUGR) of the fetoplacental unit, is classified into three classes, according to the lowest platelet count observed during the course of the disease. The aim of our work was to analyze the levels of lactate dehydrogenase (LDH), aspartate transferase (AST), alanine transferase (ALT) and platelets at the time of HELLP syndrome diagnosis, to find possible cut-off values that could predict the severity of the syndrome from its early onset.

METHODS

A retrospective analysis of the clinical records of 26 patients consecutively diagnosed with classes 1 and 2 HELLP syndrome was performed. Platelet count (x 1000/ml), LDH (IU/l), AST (IU/l), ALT (IU/l), hemoglobin (g/dl), hematocrit (%) and D-dimer (log of titer) were determined at admission and compared with the most severe peak values. Receiver operating characteristic (ROC) curves were used to calculate the best cut-off value at admission which correlated with the development of class 1 HELLP syndrome (the most severe condition). The post-test probability of developing class 1 severity was calculated.

RESULTS

Mean gestational age at diagnosis was 33.4 weeks (range 23-40 weeks). Peak values of LDH, AST and ALT were significantly higher in class 1 HELLP syndrome patients. The platelet count at admission was not informative in differentiating patients who would later develop class 1 or class 2 HELLP syndrome. According to the best cut-off values at admission for LDH, AST and ALT, the post-test probability to predict patients with class 1 HELLP syndrome was 74%, 71% and 78%, respectively. If all the three parameters were above the cut-off value, the probability increased to 90%.

CONCLUSIONS

The LDH, AST and ALT values at admission blood test, and to a greater extent the combination of all three abnormal tests, could predict the severity of HELLP syndrome.

Critical care obstetrics and gynecology

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.

[Criteria of pregnancy termination in women with preeclampsia]

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

Severe pre-eclampsia remote from term: what to expect of expectant management

OBJECTIVE

To describe the duration of expectant management and the indications for termination of expectant management of pregnancies complicated by severe pre-eclampsia remote from term.

STUDY DESIGN

We identified pregnancies complicated by severe pre-eclampsia diagnosed between 24 weeks and 31 weeks 6 days at our institution in 1991-98. Pertinent clinical data were obtained from review of maternal and neonatal charts. Comparison of patients was based on the duration of time from admission to delivery: < 48 h (group 1), 48 h to 7 days (group 2), and > or = 7 days (group 3).

RESULTS

A total of 142 women met all study criteria. Seventy-nine (55.6%) women were delivered within 48 h, 42 (29.6%) between 48 h and 7 days, and 21 (14.8%) at > or = 7 days from diagnosis. Of group 1 patients (< 48 h), 59 (74.7%) were delivered for maternal indications while 20 (25.3%) were delivered for fetal indications. Of group 2 patients (48 h to 7 days), 35 (83.3%) were delivered for maternal indications while seven (16.7%) were delivered for fetal indications. Of group 3 patients (> or = 7 days), 16 (76.2%) were delivered for maternal indications while five (23.8%) were delivered for fetal indications. There were no significant differences in the indications for delivery based on the duration from admission to delivery.

CONCLUSIONS

Despite an aggressive approach towards expectant management of preterm pregnancies complicated by severe pre-eclampsia, most patients were delivered within 48 h for maternal indications.

Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia

OBJECTIVE

The current literature emphasizes increased risk of adverse outcomes in the presence of proteinuria and hypertension. The objective of this study was to compare the frequency of adverse fetal outcomes in women who developed hypertensive disorders with or without proteinuria.

STUDY DESIGN

The study design was a secondary analysis of data from women who had preeclampsia in a previous pregnancy (n = 598) who were enrolled in a multicenter trial of aspirin for the prevention of preeclampsia. The women had no history of chronic hypertension or renal disease and were normotensive at study inclusion. The maternal and perinatal outcome variables assessed were preterm delivery at <37 and <35 weeks of gestation, rate of small-for-gestational-age infants, and abruptio placenta. Data were analyzed by using the chi-square test, and women who remained normotensive or who had mild gestational hypertension were considered as a single group because they had similar outcomes.

RESULTS

As compared to mild preeclampsia, women who developed severe gestational hypertension (without proteinuria) had higher rates of both preterm delivery at <37 weeks of gestation and small-for-gestational-age infants. In addition, when compared to women with mild preeclampsia, for women with severe gestational hypertension, gestational age and birth weight were significantly lower at delivery (P <.003 for both age and birth weight). Moreover, women who developed severe gestational hypertension had higher rates of preterm delivery at <37 weeks of gestation (54.2% vs 17.8%, P =.001) and at <35 weeks of gestation (25.0% vs 8.4%, P =.0161), and delivery of small-for-gestational-age infants (20.8% vs 6.5%, P =.024) when compared to women who remained normotensive or those who developed mild gestational hypertension. There were no statistically significant differences in perinatal outcomes between the normotensive/mild gestational hypertension and the mild preeclampsia groups. Overall, women who had severe gestational hypertension had increased rates of preterm delivery and delivery of small-for-gestational-age infants than women with mild gestational hypertension or mild preeclampsia. In the presence of severe hypertension, proteinuria did not increase the rates of preterm delivery or delivery of small-for-gestational-age infants.

CONCLUSIONS

In women who have gestational hypertension or preeclampsia, increased rates of preterm delivery and delivery of small-for-gestational-age infants are present only in those with severe hypertension. In these women, the presence of proteinuria does not influence perinatal outcome.

Vasoactive effects of 8-epi-prostaglandin F(2alpha)in isolated human placental conduit and resistance blood vessels in vitro

The effects of 8-epi-prostaglandin F(2alpha)(8-epi-PGF(2alpha)) and the thromboxane A(2)-mimetic U46619 were examined on isolated human fetal placental arteries obtained from normal pregnancies and from those complicated by pre-eclampsia. The effects of these agents were examined on both conduit and resistance arteries. 8-epi-PGF(2alpha)was found to be markedly less potent than U46619 in constricting both size vessels. Vasoconstrictor EC(50)s for 8-epi PGF(2alpha)were 4.10x10(-7) m (2.02-8.35x10(-7) m) (mean, 95 per cent CI and 2.05x10(-6) m (0.43-9.89 x10(-6) m) in conduit and resistance arteries, respectively. The maximum vasoconstriction produced by 8-epi-PGF(2alpha)(112+/-17 per cent), (relative to maximum KCl induced vasoconstriction) in conduit vessels was significantly less than that caused by U46619 (152+/-20 per cent). In resistance vessels the maximum vasoconstrictor effects to 8-epi-PGF(2alpha)(208+/-10 per cent) and U46619 (201+/-19 per cent) were similar, and in both cases significantly greater than the maximal effects seen in conduit vessels. U46619 displayed a similar vasoconstrictor potency in both conduit (EC(50)=1.21x10(-9) m, 0.58-2.51x10(-9) m) and resistance arteries [EC(50)=5.95x10(-9) m, (0.81-43.60x10(-9) m] as was found for 8-epi PGF(2alpha). 8-epi-PGF(2alpha)was equipotent in resistance arteries obtained from women with severely pre-eclamptic pregnancies (EC(50)=1.25x10(-6) m, 0.25-6.17x10(-6) m) compared with normotensive controls. However, the maximum vasoconstrictor effect induced by 8-epi-PGF(2alpha)in placental resistance arteries was significantly reduced (99+/-20 per cent) in vessels obtained from severely pre-eclamptic compared with normal pregnancies. These results indicate that 8-epi-PGF(2alpha)displays differential vasoconstrictor activity in the fetal-placental vasculature. Furthermore the vasoconstrictor effects of 8-epi-PGF(2alpha)are reduced in pre-eclampsia, the effect being selective to placental resistance vessels. This reduction may occur as a result of more serious disturbances in the placental microcirculation with the disease process in pre-eclampsia.

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.

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome versus severe preeclampsia: onset at < or =28.0 weeks' gestation

OBJECTIVE

Our purpose was to determine whether the onset of the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome in women at < or =28.0 weeks' gestation is associated with an increased risk of adverse maternal and perinatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age.

STUDY DESIGN

Sixty-four patients with either the HELLP syndrome (n = 32) or severe preeclampsia but absent HELLP syndrome laboratory test results (n = 32), admitted at < or =28.0 weeks' gestation between July 1, 1992, and April 30, 1999, were studied. Maternal and perinatal outcomes were compared between the 2 groups. Statistical analysis was performed by the Student t test and the Fisher exact test.

RESULTS

There were no significant differences between the 2 groups regarding African-American race (59% vs 75%), nulliparity (50% vs 56%), or the use of corticosteroids (59% vs 78%). There were no maternal deaths. One woman with the HELLP syndrome had a liver hematoma. The rate at which transfusion of blood products was required was significantly greater in women with the HELLP syndrome than in those with severe preeclampsia only (25% vs 3%; P <.05). There were no significant differences between the 2 groups with respect to eclampsia (16% vs 13%), abruptio placentae (6% vs 9%), disseminated intravascular coagulopathy (13% vs 0%), pulmonary edema (13% vs 6%), acute renal failure (3% vs 0%), pleural effusion (3% vs 3%), or ascites (6% vs 16%). No significant differences were found between the 2 groups with respect to neonatal death (11% vs 17%), respiratory distress syndrome (78% vs 86%), or composite neonatal morbidity.

CONCLUSIONS

Except for the need for transfusion of blood products in women with the HELLP syndrome, onset at < or =28.0 weeks' gestation is not associated with an increased risk of adverse maternal or neonatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age.