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Preeclampsia (PE): criteria of severity
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Preeclampsia (PE): criteria of severity
Pre-eclampsia is a dynamic process. The experience of recent years has shown that diagnosing a woman's condition as " mild preeclampsia" does not help, because it is a progressive disease that progresses with different speeds in different women. From low to moderate high blood pressure (140-159 mm Hg systolic or 90-109 mm Hg diastolic measured in two cases at least four hours apart) requires careful evaluation and monitoring. Thus, sBP 140 mm Hg, dBP 90 mm Hg is borderline with the norm indicating the need for careful monitoring of the pregnant woman. High blood pressure (sBP greater than or equal to 160 mm Hg. or dBP greater than or equal to 110 mm Hg. ) is a sign of severe preeclampsia.
The earlier the gestation at presentation and the more severe the hypertension, the higher is the likelihood that the woman with gestational hypertension will progress to develop preeclampsia or an adverse pregnancy outcome. (Table 9)
Table 10.
Preeclampsia: criteria of severity
| Diagnosis | dBP (mmHg) | Proteinuria (g/d) | Other signs |
| Gestational hypertension or Mild PE | 90-99 | < 0. 3 | - |
| Moderate PE | 91 -109 | 0. 3 – 5. 0 | Local edema, sometimes headache |
| Severe PE | ≥ 110 | > 5. 0 | Generalized edema, headache, visual impairment, epigastric pain, oliguria (< 500 mL/d), thrombopenia |
| Eclampsia | ≥ 90 | ≤ 0. 3 | Convulsions |
Early onset (before 32 weeks of pregnancy) of preeclampsia is used as independent criteria to classify preeclampsia as severe in some parts of the world.
Management
For pregnant women with existing risk factors for HP, preventive measures should be administered to reduce the risk during pregnancy. Main principles of risk reduction are: assessment of pregnant women for risk factors and accomplish accurate follow up, observation, additional examination for early diagnosis of HP. Conducting of preventive measures in a timely manner. Prophylactic measures are as follows:
• Acetylsalicylic acid 60-100 mg/day starting from the 16th -20th wk gestation
• Calcium supplements (1. 5g -2g/ day) from the 16th week of gestational amenorrhea for women with low dietary intake of calcium (< 600 mg/d) or high risk of PE
On the other hand, it is necessary to clearly understand: No treatment to date can reliably prevent preeclampsia in all women!
The key points of management of patients from a group of risk for HP are: close observation for early evaluation of initial stage of PE and termination of pregnancy (delivery). In women with gestational hypertension full assessment should be carried out in a secondary care setting by a healthcare professional who is trained in the management of hypertensive disorders. If the diagnosis of HP or PE is made, the definitive treatment is delivery to prevent development of maternal or fetal complications from disease progression. Only delivery leads to the resolution of the disease. Delivery is the only cure for preeclampsia.
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Timing of delivery is based upon a combination of factors, including disease severity, maternal and fetal condition, and gestational age.
The optimal management of a woman with preeclampsia depends on gestational age and disease severity.
Management of gestational hypertension or mild preeclampsia
Gestational hypertension mild to moderate may be managed expectantly in out-patient department. Out-patient care includes bed rest, lying on the left side whenever possible, and BP measurements as minimum, three times a day), laboratory monitoring, and physician visits 2 to 3 times/wk. Some patients also need drug treatment for a few hours to stabilize them and to lower systolic BP to 140 to 155 mm Hg and diastolic BP to 90 to 105 mm Hg. Hypertension can be treated with oral drugs as needed. As long as no criteria for preeclampsia are met, delivery can occur (eg, by induction) at 37 wk.
A pregnancy complicated by mild preeclampsia at or beyond 37 weeks should be delivered. Regardless of cervical status, induction of labor should be recommended. When possible, vaginal delivery is preferable to avoid the added physiologic stressors of cesarean delivery. If cesarean delivery must be used, regional anesthesia is preferred because it carries less maternal risk. In the presence of coagulopathy, use of regional anesthesia generally is contraindicated. Cesarean section may be performed based on standard obstetric criteria.
If a patient is at 34 weeks' gestation or more and has ruptured membranes, abnormal fetal testing, progressive labor, or fetal growth restriction in the setting of mild preeclampsia, delivery is recommended.
If a patient presents with mild preeclampsia before 34 weeks' gestation but appears to be stable, and if the fetal condition is reassuring, expectant management may be considered. In this situation, blood pressure should be monitored twice daily and fetal status should be assessed at least twice weekly with a non-stress test and a biophysical profile. Corticosteroids should be administered for ripening of a lung surfactant system: Betamethasone (12 mg IM q24h × 2 doses) or dexamethasone (6 mg IM q12h × 4 doses) is recommended. Delivery at maturity is still mandatory in this group of patients, unless induction has been unsuccessful. In the latter case, cesarean section or a second trial of induction must be considered. Because now-a-days a mild preeclampsia considered as a borderline condition, oral antihypertensive drug therapy is not indicated for this group of paient.
Management of moderate preeclampsia.
Inpatient care should be provided for women with moderate hypertension and preeclampsia. Indications for admission to the hospital are:
• there is concern for fetal wellbeing and/or
• sBP is greater than 140 mmHg or
• dBP greater than 90 mmHg or
• signs or symptoms of preeclampsia are present.
In the emergency setting, control of BP and seizures should be priorities. Definitive therapy is delivery of the fetus, although preeclampsia may paradoxically emerge in postpartum patients. In general, the further the pregnancy is from term, the greater the impetus to manage the patient medically. Antihypertensive therapy halves the risk of developing severe hypertension but has no clear effect on other outcomes (e. g. fetal distress, growth restriction, multiple-organ insufficiency, perinatal mortality). Concerns exist about the potential for decreased placental perfusion from aggressive BP lowering that might jeopardize fetal well-being.
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Indications for drug therapy:
• sBP is 140–160 mmHg and/or
• dBP is 90–100 mmHg and/or
• there are associated signs and symptoms (maternal organ dysfunction, utero-placental dysfunction).
The aim of BP control is to lower BP to prevent cerebrovascular and cardiac complications while maintaining uteroplacental blood flow, and prepare for more successful delivery. The goal of antihypertensive therapy is to maintain diastolic blood pressure between 90 and 100 mm Hg and systolic pressure between 140 and 155 mm Hg. Antenatal fetal monitoring while making BP control is obligatory.
First-line medications are labetalol, given by mouth or IV; nifedipine, given by mouth or IV; or hydralazine IV. Angiotensin Converting Enzyme (ACE) inhibitors and angiotensin receptor blockers are contraindicated in pregnancy due to teratogenic effect. (Table 10)
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