CHAPTER 41: Clinical Management of the Preeclampsia Syndrome

Preeclampsia remains one of the leading causes of death and severe maternal morbidity. This chapter discusses many clinical aspects of the preeclampsia syndrome and its management after recognition. Also presented are the long-term consequences that may accrue in affected women. The pathophysiology of preeclampsia was detailed in Chapter 40.

DIAGNOSIS AND EVALUATION

Diagnosis

In routine prenatal care, gravidas are seen more often during the third trimester, and this aids early detection of preeclampsia. However, it cannot always be diagnosed definitively. Increases in systolic and diastolic blood pressure can be either normal physiological changes or signs of developing pathology.

Women without overt hypertension, but in whom the early development of preeclampsia is suspected, are seen more frequently. Heightened surveillance permits recognition of ominous changes in blood pressure, critical laboratory findings, and clinical signs and symptoms. Outpatient surveillance continues unless overt hypertension, proteinuria, headache, visual changes, or epigastric pain supervene. At Parkland Hospital, women with new-onset overt hypertension—either diastolic pressures ≥90 mm Hg or systolic pressures ≥140 mm Hg—are admitted to exclude preeclampsia or to define its severity.

Evaluation

With hospitalization, a systematic evaluation begins:

• Detailed examination, which is coupled with daily scrutiny for headache, visual changes, or epigastric pain

• Daily weight measurement to identify rapid weight gain

• Quantification of proteinuria or a urine protein: creatinine ratio

• Blood pressure readings with an appropriate-size cuff every 4 hours, unless previously elevated, which would mandate more frequent readings

• Measurements of serum creatinine and hepatic transaminase levels and a hemogram that includes a platelet count. The frequency of testing is determined by hypertension severity. Although some recommend assessment of serum uric acid and lactate dehydrogenase levels and coagulation, their value has been questioned (Chescheir, 2019; Conde-Agudelo, 2015)

• Evaluation of fetal size and well-being and amnionic fluid volume

• Reduced physical activity may have benefits, although evidence is not robust.

Still investigational as a clinical tool, measurements of placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sF1t-1) levels will likely be available to help predict preeclampsia (Barton, 2020; Chappell, 2013; Zeisler, 2016). Chapter 40 (p. 694) describes their role in preeclampsia genesis.

In sum, evaluation goals are early identification of preeclampsia and then management until timely delivery. Complete abatement of all signs and symptoms is uncommon until after delivery. If severe preeclampsia is diagnosed using the criteria in Table 40-2 (p. 690), further management is subsequently described.

Consideration for Delivery

With gestational hypertension, its morbidity and management vary depending on hypertension severity, presence of preeclampsia, and gestational age of the fetus. The basic management objectives for any pregnancy complicated by preeclampsia are: (1) termination of pregnancy with the least possible trauma to mother and fetus, (2) birth of a healthy newborn that subsequently ...