High risk pregnancy series:and expert’s view
Diagnosis and Management of Gestational Hypertension and Preeclampsia

https://doi.org/10.1016/S0029-7844(03)00475-7Get rights and content

Abstract

Gestational hypertension and preeclampsia are common disorders during pregnancy, with the majority of cases developing at or near term. The development of mild hypertension or preeclampsia at or near term is associated with minimal maternal and neonatal morbidities. In contrast, the onset of severe gestational hypertension and/or severe preeclampsia before 35 weeks’ gestation is associated with significant maternal and perinatal complications. Women with diagnosed gestational hypertension–preeclampsia require close evaluation of maternal and fetal conditions for the duration of pregnancy, and those with severe disease should be managed in-hospital. The decision between delivery and expectant management depends on fetal gestational age, fetal status, and severity of maternal condition at time of evaluation. Expectant management is possible in a select group of women with severe preeclampsia before 32 weeks’ gestation. Steroids are effective in reducing neonatal mortality and morbidity when administered to those with severe disease between 24 and 34 weeks’ gestation. Magnesium sulfate should be used during labor and for at least 24 hours postpartum to prevent seizures in all women with severe disease. There is an urgent need to conduct randomized trials to determine the efficacy and safety of antihypertensive drugs in women with mild hypertension–preeclampsia. There is also a need to conduct a randomized trial to determine the benefits and risks of magnesium sulfate during labor and postpartum in women with mild preeclampsia.

Section snippets

Gestational hypertension

Defined as a systolic BP of at least 140 mm Hg and/or a diastolic BP of at least 90 mm Hg on at least two occasions at least 6 hours apart after the 20th week of gestation in women known to be normotensive before pregnancy and before 20 weeks’ gestation. The BP recordings used to establish the diagnosis should be no more than 7 days apart.1 Gestational hypertension is considered severe if there is sustained elevations in systolic BP to at least 160 mm Hg and/or in diastolic BP to at least 110

Etiology and pathophysiology

The etiology of preeclampsia is unknown. During the past centuries several etiologies have been suggested, but most of them have not withstood the test of time. Some of the remaining potential etiologies include abnormal trophoblast invasion of uterine blood vessels, immunological intolerance between fetoplacental and maternal tissues, maladaptation to the cardiovascular changes or inflammatory changes of pregnancy, dietary deficiencies, and genetic abnormalities.

The pathophysiologic

Prediction and prevention

Prevention of any disease process requires knowledge of its etiology and pathogenesis, as well as the availability of methods to predict or identify those at high risk for this disorder. Numerous clinical, biophysical, and biochemical tests have been proposed for the prediction or early detection of preeclampsia. Unfortunately, most of these tests suffer from poor sensitivity and poor positive predictive values, and the majority of them are not suitable for routine use in clinical practice.11

At

Gestational hypertension

In general, the majority of cases of mild gestational hypertension develop at or beyond 37 weeks’ gestation, and thus pregnancy outcome is similar or superior to that seen in women with normotensive pregnancies (Table 2). Both gestational age at delivery and birth weight in these pregnancies are higher than those in normotensive pregnancies.3, 4, 5, 6 However, women with gestational hypertension are more likely to have higher rates of induction of labor for maternal reasons and higher rates of

Antepartum management of mild hypertension–preeclampsia

The optimal treatment of women with mild gestational hypertension or preeclampsia before 37 weeks’ gestation is controversial. There is disagreement regarding the benefits of hospitalization, complete bed rest, and use of antihypertensive medications.

Expectant management of severe preeclampsia?

The clinical course of severe preeclampsia may be characterized by progressive deterioration in both maternal and fetal conditions. Because these pregnancies have been associated with increased rates of maternal morbidity and mortality and with significant risks for the fetus (growth restriction, hypoxemia, and death), there is universal agreement that all such patients should deliver if the disease develops after 34 weeks’ gestation. Prompt delivery is also clearly indicated when there is

Recommended management

The primary objective of management in women with gestational hypertension–preeclampsia must always be safety of the mother and then delivery of a mature newborn who will not require intensive and prolonged neonatal care. This objective can be achieved by formulating a management plan that takes into consideration one or more of the following: the severity of the disease process, fetal gestational age, maternal and fetal status at time of initial evaluation, presence of labor, cervical Bishop

Summary

The etiology and pathogenesis of gestational hypertension and preeclampsia remain unknown. Despite all the recent research efforts, there are no reliable tests to predict the development of preeclampsia and there are no effective therapeutic methods to prevent preeclampsia. As a result, gestational hypertension and preeclampsia remain a major obstetric problem, accounting for a large percentage of maternal and perinatal morbidities. At present, there are few, if any, multicenter randomized

References (36)

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