Management of preeclampsia

Abstract

Most patients with a pregnancy-induced hypertensive disorder have no clinical symptoms. So it can only be reliably detected by repetitive searches (screening) for the early signs and symptoms in the 2nd half of pregnancy. Adequate and proper prenatal care is the most important part of management of preeclampsia. Maternal antenatal monitoring includes identifying women at increased risk, early detection of preeclampsia by recognizing clinical signs and symptoms, and to observe progression of the condition to the severe state. As the etiology of preeclampsia remains in question, the only effective treatment is to deliver the infant and placenta; ancillary therapy is predominantly symptomatic and not directed at underlying causes. Once the diagnosis of preeclampsia is made, subsequent therapy will depend on the results of initial maternal and fetal evaluation. The primary objective of management of preeclampsia must always be safety of the mother. Although delivery is always appropriate for the mother, it may not be optimal for the fetus that is extremely premature. The decision between delivery and expectant management depends on fetal gestational age, maternal and fetal status at time of initial evaluation, presence of labor or rupture of fetal membranes, and level of available neonatal and maternal services. It is important to emphasize that hypertension is merely one manifestation of this disease, albeit directly related to one of the most serious consequences for the mother, i.e cerebral involvement, which may manifest itself as convulsions, focal neurological events such as cortical blindness, and even cerebral hemorrhage. The benefits of acute pharmacologic control of severe hypertension prior to delivery are generally accepted. The more contentious issues are the role of pharmacologic therapy in allowing prolongation of pregnancy and the ability of such therapy to modify the course of the underlying systemic disorder and affect fetal and maternal outcome. Ali hypertensive drugs affect both the mother and the fetus; some may produce side effects in the mother and others may produce adverse effects on the fetus or the newborn. The indirect effects of antihypertensive drugs on the fetus may be by impairing uteroplacental perfusion or directly by influencing the fetal cardiovascular circulation. In general, women with mild disease developing at 37weeks' gestation or longer have a pregnancy outcome similar to that found in normotensive pregnancy. Thus, those patients should undergo induction of labor for delivery. Induction of labor and/or delivery is also recommended for those at or beyond 34 weeks' gestation in the presence of severe preeclampsia, labor or rupture of membranes, or non-reassuring tests of fetal well-being because the mother is at slightly increased risk for development of placental abruption and progression to eclampsia. In women who remain undelivered, close maternal and fetal evaluation is essential. The type of test and frequency of evaluation will depend on fetal gestational age as well as severity of maternal condition, and presence or absence of IUGR. These tests should be repeated promptly in case of worsening maternal condition (progression to severe disease) or fetal condition (reduced fetal movement or suspected IUGR). 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, there is universal agreement that such patients be delivered if the disease develops after 34weeks' gestational, 243. Delivery is also clearly indicated when there is imminent eclampsia (persistent severe symptoms), multiorgan dysfunction, severe IUGR, suspected placental abruption, or non-reassuring fetal testing before 34 weeks' gestation. There is disagreement however, about treatment of patients with severe preeclampsia before 34 weeks' gestation where maternal condition is stable and fetal condition is reassuring. The Cochrane review on interventionist versus expectant care states that it is not possible to draw firm conclusions, as there are only two small trials (133 women) that have compared a policy of early elective delivery, with a policy of delayed delivery, and the confidence intervals for all outcomes are wide. However, the evidence is promising that short-term morbidity for the baby may be reduced by a policy of expectant care. Sibai and Barton recently reviewed the literature on maternal and perinatal of expected management of severe preeclampsia remote from term and reviewed the major studies in the literature. Based on this review, they concluded that the results of these studies suggest that expectant treatment in a select group of women with severe preeclampsia between 24 0/7 and 32 6/7weeks of gestation in a suitable hospital is safe and improves neonatal outcome. Most studies on expectant management report 7-10days of prolongation. For gestational age of 24 0/7weeks, expectant treatment was associated with high maternal morbidity with limited perinatal benefit.