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Official reprint from UpToDate www.uptodate.com ©2015 UpToDate Authors Errol R Norwitz, MD, PhD John T Repke, MD Section Editor Charles J Lockwood, MD, MHCM Deputy Editor Vanessa A Barss, MD, FACOG Preeclampsia: Management and prognosis All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2015. | This topic last updated: Mar 05, 2015. INTRODUCTION — Preeclampsia refers to the new onset of hypertension and either proteinuria or endorgan dysfunction after 20 weeks of gestation in a previously normotensive woman ( table 1 ). It is a multisystem, progressive disorder with a disease spectrum that ranges from mild to severe. Progression to severe disease ( table 2 ) may be gradual or rapid. Delivery results in resolution of the disease. GENERAL PRINCIPLES — A key aspect of routine prenatal care is monitoring pregnancies for signs and symptoms of preeclampsia. If the diagnosis is made, the definitive treatment is delivery to prevent development of maternal or fetal complications from disease progression. (See "Preeclampsia: Clinical features and diagnosis", section on 'Burden of disease' .) When to initiate delivery is based upon gestational age, the severity of the disease, and maternal and fetal condition. Patients with preeclampsia at ≥37 weeks of gestation are delivered; however, before term, the risks of serious sequelae from disease progression need to be balanced with the risks of preterm birth. Evidence of serious maternal endorgan dysfunction or indeterminate tests of fetal wellbeing may be indications for prompt delivery at any gestational age. On the other hand, when mother and fetus are stable and without findings of serious endorgan dysfunction, a conservative approach with close monitoring for evidence of progression to severe features of the disease ( table 2 ) is reasonable in order to achieve further fetal growth and maturity. APPROACH BASED ON DISEASE SEVERITY Preeclampsia with features of severe disease — Preeclampsia with features of severe disease (also called severe preeclampsia) ( table 2 ) is generally regarded as an indication for delivery in the following settings: Delivery minimizes the risk of development of serious maternal and fetal complications (eg, cerebral hemorrhage, hepatic rupture, renal failure, pulmonary edema, seizure, bleeding related to thrombocytopenia, fetal growth restriction, abruptio placentae) [14 ]. With the exception of fetal growth restriction, any of these adverse events can occur suddenly in a woman with severe disease. After fetal viability and before 34 weeks of gestation, when the mother and fetus are stable, prolongation of pregnancy in a tertiary care setting or in consultation with a maternalfetal medicine specialist is reasonable to reduce morbidity from preterm birth. Candidates for this approach and management of these pregnancies are discussed separately. (See "Expectant management of preeclampsia with severe features" .) Observational data suggest that the decision to expedite delivery in the setting of severe preeclampsia does not mandate immediate cesarean birth [46 ]. Cervical ripening agents can be used prior to induction if the cervix is not favorable [7 ]. However, we feel that a prolonged induction and inductions with a low likelihood of success are best avoided. Cesarean delivery is reasonable for women with severe preeclampsia/eclampsia who are under about 32 weeks of gestation and have a low Bishop score, given the high frequency of indeterminate fetal heart rate tracings and failure of the cervix to dilate in this setting [79 ]. Less than onethird of preterm inductions in this setting result in vaginal birth. ® ® Before fetal viability At ≥34 weeks of gestation 0/7ths When the maternal or fetal condition is unstable, regardless of gestational age

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  • 3/4/2015 Preeclampsia:Managementandprognosis

    http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=pri 1/23

    OfficialreprintfromUpToDate www.uptodate.com2015UpToDate

    AuthorsErrolRNorwitz,MD,PhDJohnTRepke,MD

    SectionEditorCharlesJLockwood,MD,MHCM

    DeputyEditorVanessaABarss,MD,FACOG

    Preeclampsia:Managementandprognosis

    Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.Literaturereviewcurrentthrough:Mar2015.|Thistopiclastupdated:Mar05,2015.

    INTRODUCTIONPreeclampsiareferstothenewonsetofhypertensionandeitherproteinuriaorendorgandysfunctionafter20weeksofgestationinapreviouslynormotensivewoman(table1).Itisamultisystem,progressivedisorderwithadiseasespectrumthatrangesfrommildtosevere.Progressiontoseveredisease(table2)maybegradualorrapid.Deliveryresultsinresolutionofthedisease.

    GENERALPRINCIPLESAkeyaspectofroutineprenatalcareismonitoringpregnanciesforsignsandsymptomsofpreeclampsia.Ifthediagnosisismade,thedefinitivetreatmentisdeliverytopreventdevelopmentofmaternalorfetalcomplicationsfromdiseaseprogression.(See"Preeclampsia:Clinicalfeaturesanddiagnosis",sectionon'Burdenofdisease'.)Whentoinitiatedeliveryisbasedupongestationalage,theseverityofthedisease,andmaternalandfetalcondition.Patientswithpreeclampsiaat37weeksofgestationaredeliveredhowever,beforeterm,therisksofserioussequelaefromdiseaseprogressionneedtobebalancedwiththerisksofpretermbirth.Evidenceofseriousmaternalendorgandysfunctionorindeterminatetestsoffetalwellbeingmaybeindicationsforpromptdeliveryatanygestationalage.Ontheotherhand,whenmotherandfetusarestableandwithoutfindingsofseriousendorgandysfunction,aconservativeapproachwithclosemonitoringforevidenceofprogressiontoseverefeaturesofthedisease(table2)isreasonableinordertoachievefurtherfetalgrowthandmaturity.

    APPROACHBASEDONDISEASESEVERITY

    PreeclampsiawithfeaturesofseverediseasePreeclampsiawithfeaturesofseveredisease(alsocalledseverepreeclampsia)(table2)isgenerallyregardedasanindicationfordeliveryinthefollowingsettings:

    Deliveryminimizestheriskofdevelopmentofseriousmaternalandfetalcomplications(eg,cerebralhemorrhage,hepaticrupture,renalfailure,pulmonaryedema,seizure,bleedingrelatedtothrombocytopenia,fetalgrowthrestriction,abruptioplacentae)[14].Withtheexceptionoffetalgrowthrestriction,anyoftheseadverseeventscanoccursuddenlyinawomanwithseveredisease.Afterfetalviabilityandbefore34weeksofgestation,whenthemotherandfetusarestable,prolongationofpregnancyinatertiarycaresettingorinconsultationwithamaternalfetalmedicinespecialistisreasonabletoreducemorbidityfrompretermbirth.Candidatesforthisapproachandmanagementofthesepregnanciesarediscussedseparately.(See"Expectantmanagementofpreeclampsiawithseverefeatures".)

    Observationaldatasuggestthatthedecisiontoexpeditedeliveryinthesettingofseverepreeclampsiadoesnotmandateimmediatecesareanbirth[46].Cervicalripeningagentscanbeusedpriortoinductionifthecervixisnotfavorable[7].However,wefeelthataprolongedinductionandinductionswithalowlikelihoodofsuccessarebestavoided.Cesareandeliveryisreasonableforwomenwithseverepreeclampsia/eclampsiawhoareunderabout32weeksofgestationandhavealowBishopscore,giventhehighfrequencyofindeterminatefetalheartratetracingsandfailureofthecervixtodilateinthissetting[79].Lessthanonethirdofpreterminductionsinthissettingresultinvaginalbirth.

    Beforefetalviability

    At34 weeksofgestation 0/7ths

    Whenthematernalorfetalconditionisunstable,regardlessofgestationalage

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    PreeclampsiawithoutfeaturesofseverediseaseExpertsconsistentlyrecommenddeliveryofwomenwithpreeclampsiaat37weeksofgestation,evenintheabsenceoffeaturesofseveredisease(previouslycalledmildpreeclampsia)[3,4,1012].Cervicalripeningagentsshouldbeusedinwomenwithunfavorablecervices.

    Theoptimummanagementforwomenwithpreeclampsiawithoutfeaturesofseverediseaseandstablematernalandfetalconditionsat34 to36 weeksremainsuncertainnorandomizedtrialshavebeenperformedinthispopulation.Thesepregnanciesaregenerallymanagedexpectantlytoenablefurtherfetalgrowthandmaturation.Progressionofthediseaseisgenerallyslowandobservationaldatashowthatmanypatientswithlateonsetdiseasewillreachtermwithoutprogressiontoseveredisease.Forpatientsmanagedexpectantly,deliveryisindicatedassoonastheydevelopsignsorsymptomsofseverepreeclampsia/eclampsia(table2)orat37weeksofgestationifthediseasedoesnotprogresstotheseverestage.

    Priorto34 weeks,guidelinesfrommajormedicalorganizationsgenerallyrecommendexpectantmanagementofpreeclampsiawithoutfeaturesofseveredisease,basedonexpertopinion,giventhehighriskofcomplicationsofprematurity[3,4,12].(See"Shorttermcomplicationsoftheprematureinfant"and"Longtermcomplicationsoftheprematureinfant"and"Incidenceandmortalityoftheprematureinfant".)

    EXPECTANTANTEPARTUMMANAGEMENTOFPREECLAMPSIAWITHOUTFEATURESOFSEVEREDISEASEWomenwithpreterm(36 weekstoinductionoflabororexpectantmanagementwithmaternal/fetalmonitoring[13].Routineinductionwasassociatedwithasignificantreductionincompositeadversematernaloutcome(RR0.71,95%CI0.590.86absoluteriskreduction12.76percent),whichwasprimarilydrivenbyareductioninpatientswhodevelopedseverehypertensionandwasnotsignificantforwomenat36 to36 weeks.Theinducedgroupdelivered,onaverage,1.2weeksearlierthanthecontrolgroupandhadasignificantlylowerrateofcesareandelivery(14versus19percent).Therewerenosignificantdifferencesbetweengroupsinneonataloutcome.

    Thistrialshowedthatpreeclampticwomenbenefitedfromearlyintervention,withoutincurringanincreasedriskofoperativedeliveryorneonatalmorbidity.Thetrialwasnotlargeenoughtodeterminewhethersmalldifferencesinnewbornoutcomesorinductionbetween36and37weeksmightbestatisticallysignificant.Afollowupeconomicanalysisofthistrialconcludedinductionwasalsolesscostlyoverallthanexpectantmanagementwithmonitoring[14].Anotherfollowupanalysisshowedthatanunfavorablecervixwasnotareasontoavoidinduction[15].

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    benefitsomepregnancies.Avoidingthesupinesleeppositionisprudent[24].Ifsignsorsymptomsofdiseaseprogressionarenoted,hospitalizationformoreintensivemonitoringandpossibledeliveryisindicated.

    Outpatientsshouldbeawareofthesignsandsymptomsofpreeclampsiaandtheyshouldmonitorfetalmovementsdaily[4].Theyshouldbetoldtocalltheirhealthcareproviderimmediatelyiftheydevelopsevereorpersistentheadache,visualchanges,shortnessofbreath,orrightupperquadrantorepigastricpain.Aswithanypregnancy,decreasedfetalmovement,vaginalbleeding,abdominalpain,ruptureofmembranes,oruterinecontractionsshouldbereportedimmediately,aswell.

    LaboratoryfollowupTheminimumlaboratoryevaluationshouldincludeplateletcount,serumcreatinine,andliverenzymes.Thesetestsshouldberepeatedatleastweeklyinwomenwithnonseverepreeclampsiatoassessfordiseaseprogression,andmoreoftenifclinicalsignsandsymptomssuggestworseningdisease[4].

    Thevalueofothertestsislessclearlydefined.Arisinghematocritcanbeusefultolookforhemoconcentration,whichsuggestscontractionofintravascularvolumeandprogressiontomoreseveredisease,whileafallinghematocritmaybeasignofhemolysis.Anelevatedserumindirectbilirubinconcentrationisabettersignofhemolysis,althoughanelevatedLDHmayalsobeamarkerofseverediseaseorHELLPsyndrome.Hemolysiscanbeconfirmedbyobservationofschistocytesandhelmetcellsonabloodsmear(picture1AB).(See"HELLPsyndrome".)

    Sinceseveralclinicalstudieshaveshownthatneithertherateofincreasenortheamountofproteinuriaaffectsmaternalorperinataloutcomeinthesettingofpreeclampsia[2528],repeated24hoururinaryproteinestimationsarenotusefuloncethethresholdof300mg/24hoursorprotein/creatinineratio0.3mg/dL/mg/dLforthediagnosisofpreeclampsiahasbeenexceeded.Serumcreatininealonecanbeusedtomonitorrenalfunction.(See"Expectantmanagementofpreeclampsiawithseverefeatures".)

    TreatmentofhypertensionBloodpressureshouldbeassessedatleasttwiceweekly.Theuseofantihypertensivedrugstocontrolmildhypertensioninthesettingofpreeclampsiadoesnotalterthecourseofthediseaseordiminishperinatalmorbidityormortality,andshouldbeavoidedinmostpatients.Theindicationsforstartingantihypertensivetherapy,thechoiceofdrug,andbloodpressuregoalsarediscussedseparately.(See"Managementofhypertensioninpregnantandpostpartumwomen",sectionon'Preeclampsia'.)

    Sodiumrestrictionbelowtherecommendeddailyintakeanddiureticshavenoroleinroutinetherapy[2931].Althoughintravascularvascularvolumeisreduced,arandomizedtrialshowedthatplasmavolumeexpansiondidnotimprovematernalorfetaloutcome[32].

    AssessmentoffetalwellbeingTherearenodatafromrandomizedtrialsonwhichtobaserecommendationsfortheoptimaltypeandfrequencyoffetalbiophysicalmonitoring.Wesuggestdailyfetalmovementcountsandtwiceweeklyfetalnonstresstestingwithassessmentofamnioticfluidvolume,ortwiceweeklybiophysicalprofiles.Testingisrepeatedimmediatelyifthereisanabruptchangeinmaternalcondition.(See"Nonstresstestandcontractionstresstest"and"Thefetalbiophysicalprofile".)

    EvaluationofumbilicalarteryDopplerindicesisalsouseful,astheresultshelpinoptimaltimingofdelivery.Inametaanalysisof16randomizedtrialsinhighriskpregnancies,knowledgeofumbilicalarteryDopplervelocimetryresultswasassociatedwitha29percentreductioninperinataldeath(RR0.71,95%CI0.520.98,10,225babies,1.2versus1.7percentnumberneededtotreat203,95%CI1034352),primarilyinpregnanciescomplicatedbypreeclampsiaand/orgrowthrestriction.ThefrequencyofassessmentdependsonthefindingsweeklyassessmentisreasonablewhenDopplerindicesarenormal.(See"Dopplerultrasoundoftheumbilicalarteryforfetalsurveillance",sectionon'Clinicaleffectiveness'and"Dopplerultrasoundoftheumbilicalarteryforfetalsurveillance",sectionon'Guidelinesforclinicalpractice'.)

    AssessmentoffetalgrowthEarlyfetalgrowthrestrictionmaybethefirstmanifestationofpreeclampsiaandisasignofsevereuteroplacentalinsufficiency.Wesuggestperformingsonographicestimationoffetalweighttoevaluateforgrowthrestrictionandoligohydramniosatthetimeofdiagnosisofpreeclampsia.Iftheinitial

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    examinationisnormal,werepeattheultrasoundexaminationeverythreeweeks.Managementofthegrowthrestrictedfetusisreviewedseparately.(See"Fetalgrowthrestriction:Evaluationandmanagement",sectionon'Serialfetalweightassessment'and"Dopplerultrasoundoftheumbilicalarteryforfetalsurveillance".)

    AntenatalcorticosteroidsAlthoughpreeclampsiamayacceleratefetallungmaturation,neonatalrespiratorydistressremainscommoninprematureneonatesofpreeclampticpregnancies[33,34].Antenatalcorticosteroids(betamethasone)topromotefetallungmaturityshouldbeadministeredtowomen

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    controlledtrialincluding10,000women(MAGPIE[magnesiumsulfateforpreventionofeclampsiatrial]),about100womenwithmildpreeclampsiaandabout60womenwithseverepreeclampsiawouldneedtobetreatedtopreventoneseizure[37].Thisrecommendationisincontrasttothe2013AmericanCollegeofObstetriciansandGynecologistsrecommendations,whichstatethatforwomenwithpreeclampsiawithsystolicbloodpressureoflessthan160mmHgandadiastolicbloodpressurelessthan110mmHgandnomaternalsymptoms,itissuggestedthatmagnesiumsulfatenotbeadministereduniversallyforthepreventionofeclampsia[4].

    Itisimportanttoemphasizethatseizureprophylaxisdoesnotpreventprogressionofdiseaseunrelatedtoconvulsions.Approximately10to15percentofwomeninlaborwithnonseverepreeclampsiawilldevelopsignsofseverepreeclampsia(eg,severehypertension,severeheadache,visualdisturbance,epigastricpain,laboratoryabnormalities)orabruptioplacenta,whetherornottheyreceivemagnesiumtherapy[38,39].

    Wedonotadministerseizureprophylaxistowomenwithonlygestationalhypertension(pregnancyrelatedhypertensionwithoutproteinuriaorendorgandysfunction),astheseizureriskinthelattergroupislessthan0.1percent[40].(See"Gestationalhypertension".)

    MagnesiumsulfateversusotheranticonvulsantsMajormedicalorganizationsworldwideconsistentlyrecommendmagnesiumsulfateasthedrugofchoiceforthepreventionofeclampsia[4,12,41].Inrandomizedtrials[37,42,43]andlargeobservationalseries[44],magnesiumsulfatewasmoreeffectiveforpreventionofafirstseizurethanphenytoin[42]oranantihypertensivedrugalone(nimodipine)[43]orplacebo[44].Asanexample,atrialthatrandomlyassigned2138preeclampticpatientsadmittedtoLaborandDeliveryatParklandHospitaltoseizureprophylaxiswithmagnesiumsulfateorphenytoinreportedeclampticseizuresin10of1089womenassignedtophenytoincomparedtononeof1049womenassignedtomagnesiumsulfate[42].Maternalandneonataloutcomesweresimilarinbothgroups.

    Inmetaanalysesofrandomizedtrialsineclampticwomen,magnesiumsulfatewassaferandmoreeffectiveforpreventionofrecurrentseizuresthanphenytoin,diazepam,orlyticcocktail(ie,chlorpromazine,promethazine,andpethidine).Thesedataprovideadditionalindirectevidenceofitseffectivenessinpreeclampsia.(See"Eclampsia",sectionon'Preventionofrecurrentseizures'.)

    MagnesiumregimenandmonitoringThereisnoconsensusontheoptimalmagnesiumregimen,whenitshouldbestartedandterminated,orrouteofadministration[45].Thedrugisusuallyinitiatedattheonsetoflabororinduction,orpriortoacesareandelivery[4,46,47].Itisusuallynotgiventostableantepartumpatientsoffthelaborunit,butissometimesusedinwomenwithseverepreeclampsiabeingconsideredforexpectantmanagement.Prolongedantepartumtherapy(morethanfivetosevendays)inwomenwithpretermlaborhasbeenassociatedwithadverseeffectsonfetalbones[48].(See"Expectantmanagementofpreeclampsiawithseverefeatures".)

    DosingAlthoughpublisheddosageregimensformagnesiumsulfatevarywidely(loadingdoseof4to6gramsintravenouslyandmaintenancedoseof1to3gramsperhour),themostcommonregimen,andtheonethatweuse,isaloadingdoseof6gramsintravenouslyover15to20minutesfollowedby2gramsperhourasacontinuousinfusion[4,39,44,47].Analternativeregimenis5gramsintramuscularlyintoeachbuttock(totalof10grams)followedby5gramsintramuscularlyeveryfourhours.However,thismethodisassociatedwithmoresideeffects,particularlypainattheinjectionsite.

    Theredoesnotappeartobeaclearthresholdconcentrationforinsuringthepreventionofconvulsions,althoughatherapeuticrangeof4.8to8.4mg/dL(2.0to3.5mmol/L)hasbeenrecommendedbasedonretrospectivedata[49].Loadingdoseslessthan6gramsaremorelikelytoresultinsubtherapeuticmagnesiumlevels(lessthan4.5mg/dL)[44,50].

    Sincemagnesiumsulfateisexcretedbythekidneys,dosingshouldbeadjustedinwomenwithrenalinsufficiency(definedasaserumcreatininegreaterthan1.0mg/dL).Suchwomenshouldreceiveastandardloadingdose(sincetheirvolumeofdistributionisnotaltered),butareducedmaintenancedose(1gramperhourornomaintenancedoseiftheserumcreatinineisgreaterthan2.5mg/dL)andclosemonitoringoftheirserum

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    magnesiumleveleverysixhoursorbyclinicalassessmenteveryonetotwohours.

    Themaintenancephaseisgivenonlyifapatellarreflexispresent(lossofreflexesbeingthefirstmanifestationofsymptomatichypermagnesemia),respirationsexceed12perminute,andtheurineoutputexceeds100mLperfourhours.(See"Symptomsofhypermagnesemia".)Followingserummagnesiumlevelsisnotrequiredifthewoman'sclinicalstatusiscloselymonitoredforevidenceofpotentialmagnesiumtoxicity(see'Complicationsandsideeffects'below).Themaintenancedoseshouldbedecreasedifthereisclinicalevidenceofmagnesiumtoxicity.

    DurationoftherapyMagnesiumsulfateisusuallycontinuedfor24hourspostpartum[47].Timingofdrugdiscontinuationhasbeenarbitrarytherearenohighqualitydatatoguidetherapy.Inwomenwhohavenonseverepreeclampsia,discontinuationoftherapyafter12hoursmaybesafe[51].Inwomenwithseverepreeclampsiaoreclampsia,seizureprophylaxisisgenerallycontinuedfor24to48hourspostpartum,afterwhichtheriskofrecurrentseizuresislow.

    Itisprobablyreasonabletoextendthedurationofmagnesiumsulfatetherapyinwomenwhosediseasehasnotbeguntoimprovepostpartumandshortenthedurationoftherapyinwomenwhoareclearlyimprovingclinically(eg,diuresisof100mL/hourfortwoconsecutivehours,absenceofsymptoms[headache,visualchanges,epigastricpain],andabsenceofseverehypertension)[5255].Diuresis(greaterthan4L/day)isbelievedtobethemostaccurateclinicalindicatorofresolutionofpreeclampsia/eclampsia,butisnotaguaranteeagainstthedevelopmentofseizures[56].Inwomenwithpersistentrenalimpairmentpostpartum,itisimportanttobecautiouswhenadministeringaprolongedmagnesiumsulfateinfusiontopreventtheoccurrenceofmagnesiumtoxicity.

    ComplicationsandsideeffectsRapidinfusionofmagnesiumsulfatecausesdiaphoresis,flushing,andwarmth,probablyrelatedtoperipheralvasodilationandadropinbloodpressure.Nausea,vomiting,headache,muscleweakness,visualdisturbances,andpalpitationscanalsooccur.Dyspneaorchestpainmaybesymptomsofpulmonaryedema,whichisararesideeffect.(See"Symptomsofhypermagnesemia".)

    Magnesiumtoxicityisuncommoninwomenwithgoodrenalfunction[57].Toxicityisrelatedtoserummagnesiumconcentration:lossofdeeptendonreflexesoccursat7to10mEq/L(8.5to12mg/dLor3.5to5.0mmol/L),respiratoryparalysisat10to13mEq/L(12to16mg/dLor5.0to6.5mmol/L),cardiacconductionisalteredat>15mEq/L(>18mg/dLor>7.5mmol/L),andcardiacarrestoccursat>25mEq/L(>30mg/dLor>12.5mmol/L)[58].Calciumgluconate(1gramintravenouslyover5to10minutes)shouldbeadministeredonlytocounteractlifethreateningsymptomsofmagnesiumtoxicity(suchascardiorespiratorycompromise).

    Magnesiumsulfateiscontraindicatedinwomenwithmyastheniagravissinceitcanprecipitateaseveremyastheniccrisis(see"Managementofmyastheniagravisinpregnancy").Neuromuscularblockadeandhypotensionduetoconcurrentuseofmagnesiumsulfateandcalciumchannelblockershavebeendescribedincasereports,buttheriskappearstobeminimal[59].

    Althoughmagnesiumsulfateisaweaktocolytic,labordurationdoesnotappeartobeaffectedbymagnesiumsulfateadministration[60].Theriskofpostpartumhemorrhage,possiblyrelatedtouterineatonyfrommagnesium'stocolyticeffects,wasslightlyincreasedinonetrial[43].

    Magnesiumfreelycrossestheplacentaasaresult,thecordbloodconcentrationapproximatesthematernalserumconcentration.Maternaltherapycausesadecreaseinbaselinefetalheartrate,whichgenerallyremainswithinthenormalrange,andadecreaseinfetalheartratevariability,whichmaybeabsentorminimal[61].Antenatalfetalassessmenttestresults(eg,biophysicalprofilescoreandnonstresstestreactivity)arenotsignificantlyaltered[62].

    Magnesiumtherapyresultsinatransientreductionoftotalandionizedserumcalciumconcentrationduetorapidsuppressionofparathyroidhormonerelease[63].Rarely,hypocalcemiabecomessymptomatic(myoclonus,delirium,ECGabnormalities).(See"Symptomsofhypermagnesemia",sectionon'Hypocalcemia'.)Cessationofmagnesiumtherapywillrestorenormalserumcalciumlevels.However,calciumadministrationmayberequiredifsymptomsarepresent(calciumgluconate1gramintravenouslyover5to10minutes).(See"Causesand

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    treatmentofhypermagnesemia".)

    MechanismofanticonvulsantactionThemechanismfortheanticonvulsanteffectsofmagnesiumsulfatehasnotbeenclearlydefined.Theprimaryeffectisthoughttobecentral.Hypothesesincluderaisingtheseizurethresholdbyitsactionatthenmethyldaspartate(NMDA)receptor,membranestabilizationinthecentralnervoussystemsecondarytoitsactionsasanonspecificcalciumchannelblocker,aswellasdecreasingacetylcholineinmotornerveterminals[64,65].Anothertheoryisthatitpromotesvasodilatationofconstrictedcerebralvesselsbyopposingcalciumdependentarterialvasospasm,therebyreducingcerebralbarotrauma[66].

    POSTPARTUMMANAGEMENTNonsteroidalantiinflammatorydrugs(NSAIDs)forpaincontrolshouldbeavoidedinwomenwithpoorlycontrolledhypertension,oliguria,renalinsufficiency,orthrombocytopenia.(See"NonselectiveNSAIDs:Overviewofadverseeffects".)

    Therearenoevidencebasedstandardsfortheoptimalapproachtopostpartummonitoringandfollowup.Wemonitorvitalsignseverytwohourswhilethepatientremainsonmagnesiumsulfateandwerepeatlaboratorytestsuntiltwoconsecutivesetsofdataarenormal.

    Severehypertensionshouldbetreatedsomepatientswillhavetobedischargedonantihypertensivemedications,whicharediscontinuedwhenbloodpressurereturnstonormal.(See"Managementofhypertensioninpregnantandpostpartumwomen",sectionon'Postpartumhypertension'.)

    Patientsshouldbefollowedcloselyasoutpatients.TheAmericanCollegeofObstetriciansandGynecologistssuggestsmonitoringbloodpressureinhospitalorathomeforthefirst72hourspostpartumandagain7to10dayspostdelivery[4].Somepatientswillrequirelongermonitoringcontinuedfollowupisneededuntilallofthesignsandsymptomsofpreeclampsiahaveresolved.Alternativediagnosesshouldbesoughtinthosewithpersistentabnormalfindingsafterthreetosixmonths[67].(See"Overviewofhypertensioninadults".)

    PostpartumonsetofpreeclampsiaInwomenwhoareinitiallydiagnosedwithpreeclampsiaafterdelivery,magnesiumsulfateshouldbeadministeredtothoseatincreasedriskofdevelopingseizures[4]:

    Antihypertensivetherapyshouldalsobeinitiated.TheAmericanCollegeofObstetriciansandGynecologistssuggeststreatmentofsystolicbloodpressure150mmHgordiastolicbloodpressure100mmHgontwooccasionsfourtosixhoursapart[4].Treatmentshouldbeinitiatedwithinonehourifsystolicbloodpressureis160mmHgordiastolicbloodpressureis110mmHg.

    GUIDELINESFROMSELECTEDORGANIZATIONSAnumberofmedicalorganizationshavepublishedguidelinesformanagementofpreeclampsia.Theseguidelinesaregenerallyconsistentwiththerecommendationsinthistopicreview.

    PROGNOSISPrognosticissuesincludetheriskofrecurrentpreeclampsiaandrelatedcomplicationsinsubsequentpregnanciesandlongtermmaternalhealthrisks.

    RecurrenceA2015metaanalysisofindividualpatientdatafromover75,000womenwithpreeclampsiawhobecamepregnantagainfoundthat20percentdevelopedhypertensioninasubsequentpregnancyand16percentdevelopedrecurrentpreeclampsia[68].

    Womenwithnewonsethypertensionandheadacheorblurredvision,orWomenwithseverehypertension

    AmericanCollegeofObstetriciansandGynecologists(ACOG).HypertensioninPregnancy[4]

    NationalInstituteforHealthandClinicalExcellence(NICE).Hypertensioninpregnancy:Themanagementofhypertensivedisordersduringpregnancy[3]

    SocietyofObstetriciansandGynaecologistsofCanada(SOGC).Diagnosis,evaluation,andmanagementofthehypertensivedisordersofpregnancy[12]

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    Therecurrenceriskvarieswiththeseverityandtimeofonsetoftheacuteepisode[69].Womenwithearlyonset,severepreeclampsiaareatgreatestriskofrecurrence(ashighas25to65percent)[7072].Theriskismuchlower(5to7percent)inwomenwhohadnonseverepreeclampsiaduringthefirstpregnancy,versuslessthan1percentinwomenwhohadanormotensivefirstpregnancy(doesnotapplytoabortions)[70,7378].Inaseriesof125womenwithseveresecondtrimesterpreeclampsiafollowedforfiveyears,65percentdevelopedrecurrentpreeclampsiaand35percentwerenormotensiveintheirsubsequentpregnancy[70].Ofthepreeclampticgroup,approximatelyonethirddevelopedthediseaseat27weeks,onethirdat28to36weeks,andonethirdat37weeks.Thus,21percentofsubsequentpregnancieswerecomplicatedbyseverepreeclampsiainthesecondtrimester.

    Recurrentpreeclampsiaismorelikelyfollowingapreeclampticsingletonpregnancythanapreeclamptictwinpregnancy[79].TherecurrenceriskinwomenwithHELLPsyndrome(whomaydevelopeitherHELLPorpreeclampsiainasubsequentpregnancy)isdiscussedseparately.(See"HELLPsyndrome",sectionon'Recurrenceinsubsequentpregnancies'.)

    PreventionPreventivetherapy(lowdoseaspirin)isreviewedelsewhere.(See"Preeclampsia:Prevention".)

    RiskofrelatedobstetricalcomplicationsPreeclampsia,growthrestriction,pretermdelivery,abruptioplacentae,andstillbirthcanallbesequelaeofimpairedplacentalfunction.Womenwithpregnanciescomplicatedbyoneofthesedisordersareatincreasedriskofdevelopingoneoftheotherdisordersinfuturepregnancies.Earlyonsetpreeclampsiaismorelikelytobeassociatedwithoneoftheseadverseeventsinasubsequentpregnancy,evenifnormotensive,thanlateonsetpreeclampsia[80,81].

    Longtermmaternalrisks

    CardiovasculardiseaseCasecontrolandcohortstudiesconsistentlyreportthatpreeclampsiaispredictiveoffuturecardiovascularandcerebrovasculardisease.Thisriskwassummarizedintwosystematicreviewsofcontrolledstudiesthatevaluatedtheriskoflatecardiovasculareventsinwomenwithandwithoutahistoryofpreeclampsia[82,83]:

    Prospectivecohortstudiespublishedafterthesereviewshavereportedsimilarfindings[8487].

    Thefutureriskofcardiovascularmorbidityandmortalityappearstoberelatedtoboththeseverityofpreeclampsiaandthenumberofepisodesofpreeclampsia[88].Womenwithearlyonset/severepreeclampsiawithpretermdeliveryareathighestriskofcardiovasculardiseaselaterinlife,includingduringthepremenopausalperiod(table3).Intwolargestudies,thesewomenhadaneighttoninefoldincreasedriskofdeathfromcardiovascularcausescomparedwithwomenwithoutahistoryofpreeclampsia[86,89].Incontrast,mildpreeclampsiaoccurringlateingestationdoesnotappeartobeassociatedwithahighriskofremotecardiovasculardisease[90].Thestrongerassociationbetweencardiovasculardiseaseandpretermpreeclampsiasuggeststhatthepathogenesisofearly

    Comparedwithwomenwithnohistoryofthedisease,womenwithpreeclampsiawereatincreasedriskofdevelopinghypertension(RR3.70,95%CI2.705.05atmeanfollowupof14years),ischemicheartdisease(RR2.16,95%CI1.862.52atmeanfollowupof11.7years),stroke(RR1.81,95%CI1.452.27atmeanfollowupof10.4years),andvenousthromboembolism(RR1.79,95%CI1.372.33atmeanfollowupof4.7years)[82].Theabsoluteriskthatawomanwithorwithoutahistoryofpreeclampsiawoulddeveloponeofthesecardiovasculareventsatage50to59yearswasestimatedtobe17.8and8.3percent,respectively.

    Inaddition,agradedrelationshipwasobservedbetweenseverityofpreeclampsiaandriskoffuturecardiacdisease(mildpreeclampsiaRR2.00,95%CI1.832.19moderatepreeclampsiaRR2.99,95%CI2.513.58severepreeclampsiaRR5.36,95%CI3.967.27),aswellasacorrelationbetweenpreeclampsiaandfutureperipheralarterydisease(RR1.87,95%CI0.943.73)[83].Theauthorsdefinedpreeclampsiaas'mild'ifthepregnancyhadanuncomplicatedcourse,'moderate'ifpreeclampsiawascomplicatedbyfetalgrowthrestrictionormaternalseizuresand'severe'ifpreeclampsiawascomplicatedbypretermdeliveryorfetaldemise.

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    versuslatepreeclampsiamaybedifferent.

    Severalstudieshavedemonstratedthatwomenwithahistoryofpreeclampsiaorsevereearlyonsetfetalgrowthrestrictionexhibitimpairedendothelialfunctionandvasodilatationremotefrompregnancy[9194].Womenwithahistoryofhypertensivedisordersinpregnancyhavehigherlevelsofglucose,insulin,andunfavorablelipidsthanwomenwithahistoryofnormotensivepregnancy[95].Datafromsomeepidemiologicstudiessuggestthattheincreasedriskoflatecardiovascularmorbidityinpreviouslypreeclampticwomenreflectsanunderlyingpredispositioninthesewomenforbothdisorders(geneticfactors,sharedriskfactors),butitisalsopossiblethatpreeclampsiaresultsinpermanentarterialchangesleadingtolatecardiovasculardisease[9699].Someinvestigatorshavehypothesizedthatincreasedinsulinresistance,sympatheticoveractivity,proinflammatoryactivity,endothelialdysfunction,andtheabnormallipidprofileinpreeclampticwomenconstituteanearlymanifestationofmetabolicsyndromeandthatthesechangespersistafterpregnancy,therebyputtingaffectedwomanatincreasedriskofcardiovasculardisease[100104].Onegroupestimatedthatlifestyleinterventionsafterpreeclampsiawoulddecreasecardiovasculardiseaseriskby4to13percent[105].

    DiabetesmellitusInapopulationbasedretrospectivecohortstudyincludingoveronemillionwomen,preeclampsiaorgestationalhypertensionintheabsenceofgestationaldiabetesmellitus(GDM)wasassociatedwithatwofoldincreaseintheincidenceofdiabetesduring16.5yearsofpostdeliveryfollowup,aftercontrollingforseveralconfoundingvariables(butnotobesity)[106].InwomenwhohadpreeclampsiaorgestationalhypertensionandGDM,theriskoffuturediabeteswasincreased16to18fold,whichwasabovethealreadyelevated13foldincreaseinriskassociatedwithGDMalone.Thesefindings,andthosefrompreviousreports[107109],suggestthatcliniciansshouldinformwomenwithahistoryofpreeclampsiaorgestationalhypertensionthattheymaybeatincreasedriskofdevelopingdiabeteshowever,theavailableevidencedoesnotsupportachangeinstandardscreeningguidelines.(See"Screeningfortype2diabetesmellitus",sectionon'Screeningrecommendationsbyexpertgroups'.)

    EndstagerenaldiseaseWomenwithpreeclampsiamaybeatincreasedriskofdevelopingendstagerenaldisease(ESRD)laterinlife,buttheabsoluteriskissmall.AstudythatlinkedfourdecadesofdatafromtheNorwegiannationalbirthandESRDregistriesfoundthatwomenwithpreeclampsiaintheirfirstpregnancyhadafourfoldincreaseinriskofESRDcomparedwithwomenwithoutpreeclampsia(RR4.7,95%CI3.66.1)afteradjustingforknownconfounders,buttheabsoluteriskofESRDwaslessthan1percentwithin20years[110].Similarly,astudyusingclaimsdatafromtheTaiwanNationalHealthInsuranceProgramnotedthatwomenwithpreeclampsia/eclampsiawereatsignificantlyhigherriskofdevelopingESRDovertimethanwomenwithouthypertensivedisordersduringpregnancy(incidence5.33versus0.34per10,000personyears)[111].

    AlthoughwomenwhowentontodevelopESRDmayhavehadsubclinicalrenaldiseaseduringpregnancy,itisalsopossiblethatasyetundefinedriskfactorspredisposedthesewomentobothpreeclampsiaandESRD.Itislesslikelythatpreeclampsiadamagesthekidney,therebyinitiatingaprocessofchronicdeterioration.

    SubclinicalhypothyroidismAnestedcasecontrolstudyfoundthatnulliparouswomenwhodevelopedpreeclampsiaweretwiceaslikelytodevelopsubclinicalhypothyroidismduringpregnancyandlongafterdeliverythanmatchednormotensivecontrols[112].Theriskwasstrongestinwomenwithrecurrentpreeclampsiaandwithoutthyroidperoxidaseantibodies,suggestingthatanautoimmunemediatedmechanismofhypothyroidismwasnotinvolved.Inastudyincluding25,000pregnantwomen,womenwithsubclinicalhypothyroidismidentifiedduringpregnancywereatincreasedriskofdevelopingseverepreeclampsiacomparedwitheuthyroidwomen(OR1.6,95%CI1.12.4),afteradjustmentforriskfactorsforpreeclampsia[113].Abnormallevelsofthyroidhormonesappeartodamageendothelialcells,potentiallyleadingtopreeclampsiaandlongtermcardiovascularsequelae.

    OtherAsystematicreviewfoundnosignificantassociationbetweenpreeclampsiaandlaterdevelopmentofcancer[82].ObservationalstudiesfromtheUnitedStates,Sweden,andNorwayreportedthatwomenwithpreeclampsiawereatreducedriskorhadnoexcessriskofcancerwhenfollowed13to19yearspostpartum[89,114119].Incontrast,astudyfromIsraelreportedanincreasedriskofcancerinsuchwomen(hazardratio1.27,95%CI1.031.57)withamedianfollowupof29years[120,121].Sitespecificincreaseswerenotedfor

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    cancerofthestomach,lungorlarynx,breast,andovary.Thediscordantresultsmaybeexplainedbyanumberoffactors,includingdifferencesinpatientpopulations,absenceoforinsufficientadjustmentforconfounders,differencesinlengthoffollowup,andincompleteascertainment.

    INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsandBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5 to6 gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10 to12 gradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.

    Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfoandthekeyword(s)ofinterest.)

    SUMMARYANDRECOMMENDATIONS

    th th

    th th

    Basicstopics(see"Patientinformation:Preeclampsia(TheBasics)"and"Patientinformation:Highbloodpressureandpregnancy(TheBasics)"and"Patientinformation:HELLPsyndrome(TheBasics)")

    BeyondtheBasicstopics(see"Patientinformation:Preeclampsia(BeyondtheBasics)")

    Thedefinitivetreatmentofpreeclampsiaisdeliverytopreventdevelopmentofmaternalorfetalcomplicationsfromdiseaseprogression.Timingofdeliveryisbasedupongestationalage,theseverityofpreeclampsia,andmaternalandfetalcondition.(See'Generalprinciples'above.)

    Preeclampsiawithfeaturesofseveredisease(table2)isgenerallyregardedasanindicationfordelivery,regardlessofgestationalage,giventhehighriskofseriousmaternalmorbidity.However,prolongedantepartummanagementinatertiarycaresettingorinconsultationwithamaternalfetalmedicinespecialistisanoptionforselectedwomenremotefromterm(

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    UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

    REFERENCES

    1. HeardAR,DekkerGA,ChanA,etal.HypertensionduringpregnancyinSouthAustralia,part1:pregnancyoutcomes.AustNZJObstetGynaecol200444:404.

    2. HauthJC,EwellMG,LevineRJ,etal.Pregnancyoutcomesinhealthynulliparaswhodevelopedhypertension.CalciumforPreeclampsiaPreventionStudyGroup.ObstetGynecol200095:24.

    3. Hypertensioninpregnancy:themanagementofhypertensivedisordersduringpregnancy.NICEClinicalGuideline.http://www.guideline.gov/content.aspx?id=24122(AccessedonJanuary11,2012).

    4. AmericanCollegeofObstetriciansandGynecologists,TaskForceonHypertensioninPregnancy.Hypertensioninpregnancy.ReportoftheAmericanCollegeofObstetriciansandGynecologistsTaskForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.

    5. CoppageKH,PolzinWJ.Severepreeclampsiaanddeliveryoutcomes:isimmediatecesareandeliverybeneficial?AmJObstetGynecol2002186:921.

    6. RedmanCW,SacksGP,SargentIL.Preeclampsia:anexcessivematernalinflammatoryresponsetopregnancy.AmJObstetGynecol1999180:499.

    7. NassarAH,AdraAM,ChakhtouraN,etal.Severepreeclampsiaremotefromterm:laborinductionorelectivecesareandelivery?AmJObstetGynecol1998179:1210.

    8. SibaiBM.Diagnosisandmanagementofgestationalhypertensionandpreeclampsia.ObstetGynecol2003102:181.

    9. AlexanderJM,BloomSL,McIntireDD,LevenoKJ.Severepreeclampsiaandtheverylowbirthweightinfant:isinductionoflaborharmful?ObstetGynecol199993:485.

    10. SpongCY,MercerBM,D'altonM,etal.Timingofindicatedlatepretermandearlytermbirth.ObstetGynecol2011118:323.

    11. AmericanCollegeofObstetriciansandGynecologists.ACOGcommitteeopinionno.560:Medicallyindicatedlatepretermandearlytermdeliveries.ObstetGynecol2013121:908.

    12. MageeLA,PelsA,HelewaM,etal.Diagnosis,evaluation,andmanagementofthehypertensivedisordersofpregnancy:executivesummary.JObstetGynaecolCan201436:416.

    13. KoopmansCM,BijlengaD,GroenH,etal.Inductionoflabourversusexpectantmonitoringforgestationalhypertensionormildpreeclampsiaafter36weeks'gestation(HYPITAT):amulticentre,openlabelrandomisedcontrolledtrial.Lancet2009374:979.

    14. VijgenSM,KoopmansCM,OpmeerBC,etal.Aneconomicanalysisofinductionoflabourandexpectantmonitoringinwomenwithgestationalhypertensionorpreeclampsiaatterm(HYPITATtrial).BJOG2010117:1577.

    15. TajikP,vanderTuukK,KoopmansCM,etal.Shouldcervicalfavourabilityplayaroleinthedecisionforlabourinductioningestationalhypertensionormildpreeclampsiaatterm?AnexploratoryanalysisoftheHYPITATtrial.BJOG2012119:1123.

    16. BartonJR,IstwanNB,RheaD,etal.Costsavingsanalysisofanoutpatientmanagementprogramforwomenwithpregnancyrelatedhypertensiveconditions.DisManag20069:236.

    Magnesiumtoxicityisuncommoninwomenwithgoodrenalfunction.Toxicityisrelatedtoserummagnesiumconcentration:lossofdeeptendonreflexesoccursat7to10mEq/L(8.5to12mg/dLor3.5to5.0mmol/L),respiratoryparalysisat10to13mEq/L(12to16mg/dLor5.0to6.5mmol/L),cardiacconductionisalteredat>15mEq/L(>18mg/dLor>7.5mmol/L),andcardiacarrestoccursat>25mEq/L(>30mg/dLor>12.5mmol/L).Calciumgluconate(1gramintravenouslyover5to10minutes)shouldbeadministeredtocounteractlifethreateningsymptomsofmagnesiumtoxicity.(See'Complicationsandsideeffects'above.)

    Thereisanincreasedriskofpreeclampsiarecurrenceinsubsequentpregnanciesandpossiblelongtermrisksofcardiovasculardiseaseandprematuredeath.Earlyonsetpreeclampsiawithseverefeatureshasahigherriskofrecurrencethanmilderdiseasewithonsetatterm.(See'Prognosis'above.)

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    http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=p 12/23

    17. BartonJR,StanzianoGJ,SibaiBM.Monitoredoutpatientmanagementofmildgestationalhypertensionremotefromterm.AmJObstetGynecol1994170:765.

    18. TurnbullDA,WilkinsonC,GerardK,etal.Clinical,psychosocial,andeconomiceffectsofantenataldaycareforthreemedicalcomplicationsofpregnancy:arandomisedcontrolledtrialof395women.Lancet2004363:1104.

    19. WaughJ,BosioP,ShennanA,HalliganA.Inpatientmonitoringonanoutpatientbasis:managinghypertensivepregnanciesinthecommunityusingautomatedtechnologies.JSocGynecolInvestig20018:14.

    20. HelewaM,HeamanM,RobinsonMA,ThompsonL.Communitybasedhomecareprogramforthemanagementofpreeclampsia:analternative.CMAJ1993149:829.

    21. DowswellT,MiddletonP,WeeksA.Antenataldaycareunitsversushospitaladmissionforwomenwithcomplicatedpregnancy.CochraneDatabaseSystRev2009:CD001803.

    22. GoldenbergRL,CliverSP,BronsteinJ,etal.Bedrestinpregnancy.ObstetGynecol199484:131.23. AbdulSultanA,WestJ,TataLJ,etal.Riskoffirstvenousthromboembolisminpregnantwomenin

    hospital:populationbasedcohortstudyfromEngland.BMJ2013347:f6099.24. GordonA,RaynesGreenowC,BondD,etal.Sleepposition,fetalgrowthrestriction,andlatepregnancy

    stillbirth:theSydneystillbirthstudy.ObstetGynecol2015125:347.25. SchiffE,FriedmanSA,KaoL,SibaiBM.Theimportanceofurinaryproteinexcretionduringconservative

    managementofseverepreeclampsia.AmJObstetGynecol1996175:1313.26. HallDR,OdendaalHJ,SteynDW,GrovD.Urinaryproteinexcretionandexpectantmanagementofearly

    onset,severepreeclampsia.IntJGynaecolObstet200277:1.27. vonDadelszenP,PayneB,LiJ,etal.Predictionofadversematernaloutcomesinpreeclampsia:

    developmentandvalidationofthefullPIERSmodel.Lancet2011377:219.28. LindheimerMD,KanterD.Interpretingabnormalproteinuriainpregnancy:theneedforamore

    pathophysiologicalapproach.ObstetGynecol2010115:365.29. UngerC,BiedermannK,SzlobodaJ,etal.[Sodiumconcentrationandpreeclampsia:issaltrestrictionof

    value?].ZGeburtshilfeNeonatol1998202:97.30. NabeshimaK.[Effectofsaltrestrictiononpreeclampsia].NihonJinzoGakkaiShi199436:227.31. MattarF,SibaiBM.Preventionofpreeclampsia.SeminPerinatol199923:58.32. GanzevoortW,RepA,BonselGJ,etal.Arandomisedcontrolledtrialcomparingtwotemporising

    managementstrategies,onewithandonewithoutplasmavolumeexpansion,forsevereandearlyonsetpreeclampsia.BJOG2005112:1358.

    33. ChangEY,MenardMK,VermillionST,etal.Theassociationbetweenhyalinemembranediseaseandpreeclampsia.AmJObstetGynecol2004191:1414.

    34. LangenveldJ,RavelliAC,vanKaamAH,etal.Neonataloutcomeofpregnanciescomplicatedbyhypertensivedisordersbetween34and37weeksofgestation:a7yearretrospectiveanalysisofanationalregistry.AmJObstetGynecol2011205:540.e1.

    35. WallaceDH,LevenoKJ,CunninghamFG,etal.Randomizedcomparisonofgeneralandregionalanesthesiaforcesareandeliveryinpregnanciescomplicatedbyseverepreeclampsia.ObstetGynecol199586:193.

    36. LiYH,NovikovaN.Pulmonaryarteryflowcathetersfordirectingmanagementinpreeclampsia.CochraneDatabaseSystRev2012:CD008882.

    37. AltmanD,CarroliG,DuleyL,etal.Dowomenwithpreeclampsia,andtheirbabies,benefitfrommagnesiumsulphate?TheMagpieTrial:arandomisedplacebocontrolledtrial.Lancet2002359:1877.

    38. LivingstonJC,LivingstonLW,RamseyR,etal.Magnesiumsulfateinwomenwithmildpreeclampsia:arandomizedcontrolledtrial.ObstetGynecol2003101:217.

    39. WitlinAG,SibaiBM.Magnesiumsulfatetherapyinpreeclampsiaandeclampsia.ObstetGynecol199892:883.

    40. CoetzeeEJ,DommisseJ,AnthonyJ.Arandomisedcontrolledtrialofintravenousmagnesiumsulphateversusplacebointhemanagementofwomenwithseverepreeclampsia.BrJObstetGynaecol1998105:300.

    41. RobertsJM,VillarJ,ArulkumaranS.Preventingandtreatingeclampticseizures.BMJ2002325:609.

  • 3/4/2015 Preeclampsia:Managementandprognosis

    http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=p 13/23

    42. LucasMJ,LevenoKJ,CunninghamFG.Acomparisonofmagnesiumsulfatewithphenytoinforthepreventionofeclampsia.NEnglJMed1995333:201.

    43. BelfortMA,AnthonyJ,SaadeGR,etal.Acomparisonofmagnesiumsulfateandnimodipineforthepreventionofeclampsia.NEnglJMed2003348:304.

    44. AlexanderJM,McIntireDD,LevenoKJ,CunninghamFG.Selectivemagnesiumsulfateprophylaxisforthepreventionofeclampsiainwomenwithgestationalhypertension.ObstetGynecol2006108:826.

    45. DuleyL,MatarHE,AlmerieMQ,HallDR.Alternativemagnesiumsulphateregimensforwomenwithpreeclampsiaandeclampsia.CochraneDatabaseSystRev2010:CD007388.

    46. HallDR,OdendaalHJ,SmithM.Istheprophylacticadministrationofmagnesiumsulphateinwomenwithpreeclampsiaindicatedpriortolabour?BJOG2000107:903.

    47. SibaiBM.Magnesiumsulfateprophylaxisinpreeclampsia:Lessonslearnedfromrecenttrials.AmJObstetGynecol2004190:1520.

    48. FDARecommendsAgainstProlongedUseofMagnesiumSulfatetoStopPretermLaborDuetoBoneChangesinExposedBabieshttp://www.fda.gov/downloads/Drugs/DrugSafety/UCM353335.pdf(AccessedonMay30,2013).

    49. SibaiBM,LipshitzJ,AndersonGD,DiltsPVJr.ReassessmentofintravenousMgSO4therapyinpreeclampsiaeclampsia.ObstetGynecol198157:199.

    50. TaberEB,TanL,ChaoCR,etal.Pharmacokineticsofionizedversustotalmagnesiuminsubjectswithpretermlaborandpreeclampsia.AmJObstetGynecol2002186:1017.

    51. EhrenbergHM,MercerBM.Abbreviatedpostpartummagnesiumsulfatetherapyforwomenwithmildpreeclampsia:arandomizedcontrolledtrial.ObstetGynecol2006108:833.

    52. AscarelliMH,JohnsonV,MayWL,etal.Individuallydeterminedpostpartummagnesiumsulfatetherapywithclinicalparameterstosafelyandcosteffectivelyshortentreatmentforpreeclampsia.AmJObstetGynecol1998179:952.

    53. IslerCM,BarrilleauxPS,RinehartBK,etal.Repeatpostpartummagnesiumsulfateadministrationforseizureprophylaxis:isthereapatientprofilepredictiveofneedforadditionaltherapy?JMaternFetalNeonatalMed200211:75.

    54. IslerCM,BarrilleauxPS,RinehartBK,etal.Postpartumseizureprophylaxis:usingmaternalclinicalparameterstoguidetherapy.ObstetGynecol2003101:66.

    55. FontenotMT,LewisDF,FrederickJB,etal.Aprospectiverandomizedtrialofmagnesiumsulfateinseverepreeclampsia:useofdiuresisasaclinicalparametertodeterminethedurationofpostpartumtherapy.AmJObstetGynecol2005192:1788.

    56. MilesJFJr,MartinJNJr,BlakePG,etal.Postpartumeclampsia:arecurringperinataldilemma.ObstetGynecol199076:328.

    57. SmithJM,LoweRF,FullertonJ,etal.Anintegrativereviewofthesideeffectsrelatedtotheuseofmagnesiumsulfateforpreeclampsiaandeclampsiamanagement.BMCPregnancyChildbirth201313:34.

    58. LuJF,NightingaleCH.Magnesiumsulfateineclampsiaandpreeclampsia:pharmacokineticprinciples.ClinPharmacokinet200038:305.

    59. MageeLA,MiremadiS,LiJ,etal.Therapywithbothmagnesiumsulfateandnifedipinedoesnotincreasetheriskofseriousmagnesiumrelatedmaternalsideeffectsinwomenwithpreeclampsia.AmJObstetGynecol2005193:153.

    60. SzalSE,CroughanMinihaneMS,KilpatrickSJ.Effectofmagnesiumprophylaxisandpreeclampsiaonthedurationoflabor.AmJObstetGynecol1999180:1475.

    61. DuffyCR,OdiboAO,RoehlKA,etal.Effectofmagnesiumsulfateonfetalheartratepatternsinthesecondstageoflabor.ObstetGynecol2012119:1129.

    62. GraySE,RodisJF,LettieriL,etal.Effectofintravenousmagnesiumsulfateonthebiophysicalprofileofthehealthypretermfetus.AmJObstetGynecol1994170:1131.

    63. CholstIN,SteinbergSF,TropperPJ,etal.Theinfluenceofhypermagnesemiaonserumcalciumandparathyroidhormonelevelsinhumansubjects.NEnglJMed1984310:1221.

    64. HallakM.Effectofparenteralmagnesiumsulfateadministrationonexcitatoryaminoacidreceptorsintheratbrain.MagnesRes199811:117.

  • 3/4/2015 Preeclampsia:Managementandprognosis

    http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=p 14/23

    65. CottonDB,HallakM,JanuszC,etal.CentralanticonvulsanteffectsofmagnesiumsulfateonNmethylDaspartateinducedseizures.AmJObstetGynecol1993168:974.

    66. BelfortMA,ClarkSL,SibaiB.Cerebralhemodynamicsinpreeclampsia:cerebralperfusionandtherationaleforanalternativetomagnesiumsulfate.ObstetGynecolSurv200661:655.

    67. BerksD,SteegersEA,MolasM,VisserW.Resolutionofhypertensionandproteinuriaafterpreeclampsia.ObstetGynecol2009114:1307.

    68. vanOostwaardMF,LangenveldJ,SchuitE,etal.Recurrenceofhypertensivedisordersofpregnancy:anindividualpatientdatametaanalysis.AmJObstetGynecol2015.

    69. BartonJR,SibaiBM.Predictionandpreventionofrecurrentpreeclampsia.ObstetGynecol2008112:359.70. SibaiBM,MercerB,SarinogluC.Severepreeclampsiainthesecondtrimester:recurrenceriskandlong

    termprognosis.AmJObstetGynecol1991165:1408.71. vanRijnBB,HoeksLB,BotsML,etal.Outcomesofsubsequentpregnancyafterfirstpregnancywithearly

    onsetpreeclampsia.AmJObstetGynecol2006195:723.72. BramhamK,BrileyAL,SeedP,etal.Adversematernalandperinataloutcomesinwomenwithprevious

    preeclampsia:aprospectivestudy.AmJObstetGynecol2011204:512.e1.73. SibaiBM,elNazerA,GonzalezRuizA.Severepreeclampsiaeclampsiainyoungprimigravidwomen:

    subsequentpregnancyoutcomeandremoteprognosis.AmJObstetGynecol1986155:1011.74. CampbellDM,MacGillivrayI,CarrHillR.Preeclampsiainsecondpregnancy.BrJObstetGynaecol1985

    92:131.75. XiongX,FraserWD,DemianczukNN.Historyofabortion,preterm,termbirth,andriskofpreeclampsia:a

    populationbasedstudy.AmJObstetGynecol2002187:1013.76. SibaiBM,SarinogluC,MercerBM.Eclampsia.VII.Pregnancyoutcomeaftereclampsiaandlongterm

    prognosis.AmJObstetGynecol1992166:1757.77. MostelloD,KallogjeriD,TungsiripatR,LeetT.Recurrenceofpreeclampsia:effectsofgestationalageat

    deliveryofthefirstpregnancy,bodymassindex,paternity,andintervalbetweenbirths.AmJObstetGynecol2008199:55.e1.

    78. McDonaldSD,BestC,LamK.Therecurrenceriskofseveredenovopreeclampsiainsingletonpregnancies:apopulationbasedcohort.BJOG2009116:1578.

    79. TrogstadL,SkrondalA,StoltenbergC,etal.Recurrenceriskofpreeclampsiaintwinandsingletonpregnancies.AmJMedGenetA2004126A:41.

    80. ChangJJ,MugliaLJ,MaconesGA.Associationofearlyonsetpreeclampsiainfirstpregnancywithnormotensivesecondpregnancyoutcomes:apopulationbasedstudy.BJOG2010117:946.

    81. WikstrmAK,StephanssonO,CnattingiusS.Previouspreeclampsiaandrisksofadverseoutcomesinsubsequentnonpreeclampticpregnancies.AmJObstetGynecol2011204:148.e1.

    82. BellamyL,CasasJP,HingoraniAD,WilliamsDJ.Preeclampsiaandriskofcardiovasculardiseaseandcancerinlaterlife:systematicreviewandmetaanalysis.BMJ2007335:974.

    83. McDonaldSD,MalinowskiA,ZhouQ,etal.Cardiovascularsequelaeofpreeclampsia/eclampsia:asystematicreviewandmetaanalyses.AmHeartJ2008156:918.

    84. FraserA,NelsonSM,MacdonaldWallisC,etal.Associationsofpregnancycomplicationswithcalculatedcardiovasculardiseaseriskandcardiovascularriskfactorsinmiddleage:theAvonLongitudinalStudyofParentsandChildren.Circulation2012125:1367.

    85. HermesW,FranxA,vanPampusMG,etal.Cardiovascularriskfactorsinwomenwhohadhypertensivedisorderslateinpregnancy:acohortstudy.AmJObstetGynecol2013208:474.e1.

    86. MongrawChaffinML,CirilloPM,CohnBA.Preeclampsiaandcardiovasculardiseasedeath:prospectiveevidencefromthechildhealthanddevelopmentstudiescohort.Hypertension201056:166.

    87. SmithGN,PudwellJ,WalkerM,WenSW.Tenyear,thirtyyear,andlifetimecardiovasculardiseaseriskestimatesfollowingapregnancycomplicatedbypreeclampsia.JObstetGynaecolCan201234:830.

    88. KessousR,ShohamVardiI,ParienteG,etal.Longtermmaternalatheroscleroticmorbidityinwomenwithpreeclampsia.Heart2015101:442.

    89. IrgensHU,ReisaeterL,IrgensLM,LieRT.Longtermmortalityofmothersandfathersafterpreeclampsia:populationbasedcohortstudy.BMJ2001323:1213.

  • 3/4/2015 Preeclampsia:Managementandprognosis

    http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=p 15/23

    90. ChesleySC,AnnittoJE,CosgroveRA.Theremoteprognosisofeclampticwomen.Sixthperiodicreport.AmJObstetGynecol1976124:446.

    91. ChambersJC,FusiL,MalikIS,etal.Associationofmaternalendothelialdysfunctionwithpreeclampsia.JAMA2001285:1607.

    92. AgatisaPK,NessRB,RobertsJM,etal.Impairmentofendothelialfunctioninwomenwithahistoryofpreeclampsia:anindicatorofcardiovascularrisk.AmJPhysiolHeartCircPhysiol2004286:H1389.

    93. LampinenKH,RnnbackM,KaajaRJ,GroopPH.Impairedvasculardilatationinwomenwithahistoryofpreeclampsia.JHypertens200624:751.

    94. YinonY,KingdomJC,OdutayoA,etal.Vasculardysfunctioninwomenwithahistoryofpreeclampsiaandintrauterinegrowthrestriction:insightsintofuturevascularrisk.Circulation2010122:1846.

    95. HermesW,KetJC,vanPampusMG,etal.Biochemicalcardiovascularriskfactorsafterhypertensivepregnancydisorders:asystematicreviewandmetaanalysis.ObstetGynecolSurv201267:793.

    96. MagnussenEB,VattenLJ,LundNilsenTI,etal.Prepregnancycardiovascularriskfactorsaspredictorsofpreeclampsia:populationbasedcohortstudy.BMJ2007335:978.

    97. MagnussenEB,VattenLJ,SmithGD,RomundstadPR.Hypertensivedisordersinpregnancyandsubsequentlymeasuredcardiovascularriskfactors.ObstetGynecol2009114:961.

    98. RomundstadPR,MagnussenEB,SmithGD,VattenLJ.Hypertensioninpregnancyandlatercardiovascularrisk:commonantecedents?Circulation2010122:579.

    99. BytautieneE,BulayevaN,BhatG,etal.LongtermalterationsinmaternalplasmaproteomeaftersFlt1inducedpreeclampsiainmice.AmJObstetGynecol2013208:388.e1.

    100. KaajaRJ,PyhnenAlhoMK.Insulinresistanceandsympatheticoveractivityinwomen.JHypertens200624:131.

    101. KaajaRJ,GreerIA.Manifestationsofchronicdiseaseduringpregnancy.JAMA2005294:2751.102. StekkingerE,ZandstraM,PeetersLL,SpaandermanME.Earlyonsetpreeclampsiaandtheprevalenceof

    postpartummetabolicsyndrome.ObstetGynecol2009114:1076.103. ZandstraM,StekkingerE,vanderVlugtMJ,etal.Cardiacdiastolicdysfunctionandmetabolicsyndromein

    youngwomenafterplacentalsyndrome.ObstetGynecol2010115:101.104. vanRijnBB,NijdamME,BruinseHW,etal.Cardiovasculardiseaseriskfactorsinwomenwithahistoryof

    earlyonsetpreeclampsia.ObstetGynecol2013121:1040.105. BerksD,HoedjesM,RaatH,etal.Riskofcardiovasculardiseaseafterpreeclampsiaandtheeffectof

    lifestyleinterventions:aliteraturebasedstudy.BJOG2013120:924.106. FeigDS,ShahBR,LipscombeLL,etal.Preeclampsiaasariskfactorfordiabetes:apopulationbased

    cohortstudy.PLoSMed201310:e1001425.107. LykkeJA,LanghoffRoosJ,SibaiBM,etal.Hypertensivepregnancydisordersandsubsequent

    cardiovascularmorbidityandtype2diabetesmellitusinthemother.Hypertension200953:944.108. CallawayLK,LawlorDA,O'CallaghanM,etal.Diabetesmellitusinthe21yearsafterapregnancythatwas

    complicatedbyhypertension:findingsfromaprospectivecohortstudy.AmJObstetGynecol2007197:492.e1.

    109. EngelandA,BjrgeT,DaltveitAK,etal.Riskofdiabetesaftergestationaldiabetesandpreeclampsia.Aregistrybasedstudyof230,000womeninNorway.EurJEpidemiol201126:157.

    110. VikseBE,IrgensLM,LeivestadT,etal.Preeclampsiaandtheriskofendstagerenaldisease.NEnglJMed2008359:800.

    111. WangIK,MuoCH,ChangYC,etal.Associationbetweenhypertensivedisordersduringpregnancyandendstagerenaldisease:apopulationbasedstudy.CMAJ2013185:207.

    112. LevineRJ,VattenLJ,HorowitzGL,etal.Preeclampsia,solublefmsliketyrosinekinase1,andtheriskofreducedthyroidfunction:nestedcasecontrolandpopulationbasedstudy.BMJ2009339:b4336.

    113. WilsonKL,CaseyBM,McIntireDD,etal.Subclinicalthyroiddiseaseandtheincidenceofhypertensioninpregnancy.ObstetGynecol2012119:315.

    114. ArnadottirGA,GeirssonRT,ArngrimssonR,etal.Cardiovasculardeathinwomenwhohadhypertensioninpregnancy:acasecontrolstudy.BJOG2005112:286.

    115. MogrenI,StenlundH,HgbergU.Longtermimpactofreproductivefactorsontheriskofcervical,

  • 3/4/2015 Preeclampsia:Managementandprognosis

    http://aplicacionesbiblioteca.udea.edu.co:4560/contents/preeclampsiamanagementandprognosis?topicKey=OBGYN%2F6825&elapsedTimeMs=0&view=p 16/23

    endometrial,ovarianandbreastcancer.ActaOncol200140:849.116. CohnBA,CirilloPM,ChristiansonRE,etal.Placentalcharacteristicsandreducedriskofmaternalbreast

    cancer.JNatlCancerInst200193:1133.117. VattenLJ,RomundstadPR,TrichopoulosD,SkjaervenR.Preeclampsiainpregnancyandsubsequentrisk

    forbreastcancer.BrJCancer200287:971.118. PolednakAP,JanerichDT.Characteristicsoffirstpregnancyinrelationtoearlybreastcancer.Acase

    controlstudy.JReprodMed198328:314.119. AagaardTilleryKM,StoddardGJ,HolmgrenC,etal.PreeclampsiaandsubsequentriskofcancerinUtah.

    AmJObstetGynecol2006195:691.120. PaltielO,FriedlanderY,TiramE,etal.Cancerafterpreeclampsia:followupoftheJerusalemperinatal

    studycohort.BMJ2004328:919.121. CalderonMargalitR,FriedlanderY,YanetzR,etal.Preeclampsiaandsubsequentriskofcancer:update

    fromtheJerusalemPerinatalStudy.AmJObstetGynecol2009200:63.e1.

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    GRAPHICS

    Criteriaforthediagnosisofpreeclampsia

    Systolicbloodpressure140mmHgordiastolicbloodpressure90mmHgontwooccasionsatleastfourhoursapartafter20weeksofgestationinapreviouslynormotensivepatient

    Ifsystolicbloodpressureis160mmHgordiastolicbloodpressureis110mmHg,confirmationwithinminutesissufficient

    and

    Proteinuria0.3gramsina24hoururinespecimenorprotein(mg/dL)/creatinine(mg/dL)ratio0.3

    Dipstick1+ifaquantitativemeasurementisunavailable

    Inpatientswithnewonsethypertensionwithoutproteinuria,thenewonsetofanyofthefollowingisdiagnosticofpreeclampsia:

    Plateletcount1.1mg/dLordoublingofserumcreatinineintheabsenceofotherrenaldisease

    Livertransaminasesatleasttwicethenormalconcentrations

    Pulmonaryedema

    Cerebralorvisualsymptoms

    Adaptedfrom:Hypertensioninpregnancy:ReportoftheAmericanCollegeofObstetriciansandGynecologists'TaskForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.

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    Thepresenceofoneormoreofthefollowingindicatesadiagnosisof"preeclampsiawithseverefeatures"

    Symptomsofcentralnervoussystemdysfunction:

    Newonsetcerebralorvisualdisturbance,suchas:Photopsia,scotomata,corticalblindness,retinalvasospasmSevereheadache(ie,incapacitating,"theworstheadacheI'veeverhad")orheadachethatpersistsandprogressesdespiteanalgesictherapyAlteredmentalstatus

    Hepaticabnormality:

    Severepersistentrightupperquadrantorepigastricpainunresponsivetomedicationandnotaccountedforbyanalternativediagnosisorserumtransaminaseconcentrationtwicenormal,orboth

    Severebloodpressureelevation:

    Systolicbloodpressure160mmHgordiastolicbloodpressure110mmHgontwooccasionsatleastfourhoursapartwhilethepatientisonbedrest(unlessthepatientisonantihypertensivetherapy)

    Thrombocytopenia:

    1.1mg/dLordoublingofserumcreatinineconcentrationintheabsenceofotherrenaldisease)

    Pulmonaryedema

    Incontrasttooldercriteria,the2013criteriadonotincludeproteinuria>5grams/24hoursandfetalgrowthrestrictionasfeaturesofseveredisease.

    Adaptedfrom:Hypertensioninpregnancy:ReportoftheAmericanCollegeofObstetriciansandGynecologists'TaskForceonHypertensioninPregnancy.ObstetGynecol2013122:1122.

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    Peripheralsmearinmicroangiopathichemolyticanemiashowingpresenceofschistocytes

    Peripheralbloodsmearfromapatientwithamicroangiopathichemolyticanemiawithmarkedredcellfragmentation.Thesmearshowsmultiplehelmetcells(smallblackarrows),otherfragmentedredcells(largeblackarrow)microspherocytesarealsoseen(bluearrows).Theplateletnumberisreducedthelargeplateletinthecenter(redarrow)suggeststhatthethrombocytopeniaisduetoenhanceddestruction.

    CourtesyofCarolavonKapff,SH(ASCP).

    Graphic70851Version5.0

    Normalperipheralbloodsmear

    Highpowerviewofanormalperipheralbloodsmear.Severalplatelets(blackarrows)andanormallymphocyte(bluearrow)canalsobeseen.Theredcellsareofrelativelyuniformsizeandshape.Thediameterofthenormalredcellshouldapproximatethat

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    ofthenucleusofthesmalllymphocytecentralpallor(redarrow)shouldequalonethirdofitsdiameter.

    CourtesyofCarolavonKapff,SH(ASCP).

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    Helmetcellsinmicroangiopathichemolyticanemia

    Peripheralsmearsfromtwopatientswithmicroangiopathichemolyticanemia,showinganumberofredcellfragments(ie,schistocytes),someofwhichtaketheformofcombat(redarrow),bicycle(thickblackarrow),orfootball(bluearrow)"helmets."Microspherocytesarealsoseen(thinblackarrows),alongwithanucleatedredcell(greenarrow).

    CourtesyofCarolavonKapff,SH(ASCP).

    Graphic50715Version3.0

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    Deathsfromcardiovascularcauses

    Population Relativehazardrate(95percentconfidenceinterval)

    Nonpreeclamptic,termdelivery

    1

    Nonpreeclamptic,pretermdelivery

    2.95(2.12to4.11)

    Preeclamptic,termdelivery 1.65(1.01to2.70)

    Preeclamptic,pretermdelivery 8.12(4.31to15.33)

    Datafrom:Irgens,HU,Reisaeter,L,Irgens,LM,Lie,RT.BMJ2001323:1213.

    Graphic76674Version1.0

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    Disclosures:ErrolRNorwitz,MD,PhDConsultant/AdvisoryBoards:Hologic[Pretermbirth(Fetalfibronectintesttopredictpretermbirth)]Natera[Fetalaneuploidyscreening(NIPTasascreeningtestforfetalaneuploidy)].PatentHolder:Bayer[Predictiontestforpreeclampsia(Useofurinaryangiogenicfactorstopredictpreeclampsia)].JohnTRepke,MDNothingtodisclose.CharlesJLockwood,MD,MHCMEquityOwnership/StockOptions:Celula[Aneuploidyscreening(PrenatalandcancerDNAscreeningtestsindevelopment)].VanessaABarss,MD,FACOGNothingtodisclose.Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.Conflictofinterestpolicy

    Disclosures