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investigators have suggested an etiologic role for circulating angiogenic factors in preeclampsia based on studies in an animal model and in women with preeclampsia The use of diuretics, dietary restriction or enhancement, sodium restriction, aspirin, and vitamin-mineral supplements such as calcium or vitamin C and E have not yet been confirmed to be useful in clinical studies The only cure is termination of the pregnancy at a time as favorable as possible for fetal survival
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Clinically, the severity of preeclampsia-eclampsia can be measured with reference to the six major sites in which it exerts its effects: the central nervous system, the kidneys, the liver, the hematologic and vascular systems, and the fetalplacental unit By evaluating each of these areas for the presence of mild to moderate versus severe preeclampsiaeclampsia, the degree of involvement can be assessed, and an appropriate management plan can be formulated that is integrated with gestational age assessment (Table 18 2)
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1 Mild to moderate Precise differentiation between mild and moderate preeclampsia is difficult because the abnormalities that define the disease are quite variable and fail to accurately predict progression to more severe disease Symp-
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Table 18 2 Indicators of mild to moderate versus severe preeclampsia-eclampsia
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Site Central nervous system Indicator Symptoms and signs Mild to Moderate Hyperreflexia Headache Seizures Blurred vision Scotomas Headache Clonus Irritability Kidney Proteinuria Uric acid Urinary output Liver AST, ALT, LDH 03 5 g/24 h > 45 mg/dL > 20 30 mL/h Normal > 5 g/24 h or catheterized urine with 4+ protein > 45 mg/dL < 20 30 mL/h Elevated LFTs Epigastric pain Ruptured liver Hematologic Vascular Fetal-placental unit Platelets Hemoglobin Blood pressure Retina Growth restriction Oligohydramnios Fetal distress > 100,000/mcL Normal range < 160/110 mm Hg Arteriolar spasm Absent May be present Absent < 100,000/mcL Elevated > 160/110 mm Hg Retinal hemorrhages Present Present Present Severe
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AST, aspartate aminotransferase; ALT, alanine aminotransferase; LDH, lactate dehydrogenase; LFTs, liver function tests
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placenta and may stabilize or even improve the degree of preeclampsia-eclampsia for a period of time Bed rest may be attempted at home or in the hospital Prior to making this decision, the provider should evaluate the six sites of involvement listed in Table 18 2 and make an assessment about the severity of disease 1 Home management Home management with bed rest may be attempted for patients with mild preeclampsia and a stable home situation This requires homemaking assistance, rapid access to the hospital, a reliable patient, and the ability to obtain frequent blood pressure readings A home health nurse can often provide frequent home visits and assessment 2 Hospital care Hospitalization is required for women with moderate or severe preeclampsia or those with unreliable home situations Regular assessment of blood pressure, reflexes, urine protein, and fetal heart tones and activity are required A complete blood count, platelet count, and electrolyte panel including liver enzymes should be checked every 1 or 2 days A 24-hour urine collection for creatinine clearance and total protein should be obtained on admission and repeated as indicated Sedatives and opioids should be avoided because the fetal central nervous system depressant effects interfere with fetal testing Magnesium sulfate is not used until the diagnosis of severe preeclampsia-eclampsia is made or until labor occurs Fetal evaluation should be obtained as part of the workup If the patient is being admitted to the hospital, fetal testing must be performed on the same day to make certain that the fetus is safe This may be done by fetal heart rate testing with nonstress or stress testing or by biophysical profile A regular schedule of fetal surveillance must then be followed Daily fetal kick counts can be recorded by the patient herself Consideration should be given to amniocentesis to evaluate fetal lung maturity status if hospitalization occurs at 30 37 weeks of gestation If immaturity is present, corticosteroids (betamethasone 12 mg or dexamethasone 16 mg, two doses intramuscularly 12 24 hours apart) can be administered to the mother Fetuses between 26 and 30 weeks of gestation can be presumed to be immature, and corticosteroids should be given The method of delivery is determined by the maternal and fetal status Cesarean section is reserved for the usual fetal indications
toms are generally minimal or mild With mild preeclampsia, patients usually have few complaints, and the diastolic blood pressure is less than 90 100 mm Hg Edema is usually more pronounced with moderate disease, and diastolic blood pressures are in the range of 90 110 mm Hg The platelet count is over 100,000/mcL, antepartum fetal testing is reassuring, central nervous system irritability is minimal, epigastric pain is not present, and liver enzymes are not elevated 2 Severe Symptoms are more dramatic and persistent The blood pressure is often quite high, with readings over 160/110 mm Hg Thrombocytopenia (platelet counts < 100,000/mcL) may be present and progress to disseminated intravascular coagulation Severe epigastric pain may be present from hepatic subcapsular hemorrhage with significant stretch or rupture of the liver capsule The HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is a form of severe preeclampsia
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