Preeclampsia

doi:10.1097/01.ogx.0000899472.90847.03

Preeclampsia

2022-11-01

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DOI：10.1097/01.ogx.0000899472.90847.03

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Preeclampsia complicates 2% to 4% of all pregnancies globally and is a leading cause of maternal morbidity and mortality. As many as 46,000 maternal and 500,000 fetal deaths occur due to this condition, most in low- and middle-income countries. Although most cases of preeclampsia occur at term, are mild, and resolve after delivery, 5% to 20% of women with the condition experience life-threatening or fatal complications. Generalized edema caused by systemic endothelial damage, increased peripheral vascular resistance, pulmonary edema and acute respiratory distress syndrome, hemorrhagic stroke due to severe hypertension, and ischemic encephalopathy in the posterior hemispheres are all potential effects of severe preeclampsia. In addition, fetal growth restriction and macrosomia, liver damage, relative hemoconcentration, and placental abruption can also occur. This article reviews our current understanding of preeclampsia. The primary focus includes prediction, prevention, diagnosis, and management of preeclampsia, both in pregnancy and long-term. Two main approaches are commonly used to identify women at the highest risk for preeclampsia: the more traditional method includes consideration of clinical risk factors, whereas the other option involves multivariable modeling of clinical, ultrasonographic, and laboratory assessment of uteroplacental function and perfusion. Most clinical practice guidelines advocate for traditional preeclampsia risk screening, but although simple, this approach yields a low detection rate (40% for preterm preeclampsia, 35% for term preeclampsia), and a positive screening rate of 10%. In contrast, the competing-risks model of the Fetal Medicine Foundation provides high detection rates when used at 11 to 13 weeks' gestation for preterm preeclampsia (90%) and at 35 to 36 weeks' gestation for term preeclampsia (75% and 80%, respectively), with a positive screening rate of approximately 10%. The competing-risks model of FetalMedicine Foundation is supported by the largest body of evidence, and comprises components commonly included in other models of assessment, such as body-mass index, blood pressure, maternal ethnic or racial background, angiogenic markers, and ultrasonographic assessment of the uterine-artery pulsatility index. The prevention of preeclampsia is a health care priority, as the only cure for this condition once it has developed is delivery of the placenta. There are, however, evidence-supported preventative strategies that include the use of aspirin, exercise, calcium, and labor induction. Exercise has been shown to reduce the risk of preeclampsia in a review of 15 randomized, controlled trials. To achieve this benefit, a weekly regimen of 140 minutes of moderate-intensity exercise is necessary. The benefits of aspirin were reported in a meta-analysis of 60 trials involving 36,716 women with increased risk of preeclampsia. Aspirin doses of 50 to 162 mg per day reduced preeclampsia risk in a dose-dependent manner, along with lowering rates of preterm birth, serious maternal complications, delivery of small-for-gestational age infants, and fetal or newborn deaths. Calcium supplementation during pregnancy was also shown to be an effective method of prevention for preeclampsia, regardless of whether dosage was begun before or after 20 weeks' gestation. The data were reported in a meta-analysis of 30 trials involving a total of 20,445 women. The ultimate purpose of diagnosing preeclampsia is to identify those women at greatest risk for adverse outcomes to optimize their management. Women with early-onset preeclampsia (<34 weeks' gestation) are more likely than those with late-term diagnoses (=34 weeks' gestation) to develop end-organ involvement, fetal growth restriction, and a hemodynamic profile of high peripheral vascular resistance and low cardiac output. Therefore, although management of all preeclampsia cases is vital, it is of particular necessity to identify early-onset cases. Management can include several factors: first, a predetermined place of care (ideally within 30 minutes of home); second, consistent monitoring of both the fetus' and the mother's symptoms, especially through assessment of fetal growth and Doppler ultrasonography; third, timing the birth is critical, as is recognition that end-organ complications can continue to worsen for up to 3 days after delivery. Thus, consideration of early birth at all stages of pregnancy with fetal viability is imperative to reduce maternal complications without increasing neonatal complications. Fourth, treatment of hypertension is warranted, as prolonged hypertension in pregnant women can lead to similar adverse fetal outcomes as those created by preeclampsia. Guideline-recommended treatments included oral nifedipine, parenteral labetalol, or parenteral hydralazine. The World Health Organization also recommends the treatment of less severe hypertension in pregnancy. Finally, magnesium sulfate is effective in the treatment of preeclampsia, but implementation of this treatment has proven difficult. Ongoing studies are ongoing, including of lower dosage treatments or abbreviated duration. The use of glucocorticoids has not been shown to improve clinical outcomes. Treatment of preeclampsia in the postpartum period is also of paramount importance, as preeclampsia during this time period results in the highest rates of maternal complications and death. Preeclampsia diagnosis during the postpartum period is also associated with higher rates of mental health problems. Preeclampsia diagnosis during any pregnancy increases the risk for subsequent preeclampsia in future pregnancies, as demonstrated by a meta-analysis of data from individual participants in 22 studies, involving a total of 99,415 women. The recurrence rate is as high as 50% for those with early-onset preeclampsia. In addition, preeclampsia diagnoses are linked to long-term cardiovascular risks. Although the link between these 2 conditions is not fully understood (eg, caused solely by preeclampsia or other factors that also contributed to the preeclampsia diagnosis itself), it is certain that this link exists. As a cautionary measure, the American Heart Association recommends women affected by hypertension during pregnancy (including preeclampsia) undergo cardiovascular risk screening within 3 months postdelivery. Further research regarding preeclampsia and treatment therapies for this disease are necessary to further improve the ability of health care providers to reduce maternal and fetal risks associated with preeclampsia diagnosis.

Preeclampsia

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