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When routine becomes extraordinary: diagnosing and managing early preeclampsia.

Classic preeclampsia occurs at the end of pregnancy, its hallmark a triad of symptoms listed in every textbook: hypertension, swelling, and elevated protein in the urine. We deliver these women, their blood pressures revert to normal, and we move on. Unless these patients have underlying renal disease, their hypertension is unlikely to recur.

But atypical preeclampsia often finds practitioners scratching their heads.

A woman with mild hypertension shows up at a routine prenatal visit in her mid-second trimester--a time when the blood pressure typically goes down. Maybe there's some protein in her urine, but we may feel tempted to shrug off these subtle blips on the radar screen as trivial variations from the norm. And that can be a very serious mistake.

When a woman in her second trimester has an elevation in blood pressure, repeat the reading as many times as necessary to obtain a true picture. Then, figure out why it is high. The mildly elevated reading recorded by the nurse may be the first sign of early preeclampsia, which probably represents a different and more serious disease than does preeclampsia at term.

Some degree of hypertension affects 5%-8% of all pregnancies, making it a significant complication. A small but important percentage of these cases involves mid-second trimester preeclampsia, which has a much higher chance of recurrence (perhaps 40%-50%) than does preeclampsia at the end of pregnancy.

Keeping in mind that medical conditions frequently drive early preeclampsia, consider relevant disorders such as diabetes, chronic hypertension, autoimmune diseases, and thrombophilia. Often, these conditions will have been monitored throughout the pregnancy, but sometimes they may be revealed only by the presence of preeclampsia. General practitioners may have overlooked these conditions or their significance before referring the patient to us.

In one such recent case, we saw a 28-year-old woman with hypertension and 8 g of protein in her urine at 25 weeks' gestation. She had a history of lupus and antiphospholipid syndrome, with previous deep vein thromboses and pulmonary emboli before this pregnancy. She had two previous miscarriages and should have been on low-dose aspirin and heparin before conception, but her local practitioners had overlooked her highly elevated risk for adverse vascular events. No renal studies had been done during her pregnancy, and no maternal-fetal medicine specialist had been consulted.

Once she entered our care, we wondered: Is this a lupus flare? Does all this protein indicate lupus nephritis? Is this early preeclampsia?

In consulation with a rheumatologist and nephrologist--and after an unsuccessful trial of steroids that ruled out a lupus flare--we were able to diagnose lupus nephritis with superimposed preeclampsia. During this patient's highly monitored hospitalization, with labs drawn several times a day, we administered steroids to accelerate the maturation of the baby's lungs. The patient gave birth at 27 weeks, and both she and the baby are doing well.

The scenario demonstrates three points. First, considering a patient's full history early in the pregnancy is crucial to determine whether she may be at risk later, even if she looks healthy in her first trimester. Second, an early consultation with a maternal-fetal medicine specialist and an evaluation at a tertiary care center may prevent a future disaster.

It's important to recognize early preeclampsia quickly and to investigate its causes aggressively, realizing that few people will be experts in the rare conditions that can lead to this complication. In our case, a multidisciplinary approach was vital. However, even the best experts in nephrology will have seen few cases of lupus nephritis in pregnancy. As you begin to sort out differential diagnoses and possible etiologies in your own patients, pay exceedingly close attention to their signs and symptoms, as well as to subtleties in their medical histories.

If a pregnant patient has epigastric pain, first consider HELLP syndrome. Known by its acronym, this condition is characterized by hemolysis, elevated liver enzymes, and low platelets. It may occur at the end of pregnancy, but--like preeclampsia--the syndrome may appear earlier. All too often, when a woman presents with HELLP at her obstetrician's office or an emergency room, she may be misdiagnosed with heartburn, gallstones, or hepatitis. My view is that any woman with epigastric pain in pregnancy has HELLP until testing can exclude that diagnosis.

Consider the possibility that an abnormal placenta may be the cause of early preeclampsia. Autoimmune disorders can lead to placental dysfunction, but so can genetic factors that will not be revealed by a triple screen test. One small segment on one chromosome may be inverted or deleted, causing severe hypertension in midpregnancy, even though ultrasound exams may fail to detect any abnormality in the fetus or placenta. If the cause of early preeclampsia remains a mystery until delivery, order a genetic screen of the placenta or the neonate, since the abnormality may recur in future pregnancies.

Management of early preeclampsia is profoundly challenging in any case. We all know that the best treatment is delivery, but at 24, 25, or 26 weeks, management of preeclampsia gets really dicey. It's a matter of racing against the clock, postponing delivery so as not to jeopardize the fetus, but not waiting so long that the mother's life and health are at stake.

I can't overemphasize the need to hospitalize and intensively monitor such a patient at a tertiary medical center staffed with maternal-fetal medicine specialists. Both the fetus and mother should be meticulously monitored for signs of deterioration that could precipitate an immediate delivery.

Several antihypertensive drugs are appropriate in pregnancy, including hydralazine and labetalol. The goal is to use an agent with an immediate onset of action and then maintain the mother's blood pressure, buying time for the fetus to develop.

In the best-case scenario, the pregnancy can be maintained until the fetus is mature enough to survive with special care in a neonatal intensive care unit. As in the case of near-term preeclampsia, delivery often results in an improvement in the mother's hypertension, although extremely careful follow-up of such patients is required to ensure that the hypertension does not recur.
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Title Annotation:The Master Class
Author:Kay, Helen H.
Publication:OB GYN News
Date:Mar 1, 2004
Words:1003
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