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Preeclampsia

Pre-eclampsia

Preeclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema.


Presentation

Diagnosing preeclampsia may be a little difficult as the mild to moderate forms may be asymptomatic and hence, most cases are detected through routine prenatal check-ups. A patient suffering from preeclampsia may present with the following signs and symptoms which are usually endorgan effects: headache, blurred vision, altered mental state, cortical or retinal blindness, edema of the lower limbs or facial edema, dyspnoea, abdominal pain and weakness [5]. There is high blood pressure as a rule.

Complications include seizures, stoke, pulmonary edema, heart failure, blindness and bleeding post-delivery. It is one of the leading causes of premature births, the complications of which include: cerebral palsy, epilepsy and learning disabilities. It also causes stillbirths.

HELLP Syndrome
  • Successful use of Eculizumab in this case suggests that complement inhibition may be an effective treatment strategy for severe preeclampsia/HELLP syndrome. Copyright 2012 Elsevier Ltd. All rights reserved.[ncbi.nlm.nih.gov]
  • KEYWORDS: Encephalopathy; Hellp syndrome; preeclampsia[ncbi.nlm.nih.gov]
  • BACKGROUND: Illnesses coincident with pregnancy may present similarly to preeclampsia or may be mistaken for severe preeclampsia or hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome.[ncbi.nlm.nih.gov]
  • After physical examination and laboratory tests, the patient was diagnosed with severe preeclampsia, HELLP syndrome, placental abruption, and MODS.[ncbi.nlm.nih.gov]
  • Preeclamptic crisis with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome developed postpartum. Blood pressures remained severely high. Intensive care management and a labetalol drip resolved the crisis.[ncbi.nlm.nih.gov]
Weight Gain
  • The purpose of this paper was to examine gestational weight gain in the Norwegian Fit for Delivery study among women who developed preeclampsia compared to those who did not, and to further explore associations between weight gain and preeclampsia by[ncbi.nlm.nih.gov]
  • A 37-year-old nulliparous woman was admitted to our hospital at gestational week (GW) 24(-1/7) due to rapid weight gain (6.2 kg/4 weeks) and oligohydramnios.[ncbi.nlm.nih.gov]
  • Common symptoms include : High blood pressure (Hypertension) Swelling Sudden weight gain Headaches Changes in vision However, some women may have few outward symptoms and many symptoms (such as swelling and weight gain) are changes that women naturally[medelabreastfeedingus.com]
  • gain NEC 646.1 face presentation 652.4 failure, fetal head to enter pelvic brim 652.5 false labor (pains) 644.1 fatigue 646.8 fatty metamorphosis of liver 646.7 female genital mutilation 648.9 fetal fibroid (tumor) (uterus) 654.1 footling presentation[icd9data.com]
  • Other common preeclampsia signs include swollen hands and feet, rapid weight gain, headaches, and protein in the urine.[momtastic.com]
Multiple Organ Dysfunction Syndrome
  • BACKGROUND AND OBJECTIVE: Preeclampsia is a multiple organ dysfunction syndrome (MODS) for its typical and atypical manifestations including hypertension, proteinuria, HELLP syndrome, hypertensive encephalopathy and coagulopathy.[ncbi.nlm.nih.gov]
Orthopnea
  • This case illustrates that we should bear in mind the possibility of PPCM if orthopnea develops while delivery is approaching in a parturient with preeclampsia.[ncbi.nlm.nih.gov]
Vomiting
  • She presented to Felegehiwot Referal Hospital with a principal complaint of vomiting, epigastric pain, headache, and blurring of vision.[ncbi.nlm.nih.gov]
  • […] dysplasia, cervix 654.6 early onset of delivery (spontaneous) 644.2 eclampsia, eclamptic (coma) (convulsions) (delirium) (nephritis) (uremia) 642.6 edema 646.1 effusion, amniotic fluid 658.1 embolism emesis (gravidarum) - see Pregnancy, complicated, vomiting[icd9data.com]
  • Nausea or vomiting. Some women experience nausea and vomiting throughout their pregnancy. However, for most women, morning sickness will go away after the first trimester.[intermountainhealthcare.org]
  • Nausea or vomiting iStock/nd3000 Morning sickness should disappear after the first trimester, so if you all of a sudden have nausea or vomiting in the second or third trimester, chances are it’s caused by something else.[rd.com]
  • Back to top Nausea or Vomiting Nausea or vomiting is particularly significant when the onset is sudden and after mid-pregnancy.[preeclampsia.org]
Nausea
  • Nausea or vomiting. Some women experience nausea and vomiting throughout their pregnancy. However, for most women, morning sickness will go away after the first trimester.[intermountainhealthcare.org]
  • Nausea or vomiting iStock/nd3000 Morning sickness should disappear after the first trimester, so if you all of a sudden have nausea or vomiting in the second or third trimester, chances are it’s caused by something else.[rd.com]
  • Back to top Nausea or Vomiting Nausea or vomiting is particularly significant when the onset is sudden and after mid-pregnancy.[preeclampsia.org]
  • Further symptoms As pre-eclampsia progresses, it may cause: severe headaches vision problems, such as blurring or seeing flashing lights severe heartburn pain just below the ribs nausea or vomiting excessive weight gain caused by fluid retention feeling[nhs.uk]
  • Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right abdominal pain. HELLP syndrome is particularly dangerous because it represents damage to several organ systems.[mayoclinic.org]
Epigastric Pain
  • Although extremely rare, aortic dissection might be a possibility in preeclampsia pregnant women, the differential diagnosis of chest and/or epigastric pain in preeclampia patient should be thoroughly investigated and treated.[ncbi.nlm.nih.gov]
  • She presented to Felegehiwot Referal Hospital with a principal complaint of vomiting, epigastric pain, headache, and blurring of vision.[ncbi.nlm.nih.gov]
  • Epigastric pain, thrombocytopenia, and visual disturbances are strong indications for delivery of the fetus. For mild to moderate preeclampsia-eclampsia, bed rest is the cornerstone of therapy.[health.am]
  • These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures.[ncbi.nlm.nih.gov]
  • […] hypertension occurring after 20 weeks gestation and resolving within 3 months of delivery with the following specific features: SBP 140mmHg or DBP 90mmHg one or more of proteinuria ( 0.3g/24hrs) renal impairment – proteinuria, high Cr liver disease – epigastric[lifeinthefastlane.com]
Morning Sickness
  • Nausea and dizziness Chances are, you’ll feel dizzy and queasy at some point while expecting (hello, morning sickness!)[momtastic.com]
  • However, for most women, morning sickness will go away after the first trimester. If nausea and vomiting come back after mid-pregnancy, it can be a sign you’re developing preeclampsia.[intermountainhealthcare.org]
  • Nausea or vomiting iStock/nd3000 Morning sickness should disappear after the first trimester, so if you all of a sudden have nausea or vomiting in the second or third trimester, chances are it’s caused by something else.[rd.com]
  • QUESTION Nothing can relieve the symptoms of morning sickness. See Answer What are complications of preeclampsia and eclampsia? Preeclampsia reduces the amount of blood flow to the placenta and the fetus.[medicinenet.com]
Hypertension
  • Hypertensive disease in pregnancy is associated with a spectrum of severity, ranging from mild pregnancy-induced hypertension to eclampsia.[ncbi.nlm.nih.gov]
  • Gestational hypertension developed in 8% (9% vs. 6%) and preeclampsia developed in 8% (9% vs. 7%).[ncbi.nlm.nih.gov]
  • […] eclampsia were at increased risks for subsequent diagnoses of diabetes, dyslipidemia, hypertension, congestive heart failure and cerebrovascular disease.[ncbi.nlm.nih.gov]
  • Abstract An asymptomatic 40-year-old para 1 black African woman with pre-existing hypertension and a booking blood pressure of 120/80 mm Hg, was admitted with superimposed preeclampsia diagnosed because of worsening hypertension and significant proteinuria[ncbi.nlm.nih.gov]
  • Up-to-Date elaborates a little further on this by defining preeclampsia as "the new onset of hypertension and proteinuria, or hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks of gestation in a previously normotensive[ncbi.nlm.nih.gov]
Heart Failure
  • […] eclampsia were at increased risks for subsequent diagnoses of diabetes, dyslipidemia, hypertension, congestive heart failure and cerebrovascular disease.[ncbi.nlm.nih.gov]
  • Abstract We report the case of a 26-year-old woman with severe renal and congestive heart failure as a primary manifestation of systemic lupus erythematosus after her premature terminated pregnancy for the symptoms of preeclampsia with HELLP syndrome.[ncbi.nlm.nih.gov]
  • Sunitinib-associated cardiotoxicity has been recognized and includes hypertension, left ventricular dysfunction and congestive heart failure; nevertheless, few data exist in the literature regarding the role of preeclampsia-related angiogenic factors[ncbi.nlm.nih.gov]
  • Complications include seizures, stoke, pulmonary edema, heart failure, blindness and bleeding post-delivery. It is one of the leading causes of premature births, the complications of which include: cerebral palsy, epilepsy and learning disabilities.[symptoma.com]
  • In moms-to-be, preeclampsia can cause rare but serious complications that include: Stroke Seizure Water in the lungs Heart failure Reversible blindness Bleeding from the liver Bleeding after you've given birth Preeclampsia can also cause the placenta[webmd.com]
Chloasma
  • […] buttocks) (complete) (frank) 652.2 cardiovascular disease (conditions classifiable to 390 - 398, 410 - 429 ) 648.6 cerebrovascular disorders (conditions classifiable to 430 - 434, 436 - 437 ) 674.0 cervicitis (conditions classifiable to 616.0 ) 646.6 chloasma[icd9data.com]
Facial Edema
  • A patient suffering from preeclampsia may present with the following signs and symptoms which are usually endorgan effects: headache, blurred vision, altered mental state, cortical or retinal blindness, edema of the lower limbs or facial edema, dyspnoea[symptoma.com]
  • Increasing maternal facial edema and rapid weight gain also should be noted because fluid retention often is associated with preeclampsia.[aafp.org]
Kidney Failure
  • If left untreated, pre-eclampsia can lead to serious problems such as: fitting or convulsions kidney failure liver failure blood clotting problems death.[betterhealth.vic.gov.au]
  • Until now, pre-eclampsia -- which, in its more severe forms, can lead to brain haemorrhages, oedema of the lungs and kidney failure -- could only be clarified by elaborate tests.[sciencedaily.com]
  • Comparing the obese and non-obese members of this group, the researchers found that the obese women were less than half as likely to have had any of the more serious outcomes of severe preeclampsia, which include stroke, liver failure, kidney failure,[dailymail.co.uk]
  • Risks of preeclampsia can include: Seizures in the mother Stroke or bleeding in the brain Temporary kidney failure Liver problems Blood clotting problems Placental abruption : The placenta pulls away from the wall of the uterus, causing distress to the[my.clevelandclinic.org]
  • Other complications can include: bleeding problems due to low platelet levels placental abruption (breaking away of the placenta from the uterine wall) damage to the liver kidney failure pulmonary edema Complications for the baby can also occur if they[healthline.com]
Oliguria
  • Oliguria was also removed as a characteristic of severe disease. [3] There have been several cases reported in the literature as well as by Obstetricians citing the incidence of preeclampsia occurring upwards of 6 to even 12 weeks postpartum.[ncbi.nlm.nih.gov]
  • Oliguria (urine output 500 cc/day) indicates a much more severe clinical picture. Sudden onset or worsening of edema is a cause of concern in preeclamptic patients. Thrombocytopenia and liver damage are other clinical manifestations.[renalandurologynews.com]
  • […] maternal age multiple pregnancy high BMI conception before age 20 connective tissue disorders protein C and S deficiencies factor V leiden mutation hyperhomocysteinemia EXAMINATION BP 140/90 hyperreflexic agitated epigastric or RUQ pain pulmonary oedema oliguria[lifeinthefastlane.com]
  • The condition is termed as severe preeclampsia when one of the following signs or symptoms is present: systolic blood pressure 160 mm Hg or when the diastolic blood pressure is 110 mm Hg or more, along with proteinuria, oliguria, pulmonary edema and frequent[symptoma.com]
  • Oliguria of 500 mL in 24 hours. Thrombocytopenia. Hemolysis, elevated liver enzymes, low platelets (HELLP). Pulmonary edema. Fetal growth restriction.[health.am]
Headache
  • CASE: We present a patient who, at 27 3/7 weeks of gestation, fulfilled diagnostic criteria for severe preeclampsia, including hypertension, proteinuria, headache, abnormal serum creatinine levels, thrombocytopenia, and liver function abnormalities, but[ncbi.nlm.nih.gov]
  • Disease definition Preeclampsia is a hypertensive disorder of pregnancy that is characterized by new-onset hypertension with proteinuria presenting after 20 weeks of gestation, and depending on mild or severe forms may initially present with severe headache[orpha.net]
  • On the second day postpartum, the patient developed severe hypertension, visual symptoms, confusion, headache, and eclamptic fits. Head computed tomography (CT) showed hypodense basal ganglia lesions.[ncbi.nlm.nih.gov]
  • Severe headache Headaches, of course, are common during pregnancy (sinus congestion is often the cause), but severe headaches or headaches that won’t go away may signal preeclampsia. 3.[momtastic.com]
  • She presented to Felegehiwot Referal Hospital with a principal complaint of vomiting, epigastric pain, headache, and blurring of vision.[ncbi.nlm.nih.gov]
Seizure
  • We report the case of a patient with pre-eclampsia who developed seizures after more than 2 days of delivery.[ncbi.nlm.nih.gov]
  • Priority must be given to controlling blood pressure and seizures.[symptoma.com]
  • The seizure may be stopped by giving an intravenous bolus of either magnesium sulfate, 4 g, or diazepam, 5-10 mg, over 4 minutes or until the seizure stops.[health.am]
  • Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures.[ncbi.nlm.nih.gov]
  • She responded well to therapy, which included antihypertensives, seizure prophylaxis and operative delivery. Vision was restored by the third day. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
Hyperreflexia
  • […] a hypertensive disorder of pregnancy that is characterized by new-onset hypertension with proteinuria presenting after 20 weeks of gestation, and depending on mild or severe forms may initially present with severe headache, visual disturbances, and hyperreflexia[orpha.net]
  • We present an unusual case of third nerve palsy, (presenting as diplopia, ptosis) with hypertension, hyperreflexia, proteinuria, easy bruising in a parturient at 34 6/52 weeks of twins gestation.[ncbi.nlm.nih.gov]
  • Back to top Hyperreflexia Hyperreflexia is when your reflexes are so strong that when your knee is tapped by a rubber “hammer,” your leg bounces back hard.[preeclampsia.org]
  • With hyperreflexia, you’d kick him over—or at least have a really strong reflex. “Hyperreflexia occurs due to central nervous system irritability because of brain swelling,” Dr. Pollio says.[rd.com]
  • Increasing blood pressure will lead to increasing hyperreflexia (overactive reflexes), until eventually uncontrollable seizures result.[medbroadcast.com]
Agitation
  • FACTORS PET during another pregnancy advanced maternal age multiple pregnancy high BMI conception before age 20 connective tissue disorders protein C and S deficiencies factor V leiden mutation hyperhomocysteinemia EXAMINATION BP 140/90 hyperreflexic agitated[lifeinthefastlane.com]

Workup

Women, who present with hypertension during pregnancy i.e. new onset hypertension, should have the following tests as mentioned: complete blood counts, serum creatinine, uric acid, serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, 24-hour urine collection to check for protein and creatinine [6].

If HELLP syndrome is suspected, the following tests are to be done: peripheral blood smear, indirect bilirubin and serum lactate dehydrogenase (LDH) level. Prothrombin time and platelet count may also be done [5] [6]. A head CT scan may be done to detect intracranial haemorrhage in patients who present with sudden severe headaches and seizures. It is also important to assess the status of the fetus by doing an utrasonogaphy.

Bilateral Pulmonary Infiltrate
  • Chest plain film showed acute pulmonary edema, bilateral pulmonary infiltration with interstitial patches, and cardiomegaly. Postpartum cardiomyopathy was diagnosed afterward by echocardiography.[ncbi.nlm.nih.gov]
Pancreatic Necrosis
  • Autopsy revealed extensive acute pancreatic necrosis, pleural effusions, ascites, and fatty liver without evidence of microthrombi. The cause of death was acute necrotizing pancreatitis resulting from severe preeclampsia.[ncbi.nlm.nih.gov]

Treatment

In cases of preeclampsia, delivery at the earliest is the only cure. It is usually induced after the 37th week of pregnancy and in severe cases, delivery should be considered after the 34th week of gestation. However, if a patient presents with severe preeclampsia before 34 weeks gestation but appears to be stable and if the condition of the foetus is reassuring, expectant management may be considered if the patient meets the criteria set by Sibai et al. Also, it should only be considered in a tertiary centre. 

Delivery might not be the best option if the fetus is still premature. Before taking any step towards expectant management, a patient must be evaluated for at least 24 hours during which all laboratory values must fall within the normal range. Priority must be given to controlling blood pressure and seizures. It is important to deliver the fetus when there is uncontrollable blood pressure, ruptured membranes, oligohydraminos, non-reassuring fetal heart status, increased levels of serum creatinine and dyspnea. In case of seizures, the airway, breathing and circulation (ABC) should be monitored; magnesium sulphate is the treatment of choice for seizures and is a prophylactic treatment indicated in severe eclampsia [7]. Lorazepam and phenytoin are second-line treatments for seizures.

Various medications such as hydralazine, nifedipine and sodium nitroprusside is used to control blood pressure. To manage fluids patients should be fluid restricted when possible, diuretics should be avoided, and total fluids should be restricted to 80 ml/hour. A check must be kept on liver function tests and the blood pressure levels prior to hospital discharge. Postpartum patients on blood pressure medication should be carefully monitored for up to 4 weeks to rule out recurrent preeclampsia [7] [8].

Prognosis

The prognosis of preeclampsia is not well defined, however most women will have positive outcomes for their pregnancies that have been complicated by preeclampsia. Signs and symptoms generally go away within 6 weeks after pregnancy. Some women will continue to have problems with their blood pressure and will thus need to be monitored closely during the post-partum period.

Most babies do well however, premature babies require a longer stay in the hospital. Seizures during the post-partum period are an uncommon complication. If a woman develops preeclampsia at the end of her pregnancy, she has around 10% chances of developing pre-eclampsia in the subsequent pregnancy. In cases of severe preeclampsia, the woman has a 20% risk of developing it in subsequent pregnancies.

Etiology

The etiology of preeclampsia is presently unknown although there are around 4 hypotheses which point out to the most probable cause.

The first hypothesis is that of placental ischemia which causes increased trophoblast deploration. Secondly, it could be due to very low-density lipoprotein (VLDL) toxicity wherein to compensate for the increased energy demand during pregnancy, non-esterified fatty acids are mobilized. The third hypothesis suggests an immune maladaptation which causes a shallow invasion of the spiral arteries by the endovascular cytotrophoblast cells [2]. And lastly, genetic imprinting; it is thought that preeclampsia might be the result of a single recessive gene or one dominant gene having incomplete manifestation.

Epidemiology

Preeclampsia is commonly seen in women who are nulliparous, above the age of 40 years, is more common amongst the black race and when there is a family history of the disease.

Women with chronic renal disease, diabetes mellitus, high body mass index, anti-phospholipid syndrome and chronic hypertension are also predisposed to developing preeclampsia in their pregnancies. Women with twin pregnancies are also at a risk for the same.

Among all cases, 10% occur in pregnancies of less than 34 weeks gestation. In developing countries, the incidence is 4-18% [3].

Sex distribution
Age distribution

Pathophysiology

Usually, in normal pregnancies the villous cytotrophoblast invades the inner third of the myometrium. The spinal arteries shed the endothelium and majority of their muscle fibres, because of which they become low-resistance vessels making them poorly sensitive, almost insensitive, to vasoconstrictive substances.

The primary cause of preeclampsia is abnormal placentation which is caused by an abnormal invasion of the cytotrophoblast cells into the spiral arteries [3] [4]. The abnormalities may also be associated with the nitric oxide pathway, that is known to contribute to vascular tone and play a role in the inhibition of maternal synthesis of nitric oxide that prevents embryo implantation. An increased resistance from uterine arteries leads to higher sensitivity to vasoconstriction. This effectively causes chronic placental ischemia and increased oxidative stress.

All these factors lead to fetal complications such as intrauterine growth retardation and intrauterine death. Also, oxidative stress causes release of oxidized lipids, cytokines, free radicals, and serum soluble vascular endothelial growth factor 1 (VEGF 1) into the maternal circulation. All these factors thus, contribute to endothelial dysfunction with vascular hyper permeability, thrombophilia and hypertension to make up for the reduced blood supply through the uterine arteries due to peripheral vasoconstriction [4].

The impairment of the hepatic endothelium contributes to the onset of HELLP (Hemolysis, Elevated Liver Enzymes and Low Platelet count) syndrome. THre is also depletion of vascular endothelial growth factors in the podocytes that blocks the slit diaphragms situated in the basement membranes, further adding to reduction in glomerular filtration ultimately producing proteinuria. Vascular hyperpermeability usually associated with low serum albumin causes oedema [4].

Prevention

There is no particular way to prevent preeclampsia as it is usually diagnosed during antenatal check-ups [9]. Also, preeclampsia is an important disease to screen as it increases maternal and perinatal morbidity and mortality.

No appropriate test is present so far so the only possible way to prevent it would be early detection of modifiable risk factors. For example, nulliparous women above the age of 35 are at higher risk and therefore, interventional care must be provided at the appropriate time.

To prevent the complications of preeclampsia, it is very important to monitor the blood pressure levels frequently, it may help if the placental growth factors and vascular endothelial growth factor levels are monitored [9] [10]. Increased vascular endothelial growth factor combined with decreased placental growth factor is associated with an increased risk of preeclampsia [10]. All these steps for early detection of preeclampsia can enable a practitioner to take the appropriate measures at the right time.

Summary

Preeclampsia is a disorder of the vascular endothelium that generally occurs after the 20th week of pregnancy. It is characterized by hypertension and proteinuria with or without the presence of pathological edema.

Mild preeclampsia is usually diagnosed when the blood pressure of a pregnant woman is found to be ≥ 140/90 mm Hg [1]. The condition is termed as severe preeclampsia when one of the following signs or symptoms is present: systolic blood pressure ≥ 160 mm Hg or when the diastolic blood pressure is 110 mm Hg or more, along with proteinuria, oliguria, pulmonary edema and frequent headaches.

There may be signs of impaired foetal growth as well. The HELLP (haemolysis, elevated liver enzyme, low platelets) syndrome may complicate severe preeclampsia as well.

Patient Information

Preeclampsia is a pregnancy related disease whose course cannot be predicted. It can have severe consequences on the life of the mother and the foetus. It is characterized by an elevated blood pressure measuring ≥ 140/90 mm Hg. The patient may experience severe headaches; pain in the stomach, dizziness and shortness of breath.

This disease is usually seen in a woman who is expecting a child when she is above the age of 35 years. There is no known way of preventing preeclampsia however; early diagnosis can reduce the risk of the complications such as the development of seizures, heart failure and liver affections in the mother and also the possibility of a premature baby.

The only way of treating preeclampsia is delivery of the baby. If the pregnancy is not up to term then, then there is a risk if the baby is born premature. It can lead to cerebral palsy, epilepsy and learning disabilities in the baby. Complications of preeclampsia can be controlled if the blood pressure of the mother is monitored regularly.

References

Article

  1. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. ACOG Technical Bulletin No. 219. Washington DC: 1996.
  2. Zhou Y, Damsky CH, Fisher SJ. Preeclampsia is associated with failure of human cytotrophoblasts to mimic a vascular adhesion phenotype. One cause of defective endovascular invasion in this syndrome. J Clin Invest. 1997 May 1;99(9):2152-64.
  3. Villar J, Betran AP, Gulmezoglu M. Epidemiological basis for the planning of maternal health services.WHO/RHR. 2001.
  4. Zhou Y, Damsky CH, Chiu K, et al. Preeclampsia is associated with abnormal expression of adhesion molecules by invasive cytotrophoblasts. J Clin Invest. 1993 Mar;91(3):950-60.
  5. Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005 Feb;105(2):402-10.
  6. Baweja S, Kent A, Masterson R, Roberts S, McMahon L. Prediction of pre-eclampsia in early pregnancy by estimating the spot urinary albumin: creatinine ratio using high-performance liquid chromatography. B J OG. 2011 Aug;118(9):1126-32.
  7. Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol. 2004 Jun;190(6):1520-6.
  8. Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol. 2007 Jun;196(6):514.e1-9.
  9. Sibai BM. Prevention of preeclampsia: a big disappointment. Am J Obstet Gynecol. 1998 Nov;179(5):1275-8.
  10. Wagner LK. Diagnosis and management of preeclampsia. Am Fam Physician. 2004 Dec 15;70(12):2317-24.

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Last updated: 2017-08-09 17:20