Gerda G. Zeeman

The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP

There has never been a definite consensus on the classification and diagnostic criteria for the hypertensive disorders of pregnancy. This uncertainty is likely to have led to between-centre differences in rates of adverse maternal and foetal outcomes for the various hypertensive disorders in pregnancy, particularly pre-eclampsia. In 2000, the International Society for the Study of Hypertension in Pregnancy (ISSHP) recognised that this lack of consensus was one reason for controversies concerning counselling, management and documentation of immediate and remote pregnancy outcomes. Accordingly, the Society appointed a committee that reviewed available classifications and endorsed and published an international recommendation for how these disorders should be classified and diagnosed in pregnancy [1]. The major stumbling block remained whether or not proteinuria should be retained as a sine qua non for the diagnosis of pre-eclampsia; the Society recommended that a broad definition, at times not including proteinuria, could be applied for the clinical definition of pre-eclampsia whilst the inclusion of proteinuria would ensure more specificity around the diagnosis when reporting clinical criteria for patients enrolled in scientific research. The purpose of this document is to update ISSHP thinking on this subject.

Preeclampsia: At Risk for Remote Cardiovascular Disease

Epidemiological data indicate that women with preeclampsia are more likely to develop cardiovascular disease (CVD) later in life. Population-based studies relate preeclampsia to an increased risk of later chronic hypertension (RR, 2.00 to 8.00) and cardiovascular morbidity/mortality (RR, 1.3 to 3.07), compared with normotensive pregnancy. Women who develop preeclampsia before 36 weeks of gestation or have multiple hypertensive pregnancies are at highest risk (RR, 3.4 to 8.12). The underlying mechanism for the remote effects of preeclampsia is complex and probably multifactorial. Many risk factors are shared by CVD and preeclampsia, including endothelial dysfunction, obesity, hypertension, hyperglycemia, insulin resistance, and dyslipidemia. Therefore, it has been proposed that the metabolic syndrome may be a possible underlying mechanism common to CVD and preeclampsia. Follow-up and counseling of women with a history of preeclampsia may offer a window of opportunity for prevention of future disease.

The definition of severe and early-onset preeclampsia. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP)

OBJECTIVE There is discrepancy in the literature on the definitions of severe and early-onset pre-eclampsia. We aimed to determine those definitions for clinical purposes and to introduce them in the classification of the hypertensive disorders of pregnancy for publication purposes. METHODS We circulated a questionnaire to the International Committee of the International Society for the Study of Hypertension in Pregnancy focusing on the thresholds for defining severe preeclampsia and the gestation at which to define early-onset preeclampsia, and on the definition and inclusion of the HELLP syndrome or other clinical features in severe preeclampsia. The questions were closed, but all answers had space for more open detailed comments. RESULTS There was a general agreement to define preeclampsia as severe if blood pressure was >160mmHg systolic or 110mmHg diastolic. There was scarce agreement on the amount of proteinuria to define severity. The HELLP syndrome was considered a feature to include in the severe classification. Most investigators considered early-onset preeclampsia as that occurring before 34weeks. CONCLUSIONS A definition of pre-eclampsia is paramount for driving good clinical practice. Classifications on the other hand are useful to enable international comparisons of clinical data and outcomes. We used the results of this survey to update our previous classification for the purposes of providing clinical research definitions of severe and early onset pre-eclampsia that will hopefully be accepted in the international literature.

Neurologic Complications of Pre-eclampsia

Pre-eclampsia is mainly responsible for the worlds large maternal mortality rates, mostly due to acute cerebral complications. This review provides insight into the pathogenesis of the neurologic complications of hypertensive disease in pregnancy. In addition, practical relevance for clinical care is highlighted. Pertaining to pregnancy, the blood pressure level at which cerebral autoregulation operates and possible deregulation occurs is unknown, but is likely to be variable. From clinical observation, eclampsia may occur despite a mild clinical picture and before the development of hypertension or proteinuria. Furthermore, failure of cerebrovascular autoregulatory mechanisms in response to either an acute and/or relatively large blood pressure increase may be more important than the absolute blood pressure value. It may be the acuity of the blood pressure rise in the setting of endothelial dysfunction that interrupts the delicate balance between capillary and cellular perfusion pressures that leads to the neurological complications of pre-eclampsia.

A systematic review of the effectiveness of training in emergency obstetric care in low-resource environments

Please cite this paper as: van Lonkhuijzen L, Dijkman A, van Roosmalen J, Zeeman G, Scherpbier A. A systematic review of the effectiveness of training in emergency obstetric care in low‐resource environments. BJOG 2010;117:777–787.

Brain lesions several years after eclampsia

OBJECTIVE Eclampsia is thought to have no long-term neurological consequences. We aimed to delineate the neurostructural sequelae of eclampsia, in particular brain white matter lesions, utilizing high-resolution 3-Tesla magnetic resonance imaging (MRI). STUDY DESIGN Formerly eclamptic women were matched for age and year of index pregnancy with normotensive parous controls. The presence and volume of brain white matter lesions were compared between the groups. RESULTS MRI scans of 39 women who formerly had eclampsia and 29 control women were performed on average 6.4 +/- 5.6 years following the index pregnancy at a mean age of 38 years. Women with eclampsia demonstrated subcortical white matter lesions more than twice as often as compared with controls (41% vs 17 %; odds ratio, 3.3; 95% confidence interval, 1.05-10.61; P = .04). CONCLUSION Cerebral white matter lesions occur more often in women who formerly had eclampsia compared with women with normotensive pregnancies. The exact pathophysiology underlying these imaging changes and their clinical relevance remain to be elucidated.

Long‐term cerebral imaging after pre‐eclampsia

Please cite this paper as: Aukes A, De Groot J, Wiegman M, Aarnoudse J, Sanwikarja G, Zeeman G. Long‐term cerebral imaging after pre‐eclampsia. BJOG 2012;119:1117–1122.

Endothelial function in normal and pre-eclamptic pregnancy: a hypothesis

Pre-eclampsia is the most common medical complication of pregnancy. Immunologic maladaptation has been suggested to play a role in the etiology of pre-eclampsia. The putative misalliance of fetal trophoblast with maternal tissue in the uteroplacental vascular bed may give rise to an increase in oxygen free radicals. Oxygen free radicals and lipid peroxides might form the link between the hypothetical immunologic maladaptation and the endothelial cell damage known to occur in pre-eclampsia. Recent studies have demonstrated the existence of increased oxygen free radical production in pre-eclampsia. Oxygen free radicals and lipid peroxides decrease vascular prostacyclin and EDRF release and increase thromboxane A2 and endothelin release. The hypothesis is put forward that in pre-eclampsia a proposed immunologic maladaptation causes an increase in oxygen free radicals by decidual lymphoid cells. A decrease in vasodilatory autocoids, prostacyclin and EDRF may result from the endothelial cell damage induced by oxygen free radicals. Uteroplacental prostacyclin production might be essential as escape mechanism. The adequacy as escape mechanism seems to determine the final clinical outcome.

Regional distribution of cerebral white matter lesions years after preeclampsia and eclampsia

OBJECTIVE: To assess the distribution of cerebral white matter lesions in women who had eclampsia, preeclampsia, or normotensive pregnancies. The pathophysiology of these lesions, more often seen in formerly eclamptic and preeclamptic women, is unclear but may be related to a predisposition for vascular disease, the occurrence of the posterior reversible encephalopathy syndrome, or both while pregnant. Assessing the distribution of such lesions may give insight into their pathophysiology and possible consequences. METHODS: This retrospective cohort study determined the presence, severity, and location of white matter lesions on cerebral magnetic resonance imaging scans of 64 formerly eclamptic, 74 formerly preeclamptic, and 75 parous control women. RESULTS: Formerly preeclamptic and eclamptic women have white matter lesions more often (34.4% [n=47] compared with 21.3% [n=16]; P<.05) and more severely (0.07 compared with 0.02 mL; P<.05) than parous women in a control group. In all women, the majority of lesions was located in the frontal lobes followed by the parietal, insular, and temporal lobes. CONCLUSION: White matter lesions are more common in women with prior pregnancies complicated by preeeclampsia or eclampsia compared with parous women in a control group. In no group does regional white matter lesion distribution correspond to the occipitoparietal edema distribution seen in posterior reversible encephalopathy syndrome. LEVEL OF EVIDENCE: II

Visual disturbances in (pre)eclampsia.

&NA; This review aims to summarize existing information concerning visual disturbances in (pre) eclampsia that have been described in the literature. Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality worldwide. Visual disturbances in (pre)eclampsia seem to be frequent phenomena. Therefore, the obstetrician/gynecologist may encounter women with serious, and sometimes debilitating, pathology of the visual pathways. Established ophthalmic entities associated with (pre)eclampsia are cortical blindness, serous retinal detachment, Purtscher-like retinopathy, central retinal vein occlusions, and retinal or vitreous hemorrhages. Ensuing visual symptoms include blurry vision, diplopia, amaurosis fugax, photopsia, and scotomata, including homonymous hemianopsia. In general, aside from lowering the blood pressure and preventing (further) seizures with magnesium sulfate, no specific therapy seems indicated for (pre)eclamptic women who experience visual changes. Although in most cases visual acuity returns to normal within weeks to months after the onset of symptoms, rarely permanent visual impairment can occur. Health care providers such as emergency room physicians, obstetricians, family physicians, neurologists, and ophthalmologists should be aware that acute onset of visual symptoms in pregnant women can be the first sign of (pre)eclampsia. Given that visual changes are a diagnostic criterion for severe preeclampsia, obstetricians should appreciate the significance of these changes and discuss appropriate diagnostic options with the ophthalmologist. Affected women can be reassured that most cases are transient. Target Audience: Obstetricians and gynecologists, ophthalmologists, neurologists, family physicians, emergency room physicians Learning Objectives: After completing this CME activity, obstetricians and gynecologists should be better able to classify visual disturbances at an early stage during pregnancy, interpret acute onset of visual disturbances as the first sign of preeclampsia, and evaluate possible residual visual symptoms during follow-up.