The markers listed in Table 40-1 are also used to classiy preeclampsia syndrome severity. lthough many use a dichotomous "mild" and "severe" classiication, the Task Force (2013) discourages the use of "mild preeclampsia." It is problematic that there are criteria for the diagnosis of "severe" preeclampsia, but the default classiication is either implied or speciically termed as "mild," "less severe," or "nonsevere" (Alexander, 2003; Lindheimer, 2008b). here are no generally agreed-on criteria for "moderate" preeclampsia-an elusive third category. We use the criteria listed in Table 40-2, which are categorized as "severe" versus "nonsevere."
Some symptoms are considered ominous. Headaches or visual disturbances such as scotomata can precede eclampsia, which is a convulsion not attributable to another cause. The
TABLE 40-1. Classification and Diagnosis of Pregnancy-Associated Hypertension
Gestational hypertension Preeclampsia: Hypertension plus • 2300 mg/24 h, or
Urine protein: creatinine ratio 20.3, or
Platelet count < 1 OO,OOO/.LL 1.1 mg/dL or doubling of baselineb
Headache, visual disturbances, convulsions aRecommended only if sole available test. bNo prior renal disease.
CAST (aspartate transaminase) or ALT (alanine transaminase). BP = blood pressure.
Modified with permission from American College ofObstetricians and Gynecologists; Task Force on Hypertension in Pregnancy: Hypertension in pregnancy. Report ofthe American College ofObstetricians and Gynecologists'Task Force on
Hypertension in Pregnancy, Obstet Gynecol. 201n3 Nov;122(S):n seizures are generalized and may appear before, during, or after labor. The proportion that develops seizures later, after 48 hours postpartum, approximates 10 percent (Sibai, 2005; Zwart, 2008). Another symptom, epigastric or right upper quadrantpain, frequently accompanies hepatocellular necrosis, ischemia, and edema that ostensibly stretches Glisson capsule. This characteristic pain is frequently accompanied by elevated serum
TABLE40-2. Indicators of Severity of Gestational (< 1 OO,OOO/LL)
None to positive
None to positive aCompare with criteria in Table 40-1.
blncludes "mild" and "moderate" hypertension not specifically defined.
cMost disregard degrees of proteinuria to classify nonsevere or severe.
BP = blood pressure.
hepatic transaminase levels. Finally, thrombocytopenia also signifies worsening preeclampsia. It represents platelet activation and aggregation as well as microangiopathic hemolysis. Other factors indicative ofsevere preeclampsia include renal or cardiac involvement, obvious fetal-growth restriction, and early-onset disease.
he more profound these signs and symptoms, the less likely it is that they can be temporized, and the more likely that delivery will be required. A caveat is that dierentiation between nonsevere and severe gestational hypertension or preeclampsia can be misleading because what might be apparenty mild disease may progress rapidy to severe disease.