Uterine Preeclampsia-Eclampsia

Pregnancy is related to a host of medical complications by which clinical management requires an understanding of both the underlying physiology of pregnancy and the pathophysiology of the specific condition. The syndrome of preeclampsia-eclampsia, characterized by hypertension, proteinuria, and edema, is chosen for focus for several factors.

Very first, preeclampsia-eclampsia is one of one of the most common causes of maternal death within the United States and also the developed world. Second, it illustrates how pathophysiologic mechanisms in being pregnant might be far more complex-and the clinical consequences far a lot more serious-than would happen to be expected from a easy consideration of each of the presenting symptoms in isolation. Third, advances have significantly altered existing considering about the pathogenesis of this condition.

Hypertension can develop during pregnancy as an isolated finding, pregnancy-induced hypertension (PIH), or as a component of the harmful disorder, preeclampsia-eclampsia. Remedy guidelines for PIH are various than those for vital hypertension in the nonpregnant patient; elevated maternal blood pressure is frequently left untreated unless symptomatic or if severe hypertension develops.

Because placental perfusion is dependent on a stress distinction in between the maternal and fetal circulations, decreases in maternal blood pressure can cause underperfusion of the placenta. This can result in placental insufficiency and fetal distress.

The hypertension observed in preeclampsia is associated with proteinuria and edema. This syndrome occurs in approximately 5% of pregnancies in the United States. Eclampsia, the superimposition of generalized tonic-clonic seizures on pregnancy-induced hypertension, can occur as the initial presenting sign of this syndrome or during its progression.

Preeclampsia-eclampsia is believed to derive from faulty implantation, resulting in a systemic condition of endothelial cell activation (see later discussion). Predisposing factors for the improvement of preeclampsia include first being pregnant, obesity, preexisting diabetes or hypertension, hydatidiform mole, malnutrition, along with a loved ones background of preeclampsia.

Pathology & Pathogenesis:

The placenta of preeclamptic patients shows signs of premature aging, including degeneration, hyaline deposition, calcification, and congestion. The maternal decidua also shows hemorrhage and necrosis with thrombosis of spiral arteries and diffuse infarcts. Normally, blood vessels with the uterine wall undergo striking morphologic changes at the site of implantation, facilitating placental perfusion. The diameters with the spiral arteries increase and the muscular and elastic components are lost.

However, for unknown (perhaps immune-mediated) reasons, these early angiogenic changes of implantation do not occur-or at least not fully-in patients who will develop preeclampsia-eclampsia later in gestation. As a result, a condition of relative placental ischemia is established, with the release of lipid and protein elements that damage the maternal vascular endothelium, at very first within the decidua and later systemically. Oxidative injury is believed to work with maternal elements (eg, obesity, diabetes, diet, genes) to cause generalized endothelial cell damage.

Endothelial activation has two important pathophysiologic consequences. Very first, the balance between vasodilation and vasoconstriction is altered, specifically by diminished production of vasodilator products such as prostacyclin and nitric oxide, increased production of vasoconstrictive thromboxane, endothelin and platelet-derived growth factor.

As a result, there is increased vasoconstriction of small placental bed arterioles, with hypoperfusion and ischemia of downstream tissues and systemic hypertension. Second, the endothelial cell barrier between platelets and also the collagen of basement membranes is breached. As a result of the latter changes, additional events are set in motion, including platelet aggregation, activation with the clotting cascade, and production of vasoactive substances causing capillary leak.

This results in further tissue hypoperfusion, edema formation, and proteinuria, the hallmarks of preeclampsia-eclampsia. Because these processes lead to further vascular endothelial damage, a vicious circle is established. Interesting speculation has centered on the potential of serotonin to modulate vasodilation and angiogenic growth elements. New data also invoke a role for agonistic autoantibodies directed against the second extracellular loop with the angiotensin II AT1 receptor, resulting in the vasospasm related to preeclampsia.

Preeclampsia has a plethora of manifestations. Beyond the presenting symptoms of hypertension, edema, and proteinuria, patients also can have increased deep tendon reflexes, or placental abruption. Hepatic periportal congestion, hemorrhage, and necrosis can lead to elevated liver function tests and ultimate rupture of the hepatic capsule.

Severe preeclampsia also can produce renal changes, including glomerular endothelial cell swelling, mesangial proliferation, and marked narrowing of glomerular capillary lumens. The renal cortex displays significant cortical ischemia that might progress to frank necrosis and acute renal failure. Thrombocytopenia and disseminated intravascular coagulopathy (DIC) as well as cerebral vascular accidents also may occur.

Eclampsia, or maternal seizure resulting from cerebral ischemia and petechial hemorrhage, can occur in this setting or can appear as the first manifestation of the disease. Preeclampsia-eclampsia also carries risks for that fetus. Placental deterioration and insufficiency can lead to intrauterine growth restriction (IUGR) and fetal hypoxia. Delivery of the fetus and placenta is the only definitive cure for this syndrome, which carries a high mortality rate for mother and child.

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