37454656 preeclampsia-atypical-sibai

Clinical Opinion www. AJOG.org

OBSTETRICS
Diagnosis and management
of atypical preeclampsia-eclampsia
Baha M. Sibai, MD; Caroline L. Stella, MD

H ypertension is the most common
medical disorder during preg-
nancy.1,2 The term gestational hyperten-
Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets
syndrome are major obstetric disorders that are associated with substantial maternal and
sion-preeclampsia is used to describe a perinatal morbidities. As a result, it is important that clinicians make timely and accurate
wide spectrum of disorders for patients diagnoses to prevent adverse maternal and perinatal outcomes associated with these
who may have only mild elevation in syndromes. In general, most women will have a classic presentation of preeclampsia
blood pressure or severe hypertension (hypertension and proteinuria) at 20 weeks of gestation and/or 48 hours after
with various organ dysfunctions that in- delivery. However, recent studies have suggested that some women will experience
clude acute gestational hypertension, preeclampsia without 1 of these classic findings and/or outside of these time periods.
preeclampsia, eclampsia and hemolysis, Atypical cases are those that develop at 20 weeks of gestation and 48 hours after delivery
elevated liver enzymes, and low platelets and that have some of the signs and symptoms of preeclampsia without the usual hypertension
(HELLP) syndrome. There are numer- or proteinuria. The purpose of this review was to increase awareness of the nonclassic and
ous reports that describe the diagnosis atypical features of preeclampsia-eclampsia. In addition, a stepwise approach toward diagnosis
and treatment of women with classic and treatment of patients with these atypical features is described.
mild and severe preeclampsia.1-3 There- Key words: atypical preeclampsia, diagnosis, eclampsia, management
fore, in this report, the discussion will fo- Cite this article as: Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-
cus on atypical preeclampsia, which re- eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.
fers to any of the clinical entities listed in
Table 1.
of women with eclampsia never demon- tations of preeclampsia (such as the pres-
Definition of classic preeclampsia strate the presence of edema.7 ence of signs and symptoms or other lab-
The so-called classic triad of preeclamp- Hypertension is defined as systolic oratory abnormalities).5,7-11 We will
sia includes hypertension, proteinuria, blood pressure of at least 140 mm Hg and focus on the clinical entities that com-
diastolic blood pressure of 90 mm Hg on prise atypical preeclampsia and eclamp-
and edema. However, there is now gen-
at least 2 occasions; the measurements sia and their respective management.
eral agreement that edema should not be
should be at least 4 hours (but not 7
considered as part of the diagnosis of
days) apart.1-3 Hypertension is consid- Gestational hypertension
preeclampsia.1-6 Indeed, edema is nei-
ered severe if the systolic blood pressure without proteinuria
ther sufficient nor necessary to confirm
is at least 160 mm Hg and/or the diastolic The pathophysiologic abnormalities in
the diagnosis of preeclampsia, because pressure is at least 110 mm Hg on 2 oc- preeclampsia are viable and can manifest
edema is a common finding in normal casions at least 4 hours apart. Proteinuria as either 1 organ or multiorgan dysfunc-
pregnancy, and approximately one-third is defined primarily as a concentration of tion. As a result, the signs and symptoms
30 mg/dL (1 ) in at least 2 random will reflect the organs involved. Protein-
urine specimens that were collected at uria in preeclampsia is a manifestation of
From the Division of Maternal-Fetal least 4 hours apart (but within a 7-day renal involvement that results from glo-
Medicine, Department of Obstetrics and
interval) or 0.3 g in a 24-hour period.1,2,4 merulo endothelial injury (altered per-
Gynecology, University of Cincinnati
The traditional criterion to confirm a meability to proteins) and abnormal tu-
College of Medicine, Cincinnati, OH.
diagnosis of preeclampsia is the presence bular handling of filtered proteins.
Received June 4, 2008; revised, July 2, 2008;
accepted July 28, 2008.
of proteinuric hypertension (new onset Traditionally, proteinuria was consid-
Reprints: Baha M. Sibai, MD, Division of
of hypertension and new onset of pro- ered the hallmark for the diagnosis of
Maternal-Fetal Medicine, University of teinuria at 20 weeks of gestation). This preeclampsia, because it usually devel-
Cincinnati, 231 Albert Sabin Way, Room 5052, criterion is appropriate to use in most ops after the onset of hypertension
Medical Sciences Building, PO Box 670526, nulliparous women; however, recent and/or onset of symptoms.12 However,
Cincinnati, OH 45267-0526. data suggest that, in some women, pre- its onset in clinical practice may be vari-
Baha.Sibai@uc.edu.
eclampsia and even eclampsia may de- able in onset in relation to hypertension
0002-9378/$36.00
velop in the absence of either hyperten- and/or other end-organ effects. There-
© 2009 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.07.048 sion or proteinuria. In many of these fore, its presence should not be consid-
women, there are usually other manifes- ered mandatory to establish the clinical

MAY 2009 American Journal of Obstetrics & Gynecology 481.e1

Clinical Opinion Obstetrics www.AJOG.org

of data from 2 multicenter trials, preg-
TABLE 1 nancy outcomes in women with severe TABLE 2
Atypical preeclampsia gestational hypertension were compared Signs and symptoms and
Gestational hypertension plus 1 of the with the outcomes of women with mild laboratory test results consistent
following items:
.................................................................................................. or severe preeclampsia.4,15 This analysis with preeclampsia
Symptoms of preeclampsia revealed that severe gestational hyper- Signs and symptoms
.................................................................................................. ..................................................................................................

Hemolysis tension is associated with higher mater- Right upper quadrant pain
.................................................................................................. ..................................................................................................

Thrombocytopenia ( 100,000/mm ) 3 nal and perinatal morbidities than those Epigastric pain
.................................................................................................. found in mild preeclampsia.4,15 The re- ..................................................................................................

Elevated liver enzymes (2 times the Retrosternal chest pain
sults of these studies also revealed that ..................................................................................................
upper limit of the normal value for Nausea and vomiting
aspartate aminotransferase or alanine women with severe gestational hyper- ..................................................................................................
aminotransferase) tension had adverse maternal or perina- Shortness of breath/congestive heart
...........................................................................................................
tal outcomes that were similar to those failure
Gestational proteinuria plus 1 of the ..................................................................................................
following items: seen in women with severe preeclampsia Headaches (not responsive to
..................................................................................................
(Table 3).4,15 However, these 2 studies analgesics)
Symptoms of preeclampsia ..................................................................................................
.................................................................................................. included only a total of 56 subjects; more Visual changes
Hemolysis data are needed. Nevertheless, women ..................................................................................................
..................................................................................................
Altered mental status
Thrombocytopenia
..................................................................................................
with uncontrollable severe gestational ..................................................................................................

hypertension or women with signs and Bleeding from mucosal membranes
Elevated liver enzymes ..................................................................................................
...........................................................................................................
symptoms of end-organ disease with any Jaundice
Early signs and symptoms of ...........................................................................................................
preeclampsia-eclampsia at 20 weeks hypertension should be treated as if they Laboratory tests
..................................................................................................
of gestation had severe preeclampsia. Furthermore,
........................................................................................................... Persistent proteinuria
Late postpartum preeclampsia-eclampsia
we recommend hospital admission until ( 300 mg/24 h)
( 48 hours after delivery) hypertension is well controlled without ..................................................................................................
3
Platelet count ( 100,000/mm )
........................................................................................................... symptoms and delivery at 34 weeks of ..................................................................................................
Sibai. Diagnosis and management of a typical Liver enzymes (aspartate
preeclampsia-eclampsia. Am J Obstet Gynecol 2009.
gestation if severe hypertension or symp-
toms persist, or earlier if indicated.17 aminotransferase or alanine
aminotransferase) 2 times the upper
limit of normal
diagnosis of preeclampsia or eclamp- Capillary leak syndrome: facial ..................................................................................................
Serum creatinine ( 1.2 mg/dL)
sia.2,5,9,10 In the absence of proteinuria, edema, ascites and pulmonary ..................................................................................................

the syndrome of preeclampsia should be edema, gestational proteinuria Lactic dehydrogenase 2 times the
considered when gestational hyperten- Hypertension is considered to be the upper limit of normal
...........................................................................................................
sion is present in association with persis- hallmark for the diagnosis of preeclamp- Sibai. Diagnosis and management of a typical
tent symptoms or with abnormal labora- sia; however, recent evidence suggests preeclampsia-eclampsia. Am J Obstet Gynecol 2009.

tory tests (Table 2).2,5,7-11 It is also that, in some patients with preeclampsia,
important to note that 25-50% of the disease may manifest itself in the
women with mild gestational hyperten- form of either a capillary leak (protein- tests should be considered to have
sion will progress to preeclampsia.13-15 uria, ascites, pulmonary edema), exces- preeclampsia.5,8-10
The rate of progression depends on ges- sive weight gain, or a spectrum of ab-
tational age at onset of hypertension (ie, normal hemostasis with multiorgan Gestational proteinuria
the rate approaches 50% when gesta- dysfunction (Figure 1).5,8,18 These pa- Gestational proteinuria is deﬁned as
tional hypertension develops before 32 tients usually experience clinical mani- urinary protein excretion of 300 mg/
weeks of gestation).14,15 In most of these festations of atypical preeclampsia (ie, 24-hour timed collection or persistent
women, the progression will result in proteinuria with or without facial proteinuria ( 1 on dipstick on at
preterm delivery and/or fetal growth re- edema, excessive weight gain [ 5 lb/ least 2 occasions at least 4 hours apart
striction.14-16 Therefore, such women wk], ascites, or pulmonary edema in as- but no more than 1 week apart).19,20
require close observation for early detec- sociation with abnormalities in labora- The exact incidence of gestational pro-
tion of preeclampsia (frequent prenatal tory values or presence of symptoms) teinuria is unknown. Two prospective
visits and serial evaluation of platelets but without hypertension.5,7-11,18 There- studies in healthy nulliparous women
and liver enzymes) and/or fetal growth fore, we recommend that women with found that approximately 4% of
(serial ultrasound). capillary leak syndrome with or without women who remained normotensive
Preeclampsia should also be consid- hypertension be evaluated for platelet, had gestational proteinuria; however,
ered when gestational hypertension is se- liver enzyme, or renal abnormalities. Ad- neither of these studies reported the
vere, because of the associated adverse ditionally, they should be questioned percentage of women who had new on-
maternal-perinatal outcome reported in about symptoms of preeclampsia. Those set gestational proteinuria and later ex-
such women.4,16 In a secondary analysis with symptoms and/or abnormal blood perienced preeclampsia.19,20

481.e2 American Journal of Obstetrics & Gynecology MAY 2009

www.AJOG.org Obstetrics Clinical Opinion

TABLE 3
Adverse pregnancy outcomes in severe gestational hypertension and in mild and severe preeclampsia
Buchbinder et al16 Hauth et al4
Severe Mild Severe Severe Mild Severe
hypertension preeclampsia preeclampsia hypertension preeclampsia preeclampsia
Outcome (n 24) (n 62) (n 45) (n 32) (n 217) (n 109)
Mean gestational age 35.8 37.8 34.8 38 39.2 37
at delivery (wk)
................................................................................................................................................................................................................................................................................................................................................................................
Preterm delivery (%) 25 9.7 35.6 3.1 1.9 18.5
................................................................................................................................................................................................................................................................................................................................................................................
Mean birthweight (g) 2637 3196 2490 2967 3212 2642
................................................................................................................................................................................................................................................................................................................................................................................
Weight 10th 20.8 4.8 11.4 9.7 10.2 18.5
percentile (%)
................................................................................................................................................................................................................................................................................................................................................................................
Abruptio placenta (%) 4.2 3.2 6.7 3.1 0.5 3.7
................................................................................................................................................................................................................................................................................................................................................................................
Respiratory distress 6.5 3.2 16.7 12.5 4.8 15.7
syndrome (%)
................................................................................................................................................................................................................................................................................................................................................................................
Perinatal death (%) 0 0 3 3.1 0.5 0.9
................................................................................................................................................................................................................................................................................................................................................................................
Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009.

Women with new onset gestational eration of the placenta with or without a teinuria, and abnormal laboratory tests
proteinuria only should be monitored coexistent fetus.7-9,25-27 Additionally, al- at 20 weeks of gestation may be due to
very closely for the early detection of pre- though exceedingly rare, preeclampsia- lupus nephritis, hemolytic-uremic syn-
eclampsia, because the presence of gesta- eclampsia can occur during the ﬁrst half drome, antiphospholipid antibody syn-
tional proteinuria alone may herald the of pregnancy without molar degenera- drome, or thrombotic thrombocytope-
early manifestation of an impending tion of the placenta.9,28-30 On the other nic purpura.31 Therefore, such women
preeclampsia.21-23 There are no prospec- hand, the presence of hypertension, pro- should be evaluated to rule out the pres-
tive studies that have evaluated the risk
of the development of preeclampsia in
patients with gestational proteinuria. In FIGURE 1
addition, such women should be evalu- Overlapping role of hypertension, capillary leak, maternal symptoms,
ated for potential preexisting renal dis- and ﬁbrinolysis/hemolysis in the spectrum of atypical preeclampsia
ease (such as chronic pyelonephritis,
lupus nephritis, immunoglobulin A ne-
phropathy, and other nephropathies).24
Evaluation for lupus nephritis is ex-
tremely important, because this is a po- Blood Capillary
tentially treatable cause of proteinuria Pressure Leak
during pregnancy. If proteinuria persists
for 8 weeks after delivery, these
women should be evaluated for underly-
ing renal disease. Some of these patients
may require renal biopsy.24 Moreover, Symptoms
women with proteinuria with cardiore-
spiratory symptoms, ascites, or pulmo-
nary edema should be evaluated for Fibrinolysis
potential cardiac disease (such as con- Hemolysis
gestive heart failure or peripartum
cardiomyopathy).
Preeclampsia-eclampsia
at < 20 weeks of gestation
Preeclampsia and/or eclampsia that oc-
curs at 20 weeks of gestation has been Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009.
reported with molar or hydropic degen-



from 87-96%.32,33 In the absence of
FIGURE 2 TABLE 5
other disease, the treatment of choice for
Sonographic findings of a fetus Differential diagnosis
such pregnancies is parenteral magne-
with triploidy (69 XXX) of eclampsia
sium sulfate to control and prevent con-
vulsions, antihypertensive drugs, and Cerebrovascular accidents
..................................................................................................
termination of the pregnancy as a defin- Hemorrhage
..................................................................................................
itive cure. Ruptured aneurysm
..................................................................................................

Late postpartum preeclampsia- Arterial embolism or thrombosis
..................................................................................................
eclampsia and HELLP syndrome Cerebral venous thrombosis
..................................................................................................
Late postpartum preeclampsia-eclamp- Hypoxic ischemic encephalopathy
..................................................................................................
sia is defined as the development of signs
Angiomas
and symptoms of preeclampsia-eclamp- ...........................................................................................................

sia for the first time at 48 hours but Hypertensive encephalopathy
...........................................................................................................

Courtesy John Barton, MD, from Central Baptist 4 weeks after delivery.34,35 Historically, Seizure disorder
...........................................................................................................
Hospital, Lexington, KY. preeclampsia and eclampsia were be- Previously undiagnosed brain tumors
...........................................................................................................
Sibai. Diagnosis and management of a typical lieved to occur only 48 hours from de-
Metastatic gestational trophoblastic
preeclampsia-eclampsia. Am J Obstet Gynecol 2009. livery. However, several reports have disease
confirmed the existence of late postpar- ...........................................................................................................
Metabolic diseases
tum preeclampsia-eclampsia.7,34-41 Ta- ...........................................................................................................

ence of these disorders. In the absence of ble 4 provides a summary of the inci- Reversible posterior leukoencephalopathy
other disease, the patient should be dence of postpartum eclampsia in the syndrome
...........................................................................................................
treated for severe preeclampsia. In addi- last 2 decades. Catastrophic antiphospholipid syndrome
...........................................................................................................
tion, women in whom convulsions de- Based on our experience and review of Thrombotic thrombocytopenic purpura
...........................................................................................................
velop in association with hypertension literature, we recommend that, after de-
Postdural puncture syndrome
and proteinuria during the first half of livery, any woman with a history of con- ...........................................................................................................

pregnancy should be considered to have vulsions at 48 hours after delivery who Cerebral vasculitis
...........................................................................................................
eclampsia until proved otherwise.9 is hypertensive and has either protein- Sibai. Diagnosis and management of a typical
These women should have ultrasound uria or symptoms of preeclampsia preeclampsia-eclampsia. Am J Obstet Gynecol 2009.

examination of the uterus to rule out should be considered eclamptic while
molar pregnancy and/or hydropic or other causes are being ruled out.7 The drome (Figure 3). In the presence of
cystic degeneration of the placenta (Fig- differential diagnosis is listed in Table 5. unexplained blindness or other neuro-
ure 2). A diagnostic modality that is also Patients who do not improve rapidly af- logic deficits, another differential diagno-
considered is the measurement of uter- ter control of seizures and control of sis is spontaneous reversible vasculopa-
ine artery Doppler velocimetry that hypertension and women who have lo- thy syndrome or cerebral angiopathy.43
shows the classic “notching” characteris- calizing findings on neurologic examina- This can be diagnosed by magnetic reso-
tic of increased resistance in the placenta tion should be evaluated aggressively nance angiograph or traditional cerebral
of patients with preeclampsia. The sensi- with neurodiagnostic tests.9,42 The clas- angiography (Figure 4).
tivity of this test in patients with estab- sic finding in preeclampsia-eclampsia is Approximately 20-30% of women
lished early onset preeclampsia ranges posterior reversible encephalopathy syn- with HELLP syndrome experience the
manifestations for the first time at 48
hours after delivery.8,18 In most cases,
TABLE 4
delivery is the ultimate cure for women
Incidence of late postpartum eclampsia
with preeclampsia/ HELLP syndrome; in
Eclampsia Late postpartum some patients, the syndrome of pre-
Year Country Study (n) eclampsia (%)
eclampsia may get worse after deliv-
1994 United Kingdom Douglas and Redman37 383 5 ery.8,18 Therefore, women who experi-
..............................................................................................................................................................................................................................................
1998 Colombia Conde-Agudelo and 164 12 ence signs and symptoms that are
Kafury-Goeta38 consistent with HELLP syndrome for the
..............................................................................................................................................................................................................................................
2000 United States Katz et al 39
53 6 first time after delivery should have
..............................................................................................................................................................................................................................................
2000 United States Mattar and Sibai 7
399 17 prompt medical evaluation that includes
..............................................................................................................................................................................................................................................
40
laboratory testing to rule out or confirm
2002 United States Chames et al 89 26
.............................................................................................................................................................................................................................................. the presence of severe preeclampsia or
41
2003 Singapore Chen et al 62 3 HELLP syndrome. The differential diag-
..............................................................................................................................................................................................................................................
Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009. nosis in such women should include
thrombotic thrombocytopenic purpura,



venous dexamethasone in patients with
FIGURE 3 FIGURE 4
antepartum and postpartum HELLP syn-
Posterior reversible Cerebral vasculitis
drome revealed no improvement in ma-
encephalopathy syndrome
ternal laboratory findings, maternal mor-
bidities, or length of hospital stay.44,45
However, both of these randomized trials
had a limited number of patients with
platelet count of 50,000/mm3 (total of
67 patients randomized in both trials).44,45
More data are needed to answer this ques-
tion in such patients. Until then, the use of
intravenous dexamethasone to improve
maternal outcome in these women re-
mains experimental.47

Comment
Preeclampsia is a syndrome that is char-
Angiogram shows multifocal narrowing and di-
acterized by heterogenous clinical and
A T2-weighted brain magnetic resonance imag- lation of cortical branches of the right anterior
laboratory findings for which the patho-
ing shows hyperintense cortical and subcortical cerebral artery, specifically the right internal
genesis can differ. The traditional teach-
signal in the occipital lobes that is consistent parietal cortical branch.
ing states that preeclampsia is defined as
with posterior reversible encephalopathy syn- Sibai. Diagnosis and management of a typical
hypertension plus proteinuria that de- preeclampsia-eclampsia. Am J Obstet Gynecol 2009.
drome. The arrows indicate cerebral edema in
velops at 20 weeks of gestation and/or
the occipital lobes.
within 48 hours after delivery. However,
Sibai. Diagnosis and management of a typical
preeclampsia-eclampsia. Am J Obstet Gynecol 2009. based on our experience and review of highly suggestive of preeclampsia. A
literature, we suggest that the aforemen- complete blood count, liver panel, lac-
tioned criteria for defining preeclampsia tate dehydrogenase, and a disintegrin-
hemolytic uremic syndrome, or exacer- should be revisited, because preeclamp- like and metalloprotease with throm-
bated systemic lupus erythematosus.18,31 sia, like many other syndromes in medi- bospondin should be considered to rule
Corticosteroids generally are recom- cine, can have atypical presentations. out thrombotic thrombocytopenic pur-
mended to enhance fetal lung maturity Therefore, we recommend that health pura.48 An antinuclear antibody screen,
in patients with severe preeclampsia at care providers in obstetric practice antimitochondrial antibodies, serum se-
34 weeks of gestation.17 In addition, should have a high index of suspicion for rology, and serum biochemistry should
some authors recommend corticoste- the potential atypical clinical manifesta- be done to exclude the diagnosis of sys-
roids, particularly dexamethasone, as a tions of preeclampsia (Figure 1), irre- temic lupus erythematosus. Addition-
treatment for patients with partial or spective of gestational age at the time of ally, anticardiolipin antibody and lupus
complete HELLP syndrome in the ante- onset or the number of days after anticoagulant should be performed to
partum and immediate postpartum pe- delivery. rule out antiphospholipid antibody syn-
riods in an attempt to improve maternal Treatment of patients with atypical drome. Urinalysis, a 24-hour urine col-
laboratory findings and/or to reduce ma- manifestations of preeclampsia-eclamp- lection, and renal tests should be per-
ternal hospital stay. An exhaustive re- sia require a well-formulated plan that formed to rule out the possibility of
view of the benefits of steroids is de- takes the following items into consider- undiagnosed renal disease.12
scribed by Martin et al.18 The use of ation: maternal risk factors; clinical, lab- Gestational hypertension or gesta-
corticosteroids antepartum actually may oratory, and imaging findings; the time tional proteinuria alone may be the first
delay the onset of HELLP syndrome un- of onset in relation to gestational age, sign for subsequent development of pre-
til the postpartum period.8,18 and delivery. eclampsia. In women with gestational
The use of intravenous dexamethasone For pregnancies that are complicated hypertension, the risk of progression to
to improve maternal outcome in women with hypertension and proteinuria that preeclampsia is related inversely to ges-
with HELLP syndrome in the postpartum occur at 20 weeks gestation, an ultra- tational age at onset.13,14 Thus, these
period remains controversial.8,18,44-46 Al- sound scan must be performed to ex- women should have close antenatal fol-
most all studies that have reported such clude the diagnosis of molar or partial low-up evaluations, with attention to
benefit were retrospective in design or they molar pregnancy, and uterine artery new onset of symptoms and regular eval-
compared treatment to no treatment in a Doppler velocimetry must be performed uation (1-2 times/wk) of platelet count
limited number of subjects.8,18 In contrast, to evaluate uterine artery resistance and and liver enzymes for early detection of
2 recent multicenter, double-blind, pla- the presence of a notch.32,33 The pres- preeclampsia. Ancillary studies may in-
cebo-controlled trials that evaluated intra- ence of notching in the uterine artery is clude ultrasound scans for the evaluation



of fetal growth and amniotic fluid and In cases with hypertension, symptoms eclampsia. Future investigations should
uterine artery Doppler velocimetry to of headache or blurred vision, with or address the maternal and perinatal out-
evaluate the presence of notching.32,33 without seizures at 48 hours after de- comes in women with atypical pre-
Patients with symptoms and/or abnor- livery, magnesium sulfate therapy eclampsia. Additionally, further research
mal laboratory tests or women with ab- should be initiated without delay while should include measurements of serum
normal ultrasound findings should be other possible causes of the aforemen- angiogenic markers and other potential
considered to have atypical preeclampsia tioned symptoms are being ruled out.9,42 biomarkers in cases of atypical pre-
and be treated. However, the results We recommend a loading dose of 6 g to eclampsia to determine whether these
from uterine artery Doppler imaging be administered over 30 minutes, fol- markers can be useful potentially to con-
have no prognostic value regarding the lowed by a maintenance dose of 2 g/hour firm the diagnosis in such women. f
timing of delivery.32 Patients with gesta- for at least 24 hours after the last seizure
tional proteinuria should be evaluated and that urine output, blood pressure,
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