Artículo preclampsia
Páginas: 24 (5944 palabras)
Publicado: 27 de septiembre de 2010
Volume 62, Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright © 2007 by Lippincott Williams & Wilkins
CME REVIEWARTICLE
4
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 CreditsTM can be earned in 2007. Instructions for how CME credits can be earned appear on the last page of theTable of Contents.
Clinical Significance of Proteinuria in Pregnancy
James Airoldi, MD,* and Louis Weinstein, MD†
*Clinical Instructor and Maternal Fetal Medicine Fellow and †Paul A. and Eloise Bowers Professor and Chairman, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania Urinary protein excretion is considered abnormal in pregnant women whenit exceeds 300 mg/24 hours at anytime during gestation, a level that usually correlates with 1 on urine dipstick. Proteinuria documented before pregnancy or before 20 weeks’ gestation suggests preexisting renal disease. The National High Blood Pressure Education Program Working Group recommended that that the diagnosis of proteinuria be based on the 24-hour urine collection. Preeclampsia is theleading diagnosis that must be excluded in all women with proteinuria first identified after 20 weeks of gestation. Given the vasospastic nature of this condition, when it is present, the degree of proteinuria may fluctuate widely from hour-to-hour. Hypertension or proteinuria may be absent in 10–15% of patients with HELLP syndrome and in 38% of patients with eclampsia. The acute onset of proteinuriaand worsening hypertension in women with chronic hypertension is suggestive of superimposed preeclampsia, which increases adverse outcomes. However, because proteinuria is not independently predictive of adverse outcome, an exclusive proteinuric criterion as an indication for preterm delivery in preeclampsia should be discouraged. Target Audience: Obstetricians & Gynecologists, Family PhysiciansLearning Objectives: After completion of this article, the reader should be able to state that measurement of urinary protein levels by simple techniques are not sensitive or specific, recall that both hypertension and proteinuria may be absent in patients with preeclampsia, and explain that proteinuria is not predictive of adverse outcomes and that delivery should not be based on proteinexcretion alone.
During pregnancy, proteinuria has traditionally been regarded as a hallmark of preeclampsia and an indicator of its severity. Dieckmann attributed the first reported demonstration of proteinuria in pregnancy to Rayer in 1840, followed in 1843 by Lever’s
The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to thiseducational activity. Lippincott Continuing Medical Education Institute, Inc. has identified and resolved all faculty conflicts of interest regarding this educational activity. Reprint requests to: James Airoldi, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, 834 Chestnut Street, Suite 400, Philadelphia, Pennsylvania 19107. E-mail:james.airoldi@mail.tju. edu.
reports of the frequent occurrence of proteinuria in eclampsia (1). In spite of the quantitation and identification of proteins excreted in the urine in normal (2–5) and hypertensive (6,7) pregnancies, the mechanism and significance of proteinuria have been debated. Furthermore, the amount of proteinuria considered to be abnormal in pregnancy has been variouslydefined. The purpose of this article is to review the literature with regard to proteinuria and to help guide the management of the pregnant preeclamptic patient. Relevant studies were identified by searching MEDLINE and PUBMED from the inception of each database through January 2006 using the terms proteinuria, albuminuria, and preeclampsia.
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Obstetrical and Gynecological Survey...
CME REVIEWARTICLE
4
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 CreditsTM can be earned in 2007. Instructions for how CME credits can be earned appear on the last page of theTable of Contents.
Clinical Significance of Proteinuria in Pregnancy
James Airoldi, MD,* and Louis Weinstein, MD†
*Clinical Instructor and Maternal Fetal Medicine Fellow and †Paul A. and Eloise Bowers Professor and Chairman, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania Urinary protein excretion is considered abnormal in pregnant women whenit exceeds 300 mg/24 hours at anytime during gestation, a level that usually correlates with 1 on urine dipstick. Proteinuria documented before pregnancy or before 20 weeks’ gestation suggests preexisting renal disease. The National High Blood Pressure Education Program Working Group recommended that that the diagnosis of proteinuria be based on the 24-hour urine collection. Preeclampsia is theleading diagnosis that must be excluded in all women with proteinuria first identified after 20 weeks of gestation. Given the vasospastic nature of this condition, when it is present, the degree of proteinuria may fluctuate widely from hour-to-hour. Hypertension or proteinuria may be absent in 10–15% of patients with HELLP syndrome and in 38% of patients with eclampsia. The acute onset of proteinuriaand worsening hypertension in women with chronic hypertension is suggestive of superimposed preeclampsia, which increases adverse outcomes. However, because proteinuria is not independently predictive of adverse outcome, an exclusive proteinuric criterion as an indication for preterm delivery in preeclampsia should be discouraged. Target Audience: Obstetricians & Gynecologists, Family PhysiciansLearning Objectives: After completion of this article, the reader should be able to state that measurement of urinary protein levels by simple techniques are not sensitive or specific, recall that both hypertension and proteinuria may be absent in patients with preeclampsia, and explain that proteinuria is not predictive of adverse outcomes and that delivery should not be based on proteinexcretion alone.
During pregnancy, proteinuria has traditionally been regarded as a hallmark of preeclampsia and an indicator of its severity. Dieckmann attributed the first reported demonstration of proteinuria in pregnancy to Rayer in 1840, followed in 1843 by Lever’s
The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to thiseducational activity. Lippincott Continuing Medical Education Institute, Inc. has identified and resolved all faculty conflicts of interest regarding this educational activity. Reprint requests to: James Airoldi, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, 834 Chestnut Street, Suite 400, Philadelphia, Pennsylvania 19107. E-mail:james.airoldi@mail.tju. edu.
reports of the frequent occurrence of proteinuria in eclampsia (1). In spite of the quantitation and identification of proteins excreted in the urine in normal (2–5) and hypertensive (6,7) pregnancies, the mechanism and significance of proteinuria have been debated. Furthermore, the amount of proteinuria considered to be abnormal in pregnancy has been variouslydefined. The purpose of this article is to review the literature with regard to proteinuria and to help guide the management of the pregnant preeclamptic patient. Relevant studies were identified by searching MEDLINE and PUBMED from the inception of each database through January 2006 using the terms proteinuria, albuminuria, and preeclampsia.
117
118
Obstetrical and Gynecological Survey...
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