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Clinical Opinion
OBSTETRICS

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Diagnosis and management of atypical preeclampsia-eclampsia
Baha M. Sibai, MD; Caroline L. Stella, MD ypertension is the most common medical disorder during pregnancy.1,2 The term gestational hypertension-preeclampsia is used to describe a wide spectrum of disorders for patients who may have only mild elevation in blood pressure or severe hypertensionwith various organ dysfunctions that include acute gestational hypertension, preeclampsia, eclampsia and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. There are numerous reports that describe the diagnosis and treatment of women with classic mild and severe preeclampsia.1-3 Therefore, in this report, the discussion will focus on atypical preeclampsia, which refers to any ofthe clinical entities listed in Table 1.

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Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets syndrome are major obstetric disorders that are associated with substantial maternal and perinatal morbidities. As a result, it is important that clinicians make timely and accurate diagnoses to prevent adverse maternal and perinatal outcomes associated with thesesyndromes. In general, most women will have a classic presentation of preeclampsia (hypertension and proteinuria) at 20 weeks of gestation and/or 48 hours after delivery. However, recent studies have suggested that some women will experience preeclampsia without 1 of these classic findings and/or outside of these time periods. Atypical cases are those that develop at 20 weeks of gestation and 48 hoursafter delivery and that have some of the signs and symptoms of preeclampsia without the usual hypertension or proteinuria. The purpose of this review was to increase awareness of the nonclassic and atypical features of preeclampsia-eclampsia. In addition, a stepwise approach toward diagnosis and treatment of patients with these atypical features is described. Key words: atypical preeclampsia,diagnosis, eclampsia, management
Cite this article as: Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsiaeclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.

Definition of classic preeclampsia The so-called classic triad of preeclampsia includes hypertension, proteinuria, and edema. However, there is now general agreement that edema should not be considered as part of the diagnosisof preeclampsia.1-6 Indeed, edema is neither sufficient nor necessary to confirm the diagnosis of preeclampsia, because edema is a common finding in normal pregnancy, and approximately one-third

From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.
Received June 4, 2008; revised, July 2, 2008; acceptedJuly 28, 2008. Reprints: Baha M. Sibai, MD, Division of Maternal-Fetal Medicine, University of Cincinnati, 231 Albert Sabin Way, Room 5052, Medical Sciences Building, PO Box 670526, Cincinnati, OH 45267-0526. Baha.Sibai@uc.edu. 0002-9378/$36.00 © 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2008.07.048

of women with eclampsia never demonstrate the presence of edema.7 Hypertension isdefined as systolic blood pressure of at least 140 mm Hg and diastolic blood pressure of 90 mm Hg on at least 2 occasions; the measurements should be at least 4 hours (but not 7 days) apart.1-3 Hypertension is considered severe if the systolic blood pressure is at least 160 mm Hg and/or the diastolic pressure is at least 110 mm Hg on 2 occasions at least 4 hours apart. Proteinuria is defined primarily asa concentration of 30 mg/dL (1 ) in at least 2 random urine specimens that were collected at least 4 hours apart (but within a 7-day interval) or 0.3 g in a 24-hour period.1,2,4 The traditional criterion to confirm a diagnosis of preeclampsia is the presence of proteinuric hypertension (new onset of hypertension and new onset of proteinuria at 20 weeks of gestation). This criterion is...