Pre-eclampsia is a major cause of maternal mortality (15-20% in developed countries) and morbidities (acute and long-term), perinatal deaths, preterm birth, and intrauterine growth restriction. Key findings support a causal or pathogenetic model of superficial placentation driven by immune maladaptation, with subsequently reduced concentrations of angiogenic growth factors and increased placental debris in the maternal circulation resulting in a (mainly hypertensive) maternal inflammatory response. The final phenotype, maternal pre-eclamptic syndrome, is further modulated by pre-existing maternal cardiovascular or metabolic fitness. Currently, women at risk are identified on the basis of epidemiological and clinical risk factors, but the diagnostic criteria of pre-eclampsia remain unclear, with no known biomarkers. Treatment is still prenatal care, timely diagnosis, proper management, and timely delivery. Many interventions to lengthen pregnancy (eg, treatment for mild hypertension, plasma-volume expansion, and corticosteroid use) have a poor evidence base. We review findings on the diagnosis, risk factors, and pathogenesis of pre-eclampsia and the present status of its prediction, prevention, and management.

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A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. This information is relevant for counseling women about their choices after a cesarean section.

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Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of preeclampsia-eclampsia for decades. Recognition of this syndrome in women with preeclampsia is increasing because of the frequency of blood test results that reveal unexpected thrombocytopenia or elevated liver enzymes. The diagnosis of HELLP syndrome requires the presence of hemolysis based on examination of the peripheral smear, elevated indirect bilirubin levels, or low serum haptoglobin levels in association with significant elevation in liver enzymes and a platelet count below 100,000/mm(3) after ruling out other causes of hemolysis and thrombocytopenia. The presence of this syndrome is associated with increased risk of adverse outcome for both mother and fetus. During the past 15 years, several retrospective and observational studies and a few randomized trials have been published in an attempt to refine the diagnostic criteria, to identify risk factors for adverse pregnancy outcome, and to treat women with this syndrome. Despite the voluminous literature, the diagnosis and management of this syndrome remain controversial. Recent studies suggest that some women with partial HELLP syndrome may be treated with expectant management or corticosteroid therapy. This review will emphasize the controversies surrounding the diagnosis and management of this syndrome. Recommendation for diagnosis, management, and counseling of these women is also provided based on results of recent studies and my own clinical experience.