A 32-year-old primigravida at 28 weeks gestation presents with blood pressure of 160/110 mmHg on two occasions 4 hours apart, headache, and right upper quadrant tenderness. Urine dipstick shows 3+ proteinuria. Which of the following is the most common maternal complication leading to maternal mortality in severe preeclampsia?

Explanation

## Most Common Maternal Complication in Severe Preeclampsia ### Epidemiology of Maternal Complications **Key Point:** Cerebral hemorrhage (intracranial hemorrhage) is the most common cause of maternal death in severe preeclampsia and eclampsia, accounting for approximately 50–60% of hypertension-related maternal deaths. ### Pathophysiology of Cerebral Involvement 1. **Hypertensive encephalopathy**: Severe elevation in BP (>160/110 mmHg) overwhelms cerebral autoregulation 2. **Endothelial dysfunction**: Loss of vascular integrity and blood–brain barrier breakdown 3. **Vasogenic edema**: Leads to increased intracranial pressure 4. **Hemorrhage**: Rupture of small penetrating arteries in the basal ganglia, pons, and cerebellum ### Clinical Manifestations | Complication | Frequency | Presentation | |---|---|---| | **Cerebral hemorrhage** | 50–60% of deaths | Sudden severe headache, loss of consciousness, focal neurological deficits | | Eclamptic seizures | 5–15% | Generalized tonic–clonic seizures, may be preceded by visual symptoms | | Pulmonary edema | 5–10% | Dyspnea, orthopnea, crackles on auscultation | | Acute kidney injury | <5% | Oliguria, rising creatinine, hyperkalemia | ### High-Yield Clinical Pearl **Clinical Pearl:** While eclamptic seizures are the defining feature of eclampsia (preeclampsia + seizures), they are NOT the most common cause of death. Cerebral hemorrhage, occurring without seizures, is more lethal. A patient with severe preeclampsia and sudden severe headache + loss of consciousness suggests hemorrhage, not seizure. ### Management Implications **Key Point:** Aggressive BP control (target MAP <125 mmHg) and seizure prophylaxis with magnesium sulfate reduce the risk of both seizures and cerebral complications, but hemorrhage remains the leading cause of mortality despite these interventions. ### Why Other Complications Are Less Common - **Eclamptic seizures**: Occur in ~1–2% of preeclamptic pregnancies; most respond to magnesium sulfate - **Pulmonary edema**: Usually iatrogenic (excessive fluid administration) or secondary to cardiac dysfunction - **Acute kidney injury**: Rare in preeclampsia; usually reversible with delivery and supportive care [cite:Williams Obstetrics 26e Ch 34]