A 32-year-old primigravida at 28 weeks of gestation presents with blood pressure of 160/110 mmHg on two occasions 4 hours apart. Urinalysis shows 2+ proteinuria. What is the most common cause of maternal mortality in pregnancy-induced hypertension?

Explanation

## Most Common Cause of Maternal Mortality in Preeclampsia/Eclampsia **Key Point:** Cerebral hemorrhage (intracranial hemorrhage) is the leading cause of maternal death in pregnancy-induced hypertension, accounting for approximately 50–60% of hypertension-related maternal deaths. ### Mechanism of Cerebral Hemorrhage in Preeclampsia 1. **Severe hypertension** → disruption of cerebral autoregulation 2. **Endothelial dysfunction** → loss of protective vasodilation 3. **Vasospasm and microangiopathy** → ischemia and edema 4. **Rupture of small cerebral vessels** → hemorrhage ### Why Cerebral Hemorrhage Dominates Mortality **High-Yield:** In eclampsia, the sudden elevation of blood pressure (often >180/120 mmHg) overwhelms the brain's autoregulatory mechanisms, leading to either: - Hemorrhagic stroke (more common in severe hypertension) - Hypertensive encephalopathy with seizures ### Comparative Frequency of Other Complications | Complication | Frequency in Severe Preeclampsia | Mortality Rate | |---|---|---| | Cerebral hemorrhage | 50–60% of deaths | Highest | | Pulmonary edema | 5–10% of cases | Moderate | | Acute renal failure | 3–5% of cases | Moderate | | Placental abruption | 5–15% of cases | Variable | | HELLP syndrome | 10–20% of cases | 1–3% | **Clinical Pearl:** The presence of **persistent headache**, **visual disturbances**, or **altered consciousness** in a patient with severe preeclampsia should raise suspicion for impending cerebral hemorrhage or hypertensive encephalopathy. **Warning:** ~~Acute renal failure~~ is a common complication but accounts for fewer deaths than cerebral hemorrhage. Similarly, ~~pulmonary edema~~ occurs but is less lethal than intracranial hemorrhage. ### Management to Prevent Cerebral Hemorrhage - **Antihypertensive therapy:** IV labetalol or IV hydralazine to target MAP <140 mmHg - **Seizure prophylaxis:** IV magnesium sulfate (gold standard) - **Delivery:** Definitive management; timing depends on gestational age and severity [cite:Williams Obstetrics 26e Ch 34]