Feeling like a beached whale may be Ruby W's greatest
worry, but her high blood pressure (BP) probably worries
her physician much more — particularly as she is
28 weeks pregnant. According to an article in the March
12 issue of the British Medical Journal, abnormally
high BP, fluid retention and albuminuria are all red flags
for pre-eclampsia.
Pre-eclampsia occurs in 2-10% of
pregnancies and is a leading cause of maternal death
and stillbirth. Tragically, up to 46% of maternal deaths
and 65% of fetal deaths due to pre-eclampsia could have
been prevented with better management. This calls for
an immediate revision of current guidelines. Thankfully,
an updated set of clinical guidelines based in part
on the BMJ research have indeed been released.
TAILORED
CARE
"The new evidence and PRECOG guidelines allow the family
practice physician, for the first time, to tailor prenatal
care according to a woman's individual risk of developing
pre-eclampsia," claims Dr Fiona Milne, one of the authors
of the updated Pre-Eclampsia Community Guideline (PRECOG)
and member of Harrow, UK's, Action on Pre-eclampsia.
"In this way, both women and their healthcare practitioners
can be prepared for and manage the situation."
Measurable factors that doctors
should keep an eye out for include, in descending order
of risk, the presence of antiphospholipid antibodies,
a history of pre-eclampsia, diabetes, carrying multiple
babies, family history, increased BMI, first pregnancy
over the age of 40, renal disease, hypertension, 10-year
or longer interval between pregnancies, and raised BP.
Study authors Drs Kirsten Dockitt
and Deborah Harrington of the John Radcliffe Hospital
in Oxford, UK, calculated the relative risk for each
of these factors through a systematic review of controlled
studies published between 1966 and 2002. Of the 1,000
studies available, 52 met the quantitative criteria
to be included in the analysis.
The authors cautioned that their
relative risk factors might underestimate the risk of
early onset pre-eclampsia, since it leads to higher
levels of maternal and perinatal mortality and morbidity
when compared to late onset pre-eclampsia. The studies
they examined didn't distinguish between the two conditions.
The PRECOG recommendations were
developed using these risk factors to provide an evidence-based
routine for monitoring and treating pre-eclampsia. The
guidelines recommend that the practitioner screen the
patient for pre-eclampsia risk factors during her initial
visit. Should the patient have one of the risk factors,
the guidelines suggest that the patient be referred
to a specialist for input before hitting the 20-week
mark for gestational age.
After 20 weeks, it's recommended
that the patient be monitored for the signs and symptoms
of pre-eclampsia, which include new hypertension, new
proteinuria, headache or visual disturbance, epigastric
pain or vomiting, reduced fetal movements or fetal weight
that's low for its gestational age.
Although no particular monitoring
schedule has proven itself to be more effective than
any other in battling pre-eclampsia, studies have shown
that a lack of prenatal care is strongly associated
with eclampsia and fetal death. The guideline authors
therefore suggest that women with one risk factor be
seen every three weeks up to 32 weeks gestational age
and every two weeks thereafter until delivery.
Pregnant women should also be educated
to recognize the signs of pre-eclampsia since it can
develop into a life-threatening situation within two
weeks of diagnosis — an alarmingly small window
of time to fight this dangerous condition.
BMJ Mar 12, 2005;330(7491):576-80
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