I read this article the other day...thought maybe it would help. I tried to find the link for the article, but no luck. Sorry this is so long.
March 14, 2005-The Pre-eclampsia Community Guideline (PRECOG), based on recommendations from the National Institute for Clinical Excellence (NICE), is published in the March 12 issue of the BMJ
. The editorialist states that PRECOG is simple, evidence based, and should be used; and an accompanying systematic review of controlled studies summarizes risk factors for preeclampsia.
The most important risk factors for developing preeclampsia are having a prior history of this condition (relative risk, 7.19; 95% confidence interval, 5.85-8.83), and the presence of antiphospholipid antibodies (relative risk, 9.72; 95% confidence interval, 4.34-21.75) according to a systematic review of controlled studies published from 1966 to 2002. Diabetes and high body mass index almost quadruple the risk, and other significant risk factors include maternal age and hypertension.
"As the failure to identify and act on known risk factors at booking contributes to deaths from pre-eclampsia, it is important to define risk at the beginning of pregnancy," write Kirsten Duckitt, MD, from the John Radcliffe Hospital in Oxford, U.K., and colleagues. "These factors and the underlying evidence base can be used to assess risk at booking so that a suitable surveillance routine to detect pre-eclampsia can be planned for the rest of the pregnancy."
Substandard care may cause or contribute to many fetal and maternal deaths from preeclampsia, according to Fiona Milne, MD, from Action on Pre-eclampsia in Harrow, Middlesex, U.K., and the other guideline authors. Common errors are failure to detect and appropriately manage risk at the beginning of pregnancy or to recognize and respond to signs and symptoms after 20 weeks.
"Our guideline applies to midwife led or general practitioner led care in the community and is applicable from first contact with a health professional until delivery," write Dr. Milne and colleagues. "We recognise that women's emotional, cultural, and midwifery needs should be taken into account when developing individual care plans
and we recognise the benefit of continuity of care."
The guideline, which targets those caring for pregnant women in the community, is a practical extension of NICE's antenatal guideline. It suggests a system of evidence-based early risk assessment and referral in hopes of facilitating specialist care for women with preeclampsia at the optimal time to ensure the best maternal and fetal outcomes. PRECOG offers criteria for early referral for specialist input, a two-tiered schedule for monitoring women in the community after 20 weeks' gestation, and referral criteria for step-up care.
"The evidence behind our guideline can be used to adapt other antenatal guidelines, both within the United Kingdom and worldwide, as local circumstances and needs dictate," the authors write. "Our guideline complements NICE's antenatal guidelines for the routine care of healthy women. Our guideline also provides advice for women excluded from the NICE remit because of risk factors or concurrent medical conditions and recommends test result thresholds and actions for step-up assessment for all women who have antenatal care in the community."
PRECOG is supported by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of General Practitioners, and the National Childbirth Trust.
Definitions used in the guideline are as follows:
- Fetal compromise: reduced fetal movements and small for gestational age infant
- Hypertension: diastolic blood pressure of 90 mm Hg or higher
- New hypertension: hypertension at or after 20 weeks' gestation in women with diastolic blood pressure less than 90 mm Hg before 20 weeks
- Preexisting hypertension: diastolic blood pressure of 90 mm Hg or higher before pregnancy or at booking (before 20 weeks)
- New proteinuria: 300 mg/L or more on dipstick testing, protein-creatinine ratio of 30 mg/mmoL or more on a random sample, or urine protein excretion of 300 mg or more in 24 hours
- Quantified proteinuria: urine protein excretion of 300 mg or more in 24 hours
- Preeclampsia: new hypertension and quantified proteinuria at 20 weeks or more of pregnancy, confirmed if it resolves after delivery
- Superimposed preeclampsia: development of features of preeclampsia in context of preexisting hypertension, preexisting proteinuria, or both
Before developing an antenatal care plan, the guideline recommends identifying the presence of any one of the following factors increasing risk of preeclampsia (grade B/C level of evidence):
- First pregnancy
- Previous preeclampsia
- Ten years or more since last baby
- Age 40 years or older
- Body mass index of 35 kg/m2 or more
- Family history of preeclampsia (mother or sister)
- Initial diastolic blood pressure of 80 mm Hg or more
- Proteinuria when first evaluated (300 mg/L or more on more than one occasion or 300 mg or more in 24 hours)
- Multiple pregnancy
- Underlying medical conditions: preexisting hypertension, renal disease, or diabetes or antiphospholipid antibodies
After the risk assessment, women should be referred to a specialist before 20 weeks if they have one of the following (grade D): previous preeclampsia, multiple pregnancy, underlying medical conditions as defined above, or any two other factors described above.
After 20 weeks, the following signs and symptoms should be evaluated at every assessment and managed accordingly: new hypertension, new proteinuria, headache and/or visual disturbance, epigastric pain and/or vomiting, reduced fetal movements, and small for gestational age infant.
Action on Pre-eclampsia received funding from GlaxoSmithKline and funding in kind by Bayer. The authors report no competing interests.
In an accompanying editorial, Ian Greer, MD, from the University of Glasgow, Scotland, notes that "The pragmatic approach of PRECOG is essential because pre-eclampsia matters."
Regarding early onset of disease, the authors may have underestimated the importance of risk factors as the studies reviewed often did not discriminate between early and late onset preeclampsia. Furthermore, the relationship between risk factors, such as obesity, maternal age, and essential hypertension, could not be studied.
"The strengths of the PRECOG guideline are its simplicity, its evidence base for risk assessment, its reliance only on clinical features for assessment, and its straightforward management plan," Dr. Greer writes. "These features make it relevant not only in the United Kingdom but also in other countries. The weakness is that the available evidence to support intervention with more frequent assessment or by different healthcare professionals is limited in quantity and quality."
Dr. Greer reports no competing interests.
2005;330:549-550, 565-567, 576-580