pre eclampsia dx tools/guidelines?

SmilingBluEyes · Apr 6, 2005

Our physicians take a "big picture approach". By that I mean, they do become concerned about elevating pressures, but also take into consideration the presence or lack of other symptoms/signs such as:

Reports of blurry vision, epigastric pain, worsening headaches; also, observation of hyper-reflexia/clonus, decreasing urinary output, edema, particularly of the face and extremeties is considered ominous. Most often, u/s is done to assess AFI and potential IUGR issues.

When patients present in the office (or the hospital) w/elevated pressures, they are assessed for these other things I just listed---and serial blood pressures are taken, to evaluate for a trend. An NST on the baby is indicated, as well. If the NST is not reactive, then a Biophysical profile is done as followup.

If indicated, labs are drawn and a 24-hour urine is collected and analyzed. (to further diagnose Pre-eclampsia).

Any "shifts" are taken very seriously and consideration given to expeditious delivery, depending on the whole clinical picture and gestational age of fetus. D-dimer and Liver enzyme test results are used to indicate the possibility of developing HELLP Syndrome, , not just pre-eclamspia. (In particular, d-dimer for HELLP).

Remember: You can't rely on any "one" symptom to define PIH/pre-eclampsia and you must look at the whole clinical picture. All symptoms/signs AND tests are used together to "get a snapshot" of what is going on with the patient and guide the physicians, and us, as to how to proceed next, and yes, most of our doctors are quite consistent in treatment modalities and protocols.

Usually, it becomes obvious pretty quickly who is becoming "sick" and needs attention ASAP. HTH.

Jayla · Apr 6, 2005

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.

BMJ. 2005;330:549-550, 565-567, 576-580

SmilingBluEyes · Apr 6, 2005

EXCELLENT ARTICLE Jayla. Thank you so much!!!!

JaneyW · Apr 6, 2005

Thanks for the replies. I am just frustrated with one of our MDs that seems to treat pregnancy more like a disease that needs to be managed than a natural process. She seems to be looking for things to intervene for. I understand that things can go wrong, but not every situation calls for aggressive treatment. She's one of those that hasn't given birth herself yet. I am feeling mean and wish she gets a doctor just like herself.

babyktchr, BSN, RN · Apr 8, 2005

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.
BMJ. 2005;330:549-550, 565-567, 576-580

FABULOUS...thanks for sharing