Identify Patients at Risk Early

In the past two Master Class installments on preeclampsia, we have discussed how the disorder presents in various ways, afflicting women of different age groups, of varying parity, and with associated medical complications or the lack thereof.

We have also discussed appropriate evaluation and management protocols. The spectrum of disease is such that it spans the very mild (requiring modest intervention) to the very severe (requiring immediate and aggressive intervention strategies). As we saw in the last installment, it is important to view preeclampsia as a multifaceted disease continuum in which designations of “mild” and “severe” are not necessarily fixed.

The variable presentation of the disorder—and the fact that it cannot be precisely predicted or prevented—may in itself be challenging to the practitioner, as he or she counsels patients who are contemplating pregnancies and may be at risk for preeclampsia.

There are certain predisposing medical and sociodemographic factors, however, that are clearly important and that can be useful if they are integrated into an evaluation and management algorithm. Integrating our knowledge of risk factors allows for the most appropriate counseling to be delivered, and the most appropriate management plan to be developed, on a case-by-case basis.

I have invited Dr. Baha Sibai to once again address the topic of preeclampsia in this third and final installment of our series on the disorder. Dr. Sibai is professor of obstetrics and gynecology at the University of Cincinnati and an international expert on preeclampsia and eclampsia, as well as a leader in both clinical care and research in this area.

In this case, we've taken a different approach to presenting the material. We think our case-by-case format will be practical and applicable to the practitioner who is counseling a number of patients who present with varying histories and risk factors.

How to Manage Recurrence Risk

Preconception

▸ Identify risk factors.

▸ Review outcome of previous pregnancy.

▸ Optimize maternal health.

First Trimester

▸ Perform ultrasonography for dating and assessing fetal number.

▸ Order baseline metabolic profile and complete blood count.

▸ Perform baseline urinalysis.

▸ Offer first-trimester combined screening.

▸ If antiphospholipid syndrome is documented, start low-dose aspirin and heparin. Otherwise, offer low-dose aspirin therapy at 12 weeks' gestation.

Second Trimester

▸ Monitor for signs and symptoms of preeclampsia.

▸ Perform ultrasonography at 18-22 weeks' gestation for fetal anomaly evaluation and to rule out molar gestation.

▸ Perform uterine Doppler studies at 18-20 weeks.

Third Trimester

▸ Monitor for signs and symptoms of preeclampsia.

▸ As indicated by the clinical situation, perform laboratory testing, serial ultrasonography (for fetal growth and amniotic fluid assessment), and umbilical artery Doppler with a nonstress test and/or biophysical profile.

▸ Hospitalize for severe gestational hypertension, fetal growth restriction, or recurrent preeclampsia.

Post Partum

▸ Counsel patient about an increased risk for cardiovascular disease and ischemic stroke.

▸ Encourage close follow-up and prevention.

Source: Adapted from Obstet. Gynecol. 2008;112:359-72

Risk Factors for Preeclampsia

The magnitude of risk depends on the number of factors, which include the following:

▸ Multifetal gestation.

▸ Unexplained fetal growth restriction.

▸ Gestational hypertension.

▸ Hydrops/hydropic degeneration of placenta (triploidy, trisomy 13).

▸ Urinary-tract and periodontal infections.

▸ Biophysical and biochemical markers.

Source: Adapted from Obstet. Gynecol. 2008;112:359-72