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Introduction

Preeclampsia, more commonly known by the term gestosis, is a complication of pregnancy and potentially dangerous for both the health of the mother and her baby. In Europe it affects about 2-5% of pregnancies; however, the "increase in the age of mothers at their first pregnancy, obesity and the higher frequency of pregnancies with chronic diseases such as diabetes, recorded in recent years, could lead to an increase in its frequency.

Typical signs of preeclampsia are high blood pressure (arterial hypertension) and the presence of protein in the urine (proteinuria) which are detected during visits and periodic check-ups during pregnancy. In some cases, disturbances (symptoms) may also appear such as, for example, abdominal pain, severe headache, nausea and vomiting, vision changes, hand tremors and sudden weight gain (sometimes over 5 pounds in a week ). If you notice any of these disorders (symptoms) it is important to seek immediate medical attention.

Identifying women with preeclampsia and severe forms of preeclampsia continues to be a challenge for doctors. The causes, in fact, are not yet completely clear and the knowledge currently available on its origin and treatment has not yet been considered definitive.It is important to actively offer pregnant women, and in particular women at greater risk and / or with high blood pressure (hypertension), an "adequate information on preeclampsia, so as to increase their knowledge and the possibility of early identification. All women , before and after giving birth, they should be informed about the signs and disorders (symptoms) it causes and, if they suspect they are affected, the importance of quickly reporting this to healthcare professionals who care for them during pregnancy. a serious illness related to high blood pressure which can affect any pregnant woman.

Symptoms

Preeclampsia rarely occurs before the 20th week of pregnancy. It frequently appears after 24-26 weeks. It can occur, albeit more rarely, even in the first six weeks after childbirth.

In most cases, the symptoms (symptoms) are initially mild and may include:

  • headache
  • blurred vision or visual flashes
  • nausea and vomit
  • pain under the ribs
  • pain in the liver
  • tremor in the hands
  • excessive weight gain (over 5 kilos in one week)

It is important to inform your doctor immediately if such complaints occur. While preeclampsia does not cause other problems in most cases and improves soon after delivery, there is a risk of serious complications for both mother and baby.

Causes

The causes of preeclampsia are not yet known. At the root of the disease is recognized an alteration in the development of the placenta and the blood vessels that supply it, which can damage the maternal-fetal exchange and slow the growth of the fetus inside the uterus.

Factors that can increase the likelihood of developing preeclampsia include:

  • diabetes (not gestational), high blood pressure or kidney disease that was present before becoming pregnant
  • antiphospholipid antibody syndrome (an autoimmune disease)
  • preeclampsia in a previous pregnancy
  • have family members who have had preeclampsia (family history for the disease)
  • age over 40
  • twin pregnancy
  • obesity

Diagnosis

Preeclampsia can occur without warning or occur in women with high blood pressure onset before or during pregnancy.

The main signs for the assessment (diagnosis) of the disease are:

  • high blood pressure (hypertension)
  • presence of protein in the urine (proteinuria)

Even in the absence of proteinuria, preeclampsia can be diagnosed if other signs such as decreased platelets (<100,000 / mm3), impaired liver function (transaminase levels doubled from normal concentration), renal failure (serum creatinine > 1.1 mg / dl) or the onset of neurological symptoms.

The main sign of preeclampsia in children is growth retardation due to the malfunction of the placenta that accompanies and characterizes preeclampsia.

The assessment of the disease is easily performed by checking blood pressure and carrying out blood and urine tests prescribed by the doctor.

A new type of examination has recently been developed, already available in Italy, which allows to predict the onset of preeclampsia, in women with risk factors, up to 4 weeks before the onset of the disorders, thus allowing to identify mothers with higher risk to which to dedicate specific investigations. The test is based on the analysis of the relationship between two biomarkers sFlt-1 (tyrosine kinase 1 FMS-like soluble) and the PlGF (placental growth factor), takes place through a simple blood sample and allows to verify not only if the pathology will conclude, but also to understand if it will manifest itself with a more or less serious form.

Blood pressure monitoring

Blood pressure (BP) should be measured periodically (at each follow-up visit) in all pregnant women, especially if at risk of preeclampsia. It can be measured using outpatient or home appliances. The accuracy of the instruments used for measuring blood pressure, both in healthcare facilities and at home, should be regularly checked by comparison with a calibrated instrument.

Women must be instructed on the appropriate methods of monitoring and interpreting the BP values ​​with particular regard to the recognition of alarm signals that require the involvement of a doctor. For BP monitoring it is important to keep in mind that BP <140/90 mmHg is considered normal in pregnancy.

Therapy

Childbirth is the definitive cure for preeclampsia. For this reason, the affected woman is closely monitored until the baby can be delivered. In case of suspicion of the disease, the woman is usually hospitalized for further specialist investigations and for any necessary treatment. Usually, if only high blood pressure is present without any other complaints, you can go home as long as you have regular checkups, preferably every 3 days.

If, on the other hand, the diagnosis of preeclampsia is confirmed, a series of tests will have to be performed in the hospital, which include:

  • blood pressure monitoring
  • regular urine tests, to ascertain the presence of proteins
  • blood tests, to ascertain kidney and liver function
  • checking the health of the child, by means of any ultrasound scans to check the flow of blood through the placenta, measure fetal growth and observe its movements and, depending on the week of pregnancy, cardiotocography

Continuous bed rest is not recommended during hospitalization as no advantages have been shown over alternating rest and moving around. In women with preeclampsia, it has not been shown that initiating treatment for high blood pressure, if the values ​​are slightly or moderately increased, can improve pregnancy outcomes compared to administering therapy only in severe hypertension. Childbirth represents the definitive cure for the mother because it protects her from the onset of any complications. In the presence of preeclampsia, the possibility of waiting to induce delivery is considered only before the 37th week of pregnancy, if the baby is too small to be born.

In any case of severe preeclampsia, immediate delivery is recommended after the mother's condition has stabilized, regardless of the week of pregnancy. In these situations, where delivery can be expected long before the term of pregnancy, corticosteroid drugs are prescribed that facilitate the development of the baby's lungs, preparing him to breathe at the time of birth. In addition, in these cases, doctors use a drug called magnesium sulfate which has the ability to reduce the possibility of brain complications related to premature birth in the baby, and the risk of a severe form of preeclampsia known as eclampsia in the mother. . Eclampsia occurs in the form of a seizure and can have very serious consequences.

Vaginal delivery is the first choice in pregnant women with high blood pressure and / or preeclampsia, without prejudice to the presence of other indications that make a caesarean section necessary.

Even after childbirth and discharge from the hospital, it is good to keep blood pressure under control and it may be necessary to continue taking antihypertensive drugs for a few weeks.Generally, high blood pressure (hypertension) resolves within 6 weeks of delivery. Women with a previous preeclampsia, especially if it appeared before the 34th week, after childbirth should be tested for the presence of high blood pressure (hypertension) pre-existing during pregnancy or a kidney disease.

Prevention

It is not yet possible to predict and prevent preeclampsia effectively. However, in early pregnancy it is recommended to examine known risk factors to identify, as soon as possible, women who may be affected and refer them to specialist clinics who follow them closely in the first trimester of pregnancy, when there is still the possibility of change an abnormality in the formation of the placenta. Currently, the most effective way to identify preeclampsia is risk factor testing, which must be done at first contact with a healthcare professional.

The main known risk factors are:

  • preeclampsia in a previous pregnancy
  • antiphospholipid antibody syndrome (an autoimmune disease)
  • multiple pregnancy
  • high pressure (hypertension)
  • diabetes
  • kidney disease (or significant proteinuria at the first early pregnancy checkup)

To date, there is no cure available that can reliably prevent preeclampsia. Reducing salt in the diet, limiting calories and taking vitamins have not proved to be effective methods in preventing the disease.

In high-risk women, it is recommended that low-dose aspirin (100 milligrams per day) be taken every day, before bedtime in the evening, starting from the 12th week of pregnancy, and no later than the 16th week, and from continue until delivery. It is important not to take any medications, vitamins, or supplements without first talking to your doctor.

Furthermore, in many Italian centers, a screening test for preeclampsia is currently available, at the same time as the combined test or Bi-test that is performed in the first trimester for the assessment of the risk of chromosomal abnormalities. This test aims to quantify the risk that the mother has of developing preeclampsia during pregnancy through some biomarkers that are measured on the mother's blood (PAPP-A, plasma protein A associated with pregnancy and PlGF), the measurement of blood pressure , data from his history and an ultrasound that studies the vessels that carry blood to the placenta (the uterine arteries). It takes place between the 11th and 14th week of gestation. This test allows you to identify the earliest and most severe forms of the disease in about 90% of cases. The importance of the test is linked to the fact that for mothers who are at high risk, the doctor will recommend taking aspirin at a higher dosage than that previously indicated (150 milligrams / day), always to be started before 16 weeks and that allows to reduce the incidence of preeclampsia.

Bibliography

Center for Maternal and Child Inquiries (CMACE). Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer: 2006-08. The Eighth Report on Confidential Inquiries into Maternal Deaths in the United Kingdom. BJOG: An International Journal of Obstetrics and Gynecology. 2011; 118 (Suppl. 1): 1-203

Tsigas E, Magee L. Advocacy organizations as partners in preeclampsia progress: patient involvement improves outcomes [Summary]. Best Practices & Research. Clinical Obstetrics and Gynaecology 25: 523-36, 2011

World Health Organization (WHO). WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. Geneva: World Health Organization, 2011

Magee L, Helewa M, et al. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Journal of Obstetrics and Gynaecology Canada. 30 (Suppl.3): 1-48, 2008

National Institute for health and Care Excellence (NICE). NICE guidelines: Hypertension in pregnancy: diagnosis and management (CG107)

Ronsmans C, Graham WJ on behalf of the Lancet Maternal Survival Series steering group. Maternal mortality; who, when, where and why [Summary]. Lancet. 2006; 368 : 1189-200  

Preeclampsia in pregnancy: new test available for early diagnosis of gestosis

Di Martino D, Cetin I, Frusca T, Ferrazzi E, Fuse F, Gervasi MT, Plebani M, Todros T. Italian Advisory Board: sFlt-1 / PlGF ratio and preeclampsia, state of the art and developments in diagnostic, therapeutic and clinical management. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2016; 206: 70-73 

Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial [Summary]. Lancet. 1995 Jun 10; 345: 1455-63

Rolnik DL, Wright D, Poon LCY, Syngelaki A, O "Gorman N, de Paco Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W, Papaioannou G, Tenenbaum -Gavish K, Nicolaides KH. ASPRE trial: performance of screening for preterm pre-eclampsia. Ultrasound Obstet Gynecol. 2017 Oct; 50: 492-495

In-depth link

National Institute for health and Care Excellence (NICE). NICE guidelines: Hypertension in pregnancy: diagnosis and management (CG107)

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