Pre-eclampsia, Elevated Liver Enzymes, and Low Platelets
Pre-eclampsia, Elevated Liver Enzymes, and Low Platelets
Pre-eclampsia and eclampsia have been known to us for centuries. Significant improvements have been made in our knowledge of the disease, however, delivery remains the only effective form of treatment. There is widespread variation of practice in the management of hypertensive disease in pregnancy, which may lead to substandard care. The use of aspirin in preventing pre-eclampsia, the lack of correlation between urinary protein and adverse outcome, and the ineffectiveness of corticosteroids in the management of hemolysis and elevated liver enzymes and low platelets syndrome are a few of the developments that will alter the way this condition is managed. This article aims to provide a general overview of pre-eclampsia, eclampsia and hemolysis, hemolysis and elevated liver enzymes and low platelets syndrome supported by the latest evidence, which will help the care provider adopt a focused approach and use the latest knowledge to understand and manage this old condition.
Hypertension in pregnancy remains a leading cause of maternal and fetal morbidity and mortality in the UK and worldwide. It is one of the most common medical disorders in pregnancy and the most frequent cause of iatrogenic prematurity. Pre-eclampsia occurs in 2–8% of all pregnancies, with the incidence of severe pre-eclampsia being around 1%. Between February 2005 and February 2006 there were 214 confirmed cases of eclampsia in the UK, representing an estimated incidence of 2.7 per 10,000 births.
Pre-eclampsia and eclampsia have been known to the ancient civilizations of Egypt, China and India. However, it was only in the mid to late 19 and early 20th century that hypertension and proteinuria, the two key features of pre-eclampsia, were recognized. It was also identified that delivery was the only effective treatment for this enigmatic condition. Although advances in management have been made, this still remains the case today.
Hypertension in pregnancy is defined as a diastolic blood pressure of 90 mmHg or more, taken on two occasions more than 4 h apart, or a single diastolic blood pressure of more than 110 mmHg. This can occur either in women who already have hypertension (which can be primary or secondary) and who become pregnant, or can manifest itself de novo in the second half of pregnancy in women who were previously normotensive, when it is called pregnancy-induced hypertension or gestational hypertension. It can be difficult to differentiate between those with chronic hypertension and those with pregnancy induced hypertension in the latter half of pregnancy. However, women who are chronically hypertensive will have a high blood pressure at their first antenatal booking visit or are known to be hypertensive prior to pregnancy (e.g., while taking the oral contraceptive pill). However, since both groups are at an increased risk of developing pre-eclampsia, they need to be closely monitored.
Pre-eclampsia is a multisystem disorder characterized by hypertension, as described earlier, with the addition of proteinuria, defined as more than 300 mg of protein in a 24 h urine collection or more than 30 mg/mmol in a spot urinary protein:creatinine sample. It occurs after 20 weeks of gestation with the hypertension and proteinuria resolving postnatally. Occasionally women present with a severe complication of pre-eclampsia such as eclampsia, or hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.
The risk of pre-eclampsia is 4.1% in women in their first pregnancy and 1.7% in later pregnancies overall. However, this risk rises to 14.7% in the second pregnancy in women who had pre-eclampsia in their first pregnancy and 31.9% in women who had pre-eclampsia in their previous two pregnancies.
In the most recent Confidential Enquiry into Maternal and Child Health in the UK (2003–2005), there were 18 reported deaths from pre-eclampsia and eclampsia, an increase of four deaths from the previous triennium. Ten of these deaths were caused by intracranial hemorrhage, highlighting the ineffective management of the systolic blood pressure in these women. A study from the USA also demonstrated a significant rise in the prevalence of hypertensive disorders amongst hospitalized pregnant women, from 67.2 per 1000 in 1998 to 81.4 per 1000 in 2006.
It has been shown that there is still significant variation in practice around the UK in the management of pre-eclampsia, which may contribute to the substandard care of this potentially lethal condition. In a survey of 370 women who developed pre-eclampsia, 34% did not receive antihypertensive treatment with a systolic blood pressure of 160 mmHg or more, while only 17% of these women received magnesium sulfate prophylactically.
In view of this, the NICE has recently launched a new clinical guideline on the management of hypertensive disorders during pregnancy in order to standardize care and improve morbidity and mortality. This guideline contains recommendations on the diagnosis and management of hypertension in pregnancy during the antenatal, intrapartum and postnatal period. It also offers guidance on the management of women who suffer from chronic hypertension and wish to conceive as well as advice to women whose pregnancy was complicated by hypertension.
Abstract and Introduction
Abstract
Pre-eclampsia and eclampsia have been known to us for centuries. Significant improvements have been made in our knowledge of the disease, however, delivery remains the only effective form of treatment. There is widespread variation of practice in the management of hypertensive disease in pregnancy, which may lead to substandard care. The use of aspirin in preventing pre-eclampsia, the lack of correlation between urinary protein and adverse outcome, and the ineffectiveness of corticosteroids in the management of hemolysis and elevated liver enzymes and low platelets syndrome are a few of the developments that will alter the way this condition is managed. This article aims to provide a general overview of pre-eclampsia, eclampsia and hemolysis, hemolysis and elevated liver enzymes and low platelets syndrome supported by the latest evidence, which will help the care provider adopt a focused approach and use the latest knowledge to understand and manage this old condition.
Introduction
Hypertension in pregnancy remains a leading cause of maternal and fetal morbidity and mortality in the UK and worldwide. It is one of the most common medical disorders in pregnancy and the most frequent cause of iatrogenic prematurity. Pre-eclampsia occurs in 2–8% of all pregnancies, with the incidence of severe pre-eclampsia being around 1%. Between February 2005 and February 2006 there were 214 confirmed cases of eclampsia in the UK, representing an estimated incidence of 2.7 per 10,000 births.
Pre-eclampsia and eclampsia have been known to the ancient civilizations of Egypt, China and India. However, it was only in the mid to late 19 and early 20th century that hypertension and proteinuria, the two key features of pre-eclampsia, were recognized. It was also identified that delivery was the only effective treatment for this enigmatic condition. Although advances in management have been made, this still remains the case today.
Hypertension in pregnancy is defined as a diastolic blood pressure of 90 mmHg or more, taken on two occasions more than 4 h apart, or a single diastolic blood pressure of more than 110 mmHg. This can occur either in women who already have hypertension (which can be primary or secondary) and who become pregnant, or can manifest itself de novo in the second half of pregnancy in women who were previously normotensive, when it is called pregnancy-induced hypertension or gestational hypertension. It can be difficult to differentiate between those with chronic hypertension and those with pregnancy induced hypertension in the latter half of pregnancy. However, women who are chronically hypertensive will have a high blood pressure at their first antenatal booking visit or are known to be hypertensive prior to pregnancy (e.g., while taking the oral contraceptive pill). However, since both groups are at an increased risk of developing pre-eclampsia, they need to be closely monitored.
Pre-eclampsia is a multisystem disorder characterized by hypertension, as described earlier, with the addition of proteinuria, defined as more than 300 mg of protein in a 24 h urine collection or more than 30 mg/mmol in a spot urinary protein:creatinine sample. It occurs after 20 weeks of gestation with the hypertension and proteinuria resolving postnatally. Occasionally women present with a severe complication of pre-eclampsia such as eclampsia, or hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.
The risk of pre-eclampsia is 4.1% in women in their first pregnancy and 1.7% in later pregnancies overall. However, this risk rises to 14.7% in the second pregnancy in women who had pre-eclampsia in their first pregnancy and 31.9% in women who had pre-eclampsia in their previous two pregnancies.
In the most recent Confidential Enquiry into Maternal and Child Health in the UK (2003–2005), there were 18 reported deaths from pre-eclampsia and eclampsia, an increase of four deaths from the previous triennium. Ten of these deaths were caused by intracranial hemorrhage, highlighting the ineffective management of the systolic blood pressure in these women. A study from the USA also demonstrated a significant rise in the prevalence of hypertensive disorders amongst hospitalized pregnant women, from 67.2 per 1000 in 1998 to 81.4 per 1000 in 2006.
It has been shown that there is still significant variation in practice around the UK in the management of pre-eclampsia, which may contribute to the substandard care of this potentially lethal condition. In a survey of 370 women who developed pre-eclampsia, 34% did not receive antihypertensive treatment with a systolic blood pressure of 160 mmHg or more, while only 17% of these women received magnesium sulfate prophylactically.
In view of this, the NICE has recently launched a new clinical guideline on the management of hypertensive disorders during pregnancy in order to standardize care and improve morbidity and mortality. This guideline contains recommendations on the diagnosis and management of hypertension in pregnancy during the antenatal, intrapartum and postnatal period. It also offers guidance on the management of women who suffer from chronic hypertension and wish to conceive as well as advice to women whose pregnancy was complicated by hypertension.
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