Last post I talked about the five parts of the PRECOG pre-eclampsia check. This time I will discuss what the PRECOG Day Assessment Unit guideline recommends is done when any one of these is found.
Firstly, new hypertension. If your diastolic blood pressure (the lowest of the two figures) has increased to 90mmHg or more (and it was less than 90mmHg before 20 weeks) you have new hypertension. If it doesnt reach 90 - even if it has gone up a lot from your booking blood pressure - then your pregnancy will probably be fine. As I said before, everyone's blood pressure in pregnancy goes down - then from about 16 weeks begins to increase. By term, some people will have a diastolic blood pressure reaching 90, as a normal part of pregnancy. The PRECOG guideline suggests that if you have a diastolic blood pressure of 90 to 99 you should be invited to to for a hospital assessment within 48 hours, and if you have symptoms as well, you should go on the same day.
The lowest of the two figures - the diastolic - is usually related to pre-eclampsia. The highest of the two figures - the systolic - is also important to watch, to know when to start treating the high blood pressure. Whether or not you go on to develop pre-eclampsia, it is important for a very high diastolic and systolic to be treated.
The earlier in pregnancy that you get new hypertension, the more likely you are to develop pre-eclampsia. If you get new hypertension before 32 weeks, then you have a 50% chance of developing pre-eclampsia (so if there are 100 women with new hypertension 50 will get pre-eclampsia and 50 will not)
The second part of the pre-eclampsia check is for proteinuria. The PRECOG group defined pre-eclampsia as new hypertension with new proteinuria. It is a simply definition, that identifies the huge majority of people who have pre-eclampsia and they or their babies are not very well because of it. Something like 15% of people will get proteinuria first, followed by hypertension.
When proteinuria is measured with a dipstick, it is recorded as none, trace, 1+, 2+, 3+ etc. Proteinuria of 2+ is almost definitely significant, and the midwife/ doctor can assume you have proteinuria. Proteinuria on dipstick of 1+ or a trace may not be significant (for lots of reasons including the concentration of your urine, and how well trained the person is at reading the colour on the dipstick). To be sure that you have proteinuria, you may be invited to collect your urine over 24 hours. This collection is then tested in a laboratory. The reason that this is done is because the amount of protein that goes into your urine varies throughout the night and day and a 24 hour collection will give a better feel for the amount you are excreting. The figure of 300mg per 24 hour or more is the level which the PRECOG group define as "significant proteinuria". Another way of testing the amount more accurately is for the hospital to do a "protein creatinine ratio"; this isnt as accurate as a 24 hour collection, but is much more convenient.
So, in the same way that you will be invited to go to a hospital day unit within 48 hours if you have new hypertension, you will be invited to do the same if you have proteinuria (2+). If you have a trace, or 1+, without any symptoms or concerns about your baby, you will probably be seen for a pre-eclampsia check more frequently than before but dont necessarily need to be checked in the hospital. If you have 1+ proteinuria with symptoms, you should be invited to the hospital on the same day.
Two parts of the pre-eclampsia check are related to symptoms that you describe to your midwife (epigastric pain with or without vomiting, headache with or without flashing lights). If you have epigastric pain after 20 weeks you should be invited to have a hospital check up the same day, whether or not you have hypertension and/or proteinuria. If you have a bad headache but do not have new hypertension or proteinuria, your GP will try and find out the cause, while checking you more frequently for pre-eclampsia.