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Re: What would you do, new caseFrom: Robert J. Woolley (wooll005@gold.tc.umn.edu)Fri Jan 3 22:46:28 1997
In message <v03007805aef361ff785c@[199.1.103.181]> writes: > >Diagnosis, if any? > > Mild pre-eclampsia This reminds me. A few years ago, my management of a case was challenged by the hospital QA committee. They claimed that the patient had pre-eclampsia and should have been managed accordingly. I insisted that she had never had pre-eclampsia. In my defense, I drew up this compilation of authoritative or quasi-authoritative criteria for diagnosing pre-eclampsia. I share it here in hopes it might be useful to others similar situated. It is interesting to note that no two of these definitions are the same. Oh, and BTW, I was able to show that my patient met only 1 of these 6 sets of diagnostic criteria. Of course, that fact didn't change any stubborn minds, but that's a whole 'nuther story.... Definitions of Preeclampsia 1. ACOG Technical Bulletin, February 1986, #91: "Hypertension is defined as a diastolic blood pressure of at least 90 mm Hg or a systolic blood pressure of at least 140 mm Hg, or a rise in the former of at least 15 mm Hg or in the latter of 30 mm Hg. These blood pressures must be manifested on at least two occasions 6 hours or more apart. Preeclampsia is the development of hypertension with proteinuria (presence of 300 mg or more of protein in a 24-hour urine collection or a protein concentration of 1 g or more per liter [Note: This level of proteinuria should produce a 2+ reaction on a standard urine dipstick.] in at least two random urine specimens collected 6 hours or more apart) or edema (a generalized accumulation of fluid of greater than 1+ pitting edema after 12 hours of bed rest or weight gain of 5 pounds or more in 1 week), or both, induced by pregnancy after the 20th week of gestation, and sometimes earlier, when there are extensive hydatidiform changes in the chorionic villi." 2. Davey DA, MacGillivray I. The classification and definition of the hypertensive disorders of pregnancy. Am J Obstet Gynecol 1988; 158: 892-8. (The definitions herein were adopted by the World Health Organization in 1985, the International Federation of Obstetrics and Gynecology in 1985, and the International Society for the Study of Hypertension in Pregnancy in 1986.): "Hypertension in pregnancy: A. Diastolic blood pressure of >= [for ASCII, that's "greater than or equal to"] 110 mm Hg on any one occasion, or B. A diastolic blood pressure of >= 90 mm Hg on two or more consecutive occasions >= 4 hours apart. Proteinuria in pregnancy: A. One 24-hour urine collection with a total protein excretion of >= 300 mg per 24 hours, or B. Two "clean-catch-midstream" or catheter specimens of urine collected >= 4 hours apart with 1. 1 gm albumin per liter or 2+ or more on reagent strip or sulfosalicylic acid "cold" test, or 2. 0.3 gm albumin per liter or 1+ on reagent strip if specific gravity < 1.030 and pH < 8." "Gestational proteinuric hypertension may be regarded as synonymous with 'preeclampsia.'" 3. Williams Obstetrics, 1993 edition: "Preeclampsia is diagnosed by the development of hypertension plus proteinuria, or edema that is generalized and overt, or both." "The diagnosis of pregnancy-induced hypertension is made when blood pressure is 140/90 mm Hg or greater." "Proteinuria is defined as 300 mg or more of urinary protein per 24 hours or 100 mg/dL [Note: Again, this would produce a dipstick reaction of 2+.] or more in at least two random urine specimens collected 6 or more hours apart." 4. DanforthÕs Obstetrics and Gynecology, 1990 edition: "Pregnancy-induced hypertension is defined as a blood pressure of 140/90 mm Hg during the second half of pregnancy in a previously normotensive woman. A rise in systolic blood pressure of 30 mm Hg or diastolic pressure of 15 mm Hg over baseline values also defines the condition. The diagnosis is established when these blood pressure changes are found on at least two occasions six or more hours apart. Preeclampsia is the development of hypertension with proteinuria (> 300 mg in a 24-hour urine specimen or a semiquantitative reaction of 2+ or more in a random urine specimen).Ó 5. Advanced Life Support in Obstetrics, syllabus from course [1997 note: This was one of the early editions of the manual put out by the University of Wisconsin Dept of Family Practice; the course has subsequently been purchased and re-formatted by the AAFP, and I do'nt know what the current course syllabus says, if anything] "Pregnancy-induced hypertension is defined by a systolic rise of greater than 30 mm. of mercury or a diastolic rise of greater than 15 mm. of mercury. The mean arterial pressure may also be used (MAP = 2x diastolic + systolic, divided by 3). In the second trimester, the MAP should not exceed 90 and, in the third trimester, should not exceed 105." "Preeclampsia is defined by the above levels of hypertension PLUS proteinuria greater than 1+. This level of proteinuria will generally correspond with about 300 mg. of protein per 24 hours." 6. National High Blood Pressure Education Working Group Report on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 1990; 163: 1689-1712: "[Preeclampsia] is determined by increased blood pressure accompanied by proteinuria, edema, or both. Either of the following criteria suffice for the diagnosis of hypertension in this situation: (1) systolic blood pressure increases of 30 mm Hg or greater or (2) diastolic blood pressure increases of 15 mm Hg or greater from early values (average of values before 20 weeks' gestation). If prior blood pressure is not known, readings of 140/90 mm Hg or greater after 20 weeks' gestation are considered sufficiently elevated to satisfy the blood pressure criteria of preeclampsia. Note, however, that many young pregnant women will show the blood pressure increase required for the diagnosis of preeclampsia without increasing their pressure to 140/90 mm Hg." "Proteinuria is defined as the excretion of 0.3 gm or greater in a 24-hour specimen. This will usually correlate with 30 mg/dl ("1+ dipstick") or greater in a random urine determination. Proteinuria usually is a late sign in the course of preeclampsia; although it is nonspecific, its appearance greatly bolsters the diagnosis of preeclampsia. Edema is diagnosed as clinically evident swelling, but fluid retention may also be manifested as a rapid increase of weight without evident swelling." I will leave it to somebody else to go through and see if the case described earlier today meets any of these criteria. ---------------------------------------------------------------------------
--------------------------------------------------------------------------- Bob Woolley -- --------------------------------------------------------------------------- St. Paul, Minnesota
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