Practice
Easily Missed?
Pre-eclampsia
Cite this as:
BMJ
2012;345:e4437
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26 August 2012
As any practicing Obstetrician with a robust clinical practice will confirm, the earlier in the course of pregnancy that pre-eclampsia develops, the more rapidly the condition will deteriorate. One should be ever mindful that pre-eclampsia is associated with , and probably caused by, poor placental function. Thus the fetus in a pregnancy affected by pre-eclampsia is highly likely to be developing in a less than ideal environment. For example that is why one so frequently encounters fetal growth restriction in cases of pre-eclampsia
Treating pregnant women with anti-hypertensives to lower their blood pressure resultant from pre-eclampsia does not cure the condition. But lowering the blood pressure can lull the unwary into a false sense of security.
The only recognised cure for pre-eclampsia is delivery. Yet discussion of the management of pre-eclampsia so often focuses on prolonging pregnancy if the gestation is pre-term. The most important advantage of prolonging a pregnancy so seriously affected by pre-eclampsia that it warrants delivery, is to allow for steroids to promote fetal lung maturity. Much of this effect can be achieved within 24 hours of their administration.
Whilst not wishing to hinder a fetus by iatrogenic premature delivery, if one embarks upon a course of prolonging a pregnancy affected by pre-eclampsia, one should do so with extreme caution. As illustrated in the case discussed, it took just one week from when the first signs of pre-eclampsia developed, until the fetus died.
Competing interests: None declared
Royal Oldham Hospital, Rochdale Road,Oldham, OL1 2JH
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22 July 2012
We read with interest the article of David Williams and Naomi Craft;
We would like to emphasize that early detection of ocular manifestations of pre-eclampsia maybe of great importance not only for the diagnosis of but also for the salvage of the vision of the patient.
Ocular manifestations develop in 25% of patients with preeclampsia and total blindness has been reported to occur in 1-2% of cases[1-2]. Visual complications may include hypertensive retinopathy, exudative retinal detachment and cortical blindness. Hypertension retinopathy is attributed to the changes of the vessels of the choroid and of the retinal pigment epithelium ,due to the increase of blood volume, of the viscosity of the blood and the levels of vasoactive hormones. The first sign is usually arterioral spasm, followed by intraretinal haemorrhages, exudates and nerve fiber layer infracts. The pathophysiology of the exudative retinal detachment has not been fully elucidated ,but ischemia occurring in choriocapillaris has been identified as the main causative factor. Cerebral edema, caused by cytotoxic and vasogenic factors can lead to cortical blindness,by damaging bilaterally any portion of the visual pathways posterior to the lateral geniculate nucleus.[3-5].
It is strongly recommended that all pregnant women - even with the suspicion of developing preeclampsia- should be advised to visit urgently an ophthalmologist for a thorough ophthalmologic examination, including best corrected visual acuity, pupillary light reflex, fundoscopy, optic coherence tomography since if this situation remains untreated the vision of the patient maybe permanently adversely affected.
1. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005 Feb-Mar;365(9461):785–99.
2. Swende TZ, Abwa T. Reversible blindness in fulminating preeclampsia. Ann Afr Med. 2009 Jul-Sep; 8 (3) :189-91.
3. Schönfeld CL. Bilateral Exudative Retinal Detachment in HELLP Syndrome. Case Report Ophthalmol. 2012 Jan; 3 (1) :35-7.
4. Mourelo M, Alvarez M, Díaz JL, García T, Galeiras R, Freire D. Postpartum amaurosis in a woman with severe preeclampsia. Indian J Crit Care Med. 2011 Oct; 15 (4) :227-9.
5. Citirik M, Simsek T, Zilelioglu O. Bilateral permanent concentric visual field defect secondary to severe pre-eclampsia. Clin Ophthalmol. 2008 Jun; 2 (2) :465-8.
Competing interests: None declared
University of Athens, Department of ophthalmlogy, 59 Chrysanthemon ,15452 Athens
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20 July 2012
Normal serum creatinine in pregnancy and hyponatremia in severe preeclampsia
Early in first trimester of pregnancy there is a 60 % increase in renal plasma flow and glomerular filtration. As a result serum creatinine falls by approximately 0.04 mmol/L. A normal serum creatinine in pregnancy is therefore between 0.03 and 0.07 mmol/L. I would regard the value of 0.09 mmol/L quoted in the review article as being indicative of significant renal pathology.
Significant hyponatremia (< 132 mmol/l) is also a marker of severity in the setting of preeclampsia. Serum sodium normally falls in pregnancy by approximately 3-5 mmol/L as a result of increase in intravascular volume and resetting of osmostat. Greater falls in serum sodium occur in severe preeclampsia as a result of increased secretion of antidiuretic hormone.
Competing interests: None declared
Mater Health Services, Raymond Tce South Brisbane 4101
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