Category: Advice from doctors

When monitoring pregnancy, “screening” is the most frequently mentioned topic, both by doctors and patients.

In order to clarify things, I would like to briefly explain the term “screening”. This term is used in many areas of daily living and means a fast and easily accessible method, by which from a general, unselected set of objects, people, documents, patients, etc. those that are special or different will be selected. In medicine, i.e. in obstetrics, this means that pregnant women who are different i.e. those with a condition that needs to be further examined are selected from general population.

There are several types of screening during pregnancy:

1. ultrasound screening (the screening for Down syndrome is part of the ultrasound screening);
2. hidden sugar screening;
3. high pressure screening and
4. screening for premature delivery.

Of all the above, the term ultrasound screening is, of course, the most familiar to patients.

As someone who has been doing ultrasound in pregnant women for longer than 20 years, I want to clarify some terminological dilemmas that patients and even doctors often have.

Other terms are often used for ultrasound screening – 4D-screening, screening for anomalies, morphological ultrasound, Doppler-ultrasound, etc. I can say that all names are used for the same thing or term.

Ultrasound examination in certain specific periods of pregnancy. The ultrasound examination itself, i.e. the appropriate ultrasound machine, as a technical possibility has a 4D technique, Doppler or color Doppler. These additional features of ultrasound machines are not always necessary.

The use of these techniques depends on the doctor performing the examination. During the examination, the doctor himself decides whether he needs to include the appropriate technique.

There are also many misconceptions concerning the term or timing of the examination itself. In everyday practice, patients and doctors often insist that the examination must be performed within a period of one week and that it would not be feasible afterwards.

Another misconception!

It is true that there are certain specific periods (I will explain later why) when the examinations should be carried out, but the misconception is that it has to be in the 21st week (for the second screening) or the 12th week (for the first screening). The time frame ranges from 3 to 4 weeks, and even if it is not within the time frame, the examination can certainly be performed.

After all, for experienced doctors, every ultrasound examination of the fetus, in any part of the pregnancy, is in some way a screening.

It is generally accepted that there are three screenings during pregnancy.

I will now explain what is specific to each of them and why they are positioned in the appropriate periods of pregnancy.

Screening in the first trimester

With the completion of organogenesis, around the 12th week of gestation, as the name suggests, the formation of fetal organs is completed.

With modern high-resolution ultrasound machines, an initial morphological (anatomical) assessment of the fetus can already be made in this period. In other words, it means that all the organs of the fetus can be seen, as well as the behavior, i.e. fetal mobility. In this period, a number of possible disorders (defects) in the embryo can already be detected.

The time frame ranges from the 11th to the 14th week of gestation, although, in my experience, the period of full 12th or 13th week is ideal. During this time, the development of the embryo changes very quickly, so somewhere around the 13th week there is more information than in the 11th week.

As an integral part of the ultrasound examination in this period is the screening for Down syndrome.

Fetuses with Down syndrome, in most cases (85%), have certain characteristics in the first trimester. It must be noted that these are not morphological defects, but specific signs (markers), which these fetuses most often have (swelling of the neck, small nose, specific circulation).

It must be emphasized that even if the embryo has these characteristics, it does not necessarily mean that it has Down syndrome. It is just a signal that the embryo should continue to be monitored by other methods. As I explained above, the essence of screening is to single out those who require further testing.

To summarize once again.

• When the embryo has specific features of Down syndrome, additional tests must be
• performed to confirm the suspicion. Although rare, a normal embryo may have these
• characteristics, which are later lost.
• These specific manifestations (not defects) are lost later in pregnancy even in fetuses with
• Down syndrome. Therefore, this period of pregnancy is very important.
• Although very rare, there are embryos with Down syndrome that look completely normal,
• i.e. do not have the aforementioned features.
• For these reasons it must be reiterated that screening can detect a high percentage of
• fetuses with Down syndrome, but never 100%.

When screening for Down syndrome is discussed, the inevitable question that arises is the one about the biochemical screening, known as PRISCA.

Although the topic is ultrasound screening, I have to clarify certain misconceptions about this.

In many countries around the world, screening for Down syndrome consists of two methods – ultrasound and biochemical markers.

Biochemical markers are, in fact, hormones that are present in every pregnant patient. In patients carrying children with Down syndrome, the level of these hormones may be disturbed, i.e. become higher or lower. It should be noted that this does not occur in every patient who carries a fetus with Down syndrome. The most comprehensive world studies report that up to 60% of Down syndrome cases can be detected this way.

Today, a combination of ultrasound and biochemical markers is made, as the gold standard in the world, to reach the figure of 90% of prenatally detected embryos with Down syndrome.

How does it function in North Macedonia? What is PRISCA?

I would like to emphasize that the name PRISCA is not a name for biochemical screening. It is the name of the software (20 years old) that calculates the risk for Down syndrome. The software includes parameters such as the patient’s age, ultrasound parameters and hormone levels, i.e. biochemical parameters.

Here I must emphasize that, after more than 10 years of experience with this software, no satisfactory results are obtained, especially since we, doctors who monitor pregnancy, often have undefined results, confusing for both patients and us. Very frequently there are so-called false positive results, i.e. a result that shows a high risk for Down syndrome in completely normal fetuses. What bothers me the most is that in these 10-15 years there is no statistical analysis of the results of biochemical screening.

When screening for Down syndrome is considered, in the first trimester I personally rely mostly on ultrasound findings.

I must emphasize that this is my subjective assessment based on more than 20 years of experience.

Screening in the second trimester

It is generally accepted among patients, even among doctors, that this is the most important examination during pregnancy.

Why?

This is a period when we are somewhere halfway through the pregnancy and when the fetus is large enough to be checked in detail, i.e. examined. This means that we treat the fetus, in a way, as an adult patient. The examination includes an analysis of the overall anatomy of the fetus: head, brain, face, limbs, sex, locomotor system, spine and all internal organs. Fetal mobility, limb posture, finger position, etc. are also important. Of course, an analysis is made of both the placenta and the amniotic fluid.

The date for this examination, on a large scale, is positioned between the 18th and the 23rd week of gestation. Why?

The fetus is large enough to be able to make the most detailed analysis, and, on the other hand, in case of detection of a problem or defect, we have enough time for possible additional examinations (amniocentesis or something else).

Also, after the analysis and the explanation to the parents by gynecologist about the possible consequences of the relevant defects in the fetus, should they decide to terminate the pregnancy, in this period the termination is safer both medically and psychologically.

When talking about screening in the second trimester, a frequently asked question is whether the heart as an organ should be examined separately by another specialist.

Let me resolve this dilemma: anyone who performs screening in the second trimester should know how to recognize possible heart defects. The possible further definition of the relevant heart problem may require additional consultation with a pediatric cardiologist, i.e. additional echocardiography.

Screening in the third trimester

Patients often have dilemmas as to whether this screening is necessary.

It is a period from the 28th to the 32nd week of gestation. Why do I think that an experienced doctor should carry out the examination during this period? Primarily because any changes resulting from dysfunction or malfunction of placenta are detected by ultrasound after the 28th week of gestation (except in rare, extreme cases). It is particularly important to detect early in order to respond appropriately with drugs that will improve the function of the placenta and that will prepare the fetus for possible preterm delivery, if necessary (corticosteroids for lung maturation). When such a condition is detected, it is a certain signal to monitor more frequently.

Also, during this period, the anatomy and morphology of the fetus are checked again because there are a number (fortunately, less frequent) of defects appear for the first time after the 28th week of gestation.

I will emphasize yet again that these are approximative time frames and details of what is relevant to check at the appropriate time of pregnancy, but any ultrasound examination, at any time during pregnancy, is in some way a screening for an experienced doctor.

It is misconception that in certain period only one thing is seen, while in other it cannot be seen; that the heart can only be seen in the 21st week or that Down syndrome shows no signs in the 20th week, as well as countless other examples of various misconceptions.

Finally, I would like to resolve a few more dilemmas I encounter with patients.

How long does the screening last and who can do it?

The screening can last 5-10 minutes, but it is also possible for it not to be completed after 40 minutes, i.e be incomplete.

What does it depend on?

• the experience and knowledge of the doctor above all;
• patient’s built (in overweight patients, of course, the examination is more difficult than in thinner);
• the position of the fetus;
• the position of the placenta (the placenta on the front wall makes the examination difficult) and
• I intentionally listed the quality of the ultrasound device as the last factor, since all the devices in the last 5-10 years have a high resolution, regardless of their price.

Who can or should do the screening?

Anyone who feels capable and experienced and whom the patient trusts!

Omega-3 fatty acids are fats that have a range of health benefits: cell membrane stability, fetal development, improved cardiovascular health and Alzheimer’s disease.

DHA (docosahexaenoic acid) is an omega-3 fatty acid that is one of the primary structural components of the human cerebral cortex, skin and retina. DHA represents 97% of all omega-3 fatty acids in the brain and 93% of omega-3 fatty acids in the retina.

Sources of DHA

It can be found in cold water fish (salmon, anchovies, tuna, herring, catfish), shrimps, mussels, caviar, seaweed and eggs. Moderate consumption of certain types of sea fish is advised during pregnancy to avoid the risk of mercury intake.

Vegan diet lacks DHA and there is only a limited amount in the vegetarian diet. An important source of omega 3 fatty acids are flaxseed oil, canola and soy.

The diet of pregnant women in most parts of the world is considered to be deficient in DHA and it is not possible to meet the needs of pregnancy without supplementation.

DHA supplementation

In pregnancy, metabolic needs for DHA are increased due to increased needs of the fetus and placenta, compared to women who are not pregnant.

DHA supplementation in pregnancy is safe and numerous observational studies are being conducted worldwide on the impact of n-3 (omega-3) polyunsaturated fatty acid intake on the outcome of pregnancy and maternal and neonatal complications.

Prenatal DHA supplementation appeared on the market 15 years ago and the recommended dose is 400 and 800 mg DHA during the second half of pregnancy.

Impact of DHA supplementation on pregnancy outcome

Pregnancy is thought to last longer in pregnant women taking the supplement, and in some it reduces the risk of premature birth, preeclampsia and gestational diabetes mellitus.

According to a study conducted in 2018, pregnant women with gestational diabetes mellitus who received DHA supplementation of 800 mg / day had children who were less likely to become obese at 2 and 4 years of age.

Studies have shown that newborns of DHA-supplemented pregnant women have significantly higher birth weight and length as well as head length and circumference.

DHA is an important component for the accumulation of lipids in neural tissue during development. Therefore, DHA is essential for the neurological and eyesight development in the fetus. A study of monitoring the development of children aged 4-6 years whose mothers were supplemented with DHA in pregnancy, confirmed that supplementation with DHA was positively correlated with language ability, cognitive performance, coordination of movements and short-term memory in children.

DHA supplementation during pregnancy is thought to reduce maternal depression, but studies that made such findings have been found to be of low to moderate quality.

In contrast, studies show encouraging findings that supplementation with fish oil in pregnant women reduces the incidence of asthma in children. This may be due to the fact that supplementation is associated with reduced levels of cellular elements associated with inflammation and the immune response.

Omega-3 fatty acids are important for health in general and supplementation during pregnancy can lead to numerous benefits for the mother and fetus.

*The author confirms that there is no conflict of interest.

References:

1. Susan E Carlson ¹, John Colombo, Byron J Gajewski, Kathleen M Gustafson, David Mundy, John Yeast, Michael K Georgieff, Lisa A Markley, Elizabeth H Kerling, D Jill Shaddy DHA supplementation and pregnancy outcomes. Am J Clin Nutr. 2013 Apr;97(4):808-15.

2. Maria Makrides. DHA supplementation during the perinatal period and neurodevelopment: Do some babies benefit more than others? Prostaglandins Leukot Essent Fatty Acids. 2013 Jan;88(1):87-90.

3. Elvira Larqué , Alfonso Gil-Sánchez, María Teresa Prieto-Sánchez, Berthold Koletzko

Omega 3 fatty acids, gestation and pregnancy outcomes. Br J Nutr 2012 Jun;107 Suppl 2:S77-84.

4. Danielle Swanson, Robert Block, and Shaker A. Mous. Omega-3 Fatty Acids EPA and DHA: Health Benefits Throughout Life

Adv Nutr. 2012 Jan; 3(1): 1–7.

In pregnancy there is a more pronounced tendency for the blood to clot, the so-called hypercoagulable state. This is one of the so-called physiological, – natural changes in pregnancy, which prepare the body for the blood loss that occurs during childbirth.

Most pregnant women do not need routine testing for coagulation (so-called hemostasis). Normally, prothrombin time and activated partial thromboplastin time are usually normal or slightly reduced (shortened). D-dimers do not have high sensitivity and specificity during pregnancy and are a sign of an already formed clot in the body. They do not show where they come from.

Fibrin D-dimers are for the most part products of the breakdown of the clot (a blood clot that contains so-called fibrin). The normal plasma level of D-dimers with the ELISA test is < 500 ng / ml (measure unit FEU) or < 250 ng / ml (measure unit DDU). Increased plasma concentrations of D-dimers indicate recent or ongoing clotting in blood vessels and its subsequent breakdown, the so-called fibrinolysis.¹

CHANGES DURING PREGNANCY²

Sensitivity of D-dimers (sensitivity to change detection)

False positive findings

Liver disease, high rheumatoid factor, inflammation, malignancy, trauma, pregnancy, surgery, advanced age.

False negative findings

If blood is taken shortly after a blood clot has formed and testing is delayed for several days, take anticoagulants.

INDICATIONS (REASONS) FOR DETERMINATION OF D-DIMER

The need for d-dimer haemostasis is determined based on the current pregnancy status associated with:

1. data from personal history – conditions that are present or that have occurred previously in a

pregnant woman, related to thrombosis;

2. presence of thrombosis in the family – family history and

3. Obstetric history – data from possible previous pregnancies.

This is the starting point. The following is an interpretation of the result depending on the current state of pregnancy and the gestation week. A risk assessment is made – low, medium or high risk for venous thrombosis. On the other hand, there should be a reason to monitor haemostasis with D-dimers and a possible indication to monitor for the presence of congenital thrombophilia.

Non-obstetric causes (unrelated to pregnancy)

The D-dimer assay is clinically useful when suspected of: DVT (deep vein thrombosis), PE (pulmonary embolism), and DIC (disseminated intravascular coagulation).

D-dimers are not indicated in patients with moderate or high risk for DVT and PE, where prophylaxis is indicated on its own, and should only be taken as a control. D-dimers whose clinical picture is not related to DVT, PE or DIC are not indicated.

D-dimers are most useful in patients with a low chance for DVT or PE, where a negative result minimizes the possibility of DVT or PE.²

Obstetric causes

1. Placental lakes – the so-called lacunae on ultrasound examination – correlation with pregnancy outcome and pathological findings

Placental lakes are present in about 2.2% (92 / 4,106) of cases. No statistically relevant difference was observed in birth weight, gestational age at delivery, unfavorable obstetric outcome and in macroscopic or microscopic changes between the control and examined groups.

CONCLUSION: Study data do not indicate an increased risk of adverse pregnancy outcome in cases where only placental lakes occur⁴

2. Are there placental lakes of clinical significance?

At 1,198 consecutive ultrasound examinations in the second trimester, placental lakes were detected in 17.8% of ultrasound examinations.

Detection of placental lakes is six times more likely with a thick placenta if it is more than 3 cm thick in the 20th week of gestation and if they cover more than 30% of the placental surface. It is associated with uteroplacental complications or an unfavorable pregnancy outcome. Lesions are more common with increasing placental thickness.⁵

Prevention of complications in pregnancy

Prevention of complications, such as preeclampsia, fetal growth retardation (growth retardation), premature placental abruption (abruption). Most of the available evidence does not support the association between inherited thrombophilia and complications. Prophylactic anticoagulant therapy to prevent preeclampsia, pregnancy loss, fetal growth restriction, or abruption in women with inherited thrombophilia is indicated in high-risk thrombophilia. One of the most common thrombophilias, MTHFR, is prevented by folic acid supplementation in PreMama Duo.

CONCLUSION AND RECOMMENDATIONS

1. Patients with hereditary thrombophilia are at greater risk of thromboembolic complications during pregnancy due to pregnancy-related changes in several coagulation factors that are physiologically present in pregnancy.

2. The risk of thromboembolism is higher in patients who have a personal history and / or a confirmed family history of thromboembolic events.

3. Most large studies do not indicate a persistent association between inherited thrombophilia and adverse pregnancy outcomes in low-risk populations.

4. Routine testing for hereditary thrombophilia in women with a history of recurrent or irreversible fetal loss, abruption, intrauterine growth restriction, or preeclampsia is advised. There is evidence that the administration of anticoagulants does not improve the outcome of pregnancy in diseased patients.

5. It is recommended not to give prophylactic, anticoagulant therapy during pregnancy to prevent complications related to placental changes, if the fetus is of normal growth and development, with regular fetoplacental flows and a normal amount of amniotic fluid.

References

Weitz JI, Fredenburgh JC, Eikelboom JW . A Test in Context: D-Dimer SOJ Am Coll Cardiol. 2017;70(19): 2411-2420

Hoodwinker . Haematology .Content by Dr. Í. O’ Sullivan 31/01/2011

RCOG GUIDELINE-Green top guideline,No37a

Reis NS1, Brizot ML, Schultz R, Nomura RM, Zugaib M. Clinical uses of the D-dimer include evaluation for the following risk for an adverse pregnancy outcome in cases presenting with placental lakes .J Clin Ultrasound. 2005 Feb; 33(2):. 67-71

Thompson MO1, Vines SK, Aquilina J, Wathen NC, Harrington K .Are placental lakes of any clinical significance? Placenta. 2002 Sep-Oct;23(8-9):685-90

Practice Bulletin No. 138. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:122:706-17.

Preeclampsia is a condition unique to human pregnancy.

What is preeclampsia?

Preeclampsia is a condition unique to human pregnancy.

Preeclampsia is manifested by an increase in blood pressure during pregnancy or immediately after delivery, in pregnant women who had normal blood pressure before pregnancy, accompanied by increased levels of protein in the urine. Rarely, high blood pressure may cause a decrease in platelet count, liver or kidney problems, fluid in the lungs, or signs of brain problems, such as seizures (eclampsia) and / or problems with vision.

The exact cause of preeclampsia is still unknown. Very often you may not have any symptoms and the disease may be discovered by chance during a routine blood pressure measurement and urine test at the antenatal examination at your family gynecologist.

Most women with preeclampsia will give birth to healthy babies and recover completely. However, some women will experience complications, some of them life-threatening for both mother and baby. The mother’s condition can progress to a severe form in a very short period of time.

Why do I need to know if I have preeclampsia?

This disease is relatively common and affects the health of two to eight out of a hundred women during their pregnancy. Fortunately, it is usually in a mild form and has very little effect on pregnancy. However, it is very important to know if you have this disease because in a small number of women it can progress to a much more serious disease. Severe preeclampsia can be a life-threatening condition for both the mother and the newborn.

About one in two hundred women (0.5%) will develop severe preeclampsia during their pregnancy. Symptoms tend to develop at the end of pregnancy, but may also occur for the first time after the delivery.

The symptoms of the so-called. severe preeclampsia include:

• swelling of the face, arms or legs and sudden weight gain (more than 1 kg per week);
• severe headache, which is not relieved with the use of daily analgesics;
• vision problems, such as blurred vision or flashing light in eyes and
• intense pain just below the ribs.

These symptoms are serious and, if you experience them, you should seek medical attention immediately.

In severe preeclampsia, other organs may be involved, such as the kidneys or liver, and blood clots may be present. Severe preeclampsia can progress to convulsions (epilepsy-like cramps) before birth or shortly after your baby is born. These seizures are called eclamptic seizures and are rare, occurring in one in 4,000 pregnancies.

How can preeclampsia affect a newborn baby?

Prematurity

Worldwide, preeclampsia is responsible for 20% of all 13 million preterm births each year.

The baby is considered premature if it is born before the 37th gestation week, but there can be serious problems if it is born before the 32nd week of gestation.

The effect of being born prematurely varies widely. Some babies may only need a day or two under intensive care, while others may spend the first months of their lives in intensive care units. Some babies may also have long-term consequences, such as learning difficulties, cerebral palsy, epilepsy, blindness or deafness (especially those born before the 32-nd gestation week and having a very low birth weight – less than 1,500 grams).

Having a premature baby can also mean a lot of emotional and financial stress for the family.

Intrauterine growth retardation (IUGR)

Preeclampsia can cause reduced blood flow through the placenta, limiting the food supply to the baby. As a result, the baby may become malnourished and small for gestational age. Ultrasound can help detect this condition.

Most babies born with IUGR regain weight in the first few months of life, although recent studies suggest that babies born with impaired growth are more likely to develop certain diseases in adulthood, such as diabetes, congestive heart failure and hypertension.

Of the 30 million IUGR babies born worldwide each year, 15% (4.5 million) are associated with preeclampsia.

Mothers should not blame themselves or malnutrition for IUGR as it is caused by underdeveloped placenta and not by the mother’s diet. You can eat everything that is healthy, but if the placenta is not able to transfer nutrients to the fetus, the baby’s growth will be affected.

Acidosis

Your baby survives in the womb by getting nutrients and oxygen from placenta. Poorly developed placenta in pregnancy with preeclampsia contributes to the baby’s body starting to restrict blood flow through the limbs, kidneys and abdomen, in an attempt to preserve the vital blood supply to the brain and heart. As your baby’s oxygen supply is depleted, its body will begin to produce too much lactic acid. If too much lactic acid builds up, the baby will develop acidosis and lose consciousness by stopping movements. Childbirth is essential at this time, even if the baby is immature.

Long-term consequences

Preeclampsia is associated with a number of long-term consequences for premature babies, such as learning difficulties, cerebral palsy, epilepsy, blindness and deafness. Prematurity also carries the risk of prolonged hospitalization, low birth weight for gestational age, and disruption of significant family bonding time. Prematurity causes stress in the family, and this stress is even greater if the mother is also ill.

An integrated baby and mother care system can reduce some of the above consequences. This includes early diagnosis of preeclampsia; monitoring the condition of the fetus; use of magnesium sulphate, both for the prevention of maternal seizures and for neurological protection of the new-born; safe preterm delivery when indicated and ensuring necessary intensive care for preterm infants. Nevertheless, further research is needed. Effective treatment should be found that does not involve childbirth.

What is the cure?

For the time being, the only “cure” for preeclampsia is childbirth and placenta. When preeclampsia is diagnosed in pregnancy, the mother and her unborn baby should be closely monitored. There are medications and treatments (symptomatic) that can prolong pregnancy, which can increase the baby’s chances of survival. Once preeclampsia develops, it cannot be stopped. In some cases, the baby must be born immediately, without delay, in order to save the life of the mother or the baby.

Obstetricians say that treatment begins with childbirth since the woman is still at risk of preeclampsia and other hypertensive disorders during pregnancy and after childbirth. Therefore, it is essential that every woman continues to control her condition for at least another 6 weeks after childbirth.

Who is at risk for developing preeclampsia and can it be prevented?

Preeclampsia can develop in any pregnancy, but you have a higher risk if:

• your blood pressure was high before pregnancy or in a previous pregnancy and if
• you have a kidney problem or diabetes (diabetes) or a disease that affects the immune system,
• such as lupus.

If any of the above are present in you, it is advisable to start taking 75-150 mg of aspirin once a day, no later than the 16th week of gestation.

The significance of other risk factors is less clear, but you have a higher risk of developing preeclampsia than the general population if you have more than one of the following risk factors:

• this is your first pregnancy;
• you are 40 or older;
• the last pregnancy was more than 10 years ago;
• you are overweight – BMI (body mass index) > 35;
• your mother or sister had preeclampsia and
• you are pregnant with more than one baby (twin pregnancy).

How is a pregnant woman with preeclampsia monitored?

If you are diagnosed with preeclampsia, you should be hospitalized. Your blood pressure will be measured regularly during your hospitalization and, if necessary, you will be given treatment to lower it. Your urine will be tested to measure the exact amount of protein in it and a detailed blood count analysis will be done. Your baby’s heart rate will be monitored and an ultrasound will be carried out to monitor your baby’s growth and well-being.

This monitoring is continued until the results show that you can safely continue your pregnancy. These tests can also be carried out on an outpatient basis if you have a mild form of preeclampsia. However, if you have a severe form of preeclampsia and if there is a danger to your health or the well-being of your baby, you may have to give birth earlier, either with the so-called induced preterm delivery or premature caesarean section. All this is left to the assessment of the experienced obstetrician.

Each decision of the obstetrician should be explained to the patient.

What happens after childbirth?

Preeclampsia usually passes after childbirth. However, if the patient has a severe form of preeclampsia, complications can occur in the first few days after delivery and therefore the patient should be monitored intensively. When she is discharged from the hospital, she will receive advice from her doctor on how often to measure her blood pressure and how long to take the pills. Six to eight weeks after delivery it is necessary to check with the family gynecologist to assess whether her blood pressure has normalized and check the urine for the presence of protein. If high blood pressure is found after the sixth week of delivery or protein is present in the urine, the patient should be referred to nephrologist because it is likely to be previously undiagnosed chronic hypertension.

Will preeclampsia recur in the next pregnancy?

One in six women who have had preeclampsia will develop it again in their next pregnancy.

One in two women will have preeclampsia again in the next pregnancy if the baby had to be born before the 28th week of gestation.

One in four women will have preeclampsia again in the next pregnancy if the baby had to be born before the 34^th gestation week.

Each patient should be explained the possibility of recurrent preeclampsia in the next pregnancy and the need for additional treatment to prevent it.