From Newsletter 41

SUSIE'S STORY

The happy ending to this story comes first - something that even winning Lotto couldn't buy - the birth of a long awaited, healthy, good sized PET-free baby girl named Daisy.  A lot of work, watching and angst went into the 'behind the scenes' of our darling daughter's pregnancy.

I kept a blog throughout this journey. After my last pregnancy ended so abruptly at 25 weeks I wanted something tangible that I could refer back to, to see how far we'd come and, if my imagined worst case scenario repeated, it would be a memento to treasure. My expectations weren't overly high in terms of length of this pregnancy because at my 6 week postnatal appointment last time, I'd been advised in any future endeavour "to hope for 30 weeks and expect 28".  At about 7 weeks I wrote:

Just in case you're wondering, preeclampsia is never far from my mind. I consider myself to be a bit of an amateur expert of the subject. I could rattle off to you the studies that are underway, or have recently been completed... where to find the best source of info.... I've had SEVEN years to read up. I was so naive last time - maybe naive isn't quite the right word, perhaps blissfully unaware or normal or undented would be better terms.  

At 5 weeks I met with the Hospital team and was started on prophylactic Clexane 40mg and low dose aspirin. My blood pressure, which never returned to its old self after my previous bout of PET, was managed with small amounts of Labetalol.

I suppose it's "normal" after losing a child to be afraid of having the same thing happen again. I tried hard to distance myself from the reality of what was going on within my body for ages. I treated it like an academic exercise, which sounds silly on reflection, but was my coping mechanism. At 15 weeks the obstetrician was already talking about having me finish up work at sometime between 20 -  24 weeks to 'grow the baby'. At 22 weeks we finally found out that we were having a daughter. That changed me - all of a sudden it was real and I wanted to be more emotionally involved.

Probably the hardest psychological point in this pregnancy was leading up to the 23 week arterial doppler scan. I was a 'cot case' for the fortnight leading up to it and on the actual day of the scan I was practically hysterical with fear.

(The sonographer) was patient with us and once she realised that we knew what we were looking for, she took the time to explain everything to us and kept reiterating that everything was NORMAL. Oh the bliss. Bearing in mind that with wee Ben there was 'severe notching' I was totally prepared to be told that there was at least some notching, but to be told that there was none... this is now really really real.

After that things became a little easier. We passed the milestone of Ben's birth at 25 weeks with a baby on board who was twice the size he'd been.  Every Saturday, as we clocked over to another week, I'd check the stats for viability and oxygen support required in the NICU. Weird? Yes. But that was my way of knowing that our baby was getting that much closer to being a 'keeper'.

Things trucked along from there quite nicely. I finished up work at 28 weeks and spent 4.5 weeks doing girly things at home and visiting the hospital occasionally for a check up. I was still worried though, enough to refuse all kind offers of baby showers and the like. Things ticked along nicely until 33 weeks when my insulin requirements (I'm a Type 1 Diabetic) plummeted, which I knew could be a sign of placental problems. I was admitted at 33+5 with a baby on board estimated at 7lb! Daisy was born a few days later at 34+1 after a CTG trace concerned the doctors. We had an emergency c-section and a GA due to the clexane in my system. I was briefly disappointed to be having another emergency c-section and another GA and was scared in some ways that this was history repeating itself, but of course I wanted Daisy out safely and history wasn't repeating itself.  When I woke up in Recovery I learned that indeed we had a 6lb 3oz daughter who was doing well in the NICU. 12 days later, we all came home before Daisy was even 36 weeks.

I'll never underestimate the mean beast that is preeclampsia - the speed and severity with which it can appear. I spent the entire pregnancy in fear of a recurrence. There wasn't a day that went by that I didn't think about it. However, in the end, although not a textbook finish, the outcome was magnificent. Daisy is the apple of our eye and words will never be enough to thank the team at Wellington Hospital for the gift we now have. Christmas this year is indeed  very merry.

Sample research article from this issue

Diagnosis of Preterm Preeclampsia

In Issue 40 we included an article on a prospective new screening test for preeclampsia, Currently a test is being developed that will measure the levels of two substances, placental growth factor (PlGF) and soluble Flt 1) which are useful biomarkers when measured as a ratio. Soluble Flt is also known as soluble vascular endothelial growth factor receptor 1 (sVEGR R1). 

 The January issue of the American Journal of Obstetrics and Gynecology published an article reporting another study, (Sunderji et al., 2010) which has assessed the utility of measuring these proteins to aid in the diagnosis of preeclampsia.

Preeclampsia is characterised by hypertension and proteinuria after 20 weeks of pregnancy but unfortunately diagnosis is not always clear-cut because the classic criteria for preeclampsia are not always met and the disease may progress undiagnosed with severe morbidity and mortality risks for mother and baby, particularly at early gestations.

Recent studies (Levine et al, 2004;Krauss, Pauer & Augustin, 2004), have indicated a strong correlation between altered levels of PlGF and SolFlt 1 in pregnant women with diagnosed preeclampsia as well as those who will later go on to develop the disease.  These studies have found that SolFlt 1 levels rise earlier and to a greater extent in women who will develop preeclampsia. In contrast PlGF levels are significantly lower in these women. (See article in Issue 40 for a further explanation).

457 women, at gestations between 20 and 36 weeks, participated in the study conducted by Sunderji and co-researchers. The work has provided further evidence in support of blood testing for the ratio of these two biomarkers. The ability to accurately diagnose preeclampsia at gestations remote from term will be of benefit to both women and their maternity caregivers as confirmation of a diagnosis in complex situations will help target correct treatment and timing of delivery, as well as ruling out the diagnosis of preeclampsia in other conditions such as chronic renal disease, systemic lupus erythematosus and acute fatty liver of pregnancy.

Larger prospective longitudinal studies are needed to confirm these results.

References

Levine, R.J., Maynard, S.E., Qian, et al. (2004) Circulating angiogenic factors and the risk for preeclampsia. New England Journal of Medicine; 350:672-83

Krauss, T., Pauer, H.U., Augustin, H.G. (2004). Prospective   analysis of placental growth factor (PlGF) concentrations in the plasma of women with normal pregnancy and pregnancies complicated by preeclampsia. Hypertens Pregnancy; 23:101-11

Sunderji, S., Gaziano, E., Wothe, D et al. (2010) Automated assays for sVEGF R1 and PlGF as an aid in the diagnosis of preterm preeclampsia: a prospective clinical study. American Journal of Obstetrics and Gynecology, 202: 40.e1-7.