Assessment of mother

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The purpose of the ADU is to triage those women who have transient hypertension, or mild pregnancy-induced hypertension from those with true pre-eclampsia. This is done by a mixture of clinical assessment, biophysical monitoring and blood analysis (Table 24.2). Fetal assessment is carried out using standard techniques of CTG (NST) and ultrasound (Table 24.2). When the ADU was first started all the tests were carried out in all

Table 24.2. Antenatal Day Unit investigations in St James University Hospital, Leeds

Patient

Investigation

Mother

Full history, including specific questions

on symptoms

Blood pressure level (average of at least

three readings)

Proteinuria (confirms pre-eclampsia;

increased fetal risk)

Platelet count

Uric acid

Liver function tests (alanine

aminotransterase)

Creatinine

Fetus

Cardiotocograph (Nonstress test)

Ultrasound:

Umbilical artery Doppler

Liquor volume

Growth studies

women. It became clear that this was not necessary and a stepwise approach was developed. Initially, a history is taken to assess maternal wellbeing and maternal appreciation of fetal movements. Any symptoms, such as headache, abdominal pain, nausea, flu-like symptoms and visual disturbances should be taken seriously and the management is guided by this. If they are significant, admission to hospital is mandatory. If all is well, four blood pressure readings are taken, 30min apart, and averaged to assess the average blood pressure level. The reason for this is that blood pressure is an inherently variable parameter and the average gives a better idea of what the true blood pressure is (Pickering, 1993). Urine is tested for the presence of protein. A CTG (NST) is normally carried out at the same time while the woman is waiting to have her blood pressure checked. It was found that 60% of women attending an ADU will have no clinical symptoms, normal blood pressure averages, no proteinuria and a reactive CTG (Walker, 1993). These women do not have any increased risk at this time and can be referred back to the antenatal care system. If the average diastolic blood pressure

Table 24.3. Threshold levels of normality in the assessment of pre-eclampsia

Patient

Investigation

Mother

Diastolic blood pressure >90 mmHg

Proteinuria > 0.3 g day"1

Uric acid >2SD

Platelet count <150 x 109 l"1

Alanine aminotransferase >32 ul"1

Symptoms

Headache

Abdominal pain

Fetus

Intrauterine growth restriction

AC <10th centile

UA PI > 2SD

MVP <2 cm

Or

AFI < 5

is above 90, there is evidence of proteinuria, or signs of fetal compromise, further testing is carried out (Table 24.2). This consists of tests looking for changes associated with progressive pre-eclampsia, platelet count (Redman et al., 1978), uric acid (Redman et al., 1977) and abnormalities of liver function (Weinstein, 1982). None of these parameters should be taken in isolation and should be considered together. If there is any cause for concern (Table 24.3) admission should be arranged for continued monitoring and management decisions. Around 20% of those that attend ADU will be admitted but not necessarily on the first visit. The other 20%, plus any that return from the antenatal care service, are seen through the ADU for signs of progression. The frequency of visits will in general be determined on an individual basis but for women with stable disease the number of visits is likely to be once to twice per week. The development of proteinuria, increasing edema, signs of systemic involvement which can be assessed by decreasing platelet count, rise in uric acid concentration, abnormal liver function, or the presence of clinical symptoms such as headache, visual disturbance, or epigastric pain should prompt careful assessment with probable admission.

Women should be warned of the symptoms associated with worsening disease in order that they can self refer if they occur between visits.

Therefore, the majority of women attend the ADU once for triage and are either admitted or discharged back into the community. Only 20—25% of women have repeated visits, either to verify the assessment or monitor for signs of progression (Table 24.1).

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