Point-of-Care Ultrasound Abnormalities in Late-Onset Severe Preeclampsia: Prevalence and Association With Serum Albumin and Brain Natriuretic Peptide

Abstract

BACKGROUND: Pilot studies applying point-of-care ultrasound (POCUS) in preeclampsia indicate the presence of pulmonary interstitial edema, cerebral edema, and cardiac dysfunction. Laboratory markers of oncotic pressure (albumin) and cardiac dysfunction (brain natriuretic peptide [BNP]) may be abnormal, but the clinical application remains unclear. We investigated the prevalence of pulmonary interstitial syndrome (PIS), cardiac dysfunction, and increased optic nerve sheath diameter (ONSD) in late-onset preeclampsia with severe features. The primary aim was to examine the association between PIS or ONSD and maternal serum albumin level. The secondary aims were to explore the association between cardiac dysfunction and PIS, ONSD, BNP, and serum albumin level and between POCUS-derived parameters and a suspicious or pathological cardiotocograph. METHODS: Ninety-five women were enrolled in this prospective observational cohort study. A POCUS examination of lungs, heart, and ONSD was performed. PIS was defined as a bilateral B-line pattern on lung ultrasound and diastolic dysfunction according to an algorithm of the American Society of Echocardiography. ONSD >5.8 mm was interpreted as compatible with raised intracranial pressure (>20 mm Hg). Serum BNP and albumin levels were also measured. RESULTS: PIS, diastolic dysfunction, systolic dysfunction, and raised left ventricular end-diastolic pressure (LVEDP) were present in 23 (24%), 31 (33%), 9 (10%), and 20 (25%) women, respectively. ONSD was increased in 27 (28%) women. Concerning the primary outcome, there was no association between albumin level and PIS (P = .4) or ONSD (P = .63). With respect to secondary outcomes, there was no association between albumin level and systolic dysfunction (P = .21) or raised LVEDP (P = .44). PIS was associated with diastolic dysfunction (P = .02) and raised LVEDP (P = .009; negative predictive value, 85%). BNP level was associated with systolic (P < .001) and diastolic dysfunction (P = .003) and LVEDP (P = .007). No association was found between POCUS abnormalities and a suspicious/pathological cardiotocograph (P = .07). CONCLUSIONS: PIS, diastolic dysfunction, and increased ONSD were common in preeclampsia with severe features. Cardiac ultrasound abnormalities may be more useful than albumin levels in predicting PIS. The absence of PIS may exclude raised LVEDP. The further clinical relevance of PIS and raised ONSD remains to be established. BNP level was associated with cardiac ultrasound abnormalities. Although this study was not designed to directly influence clinical management, the findings suggest that POCUS may serve as a useful adjunct to clinical examination for the obstetric anesthesiologist managing these complex patients.

Ultrasonography For Fluid Assessment in Parturients with Preeclampsia Undergoing Elective Cesarean Section Under Spinal Anesthesia

“…The alterations in the ONSD indicate a state of cerebral edema as a part of generalized edema, fluid overload and serves as a predictor of volume status in women with severe preeclampsia (31) . Three studies (15,19,20) demonstrated ONSD levels before delivery in preeclampsia, and one study evaluated ONSD before and after delivery in parturients with severe preeclampsia and found that ONSD was lower significantly at 24 hours after delivery compared to predelivery values.. In addition, they found a significant correlation between ECS and ONSD measurements both before and after delivery (15) .…”

“…Pachtman et al (18) demonstrated that women with severe preeclampsia had B-lines measured before delivery more frequently than women without severe features. Another 2 studies were able to detect B-patterns by LUS before delivery (indicating pulmonary interstitial syndrome) in women with severe preeclampsia (19,20) .…”

Detection of Unknown Pregnancy With Complications Using Point-of-Care Ultrasound

“…The POCUS helped narrow the differential rapidly and facilitate immediate treatment. There has been support for POCUS examination of the lungs, heart, and optic nerve sheath diameter to help detect the presence of pulmonary interstitial edema, cerebral edema, and/or cardiac dysfunction while managing patients with pre-eclampsia and eclampsia [13]. Some managing critically ill pregnant women suggest opportunities for further use of multiorgan POCUS including transcranial Doppler and transcranial color-coded duplex sonography which are not traditionally done in the ED setting [14].…”

Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study

“…In their study, B-lines were detected in 5 parturients of 20, giving an incidence of 25%. 27 In another study, Ortner et al 28 described a high proportion of pre-eclamptic patients (24%) with pulmonary interstitial syndrome in their cohort of 95 pre-eclamptic patients. We found a remarkably higher incidence, 64.3%, than in previous studies, 27,28 whereas the lower incidence reported by Zieleskiewicz et al 27 may have been due to their smaller sample size.…”

“…27 In another study, Ortner et al 28 described a high proportion of pre-eclamptic patients (24%) with pulmonary interstitial syndrome in their cohort of 95 pre-eclamptic patients. We found a remarkably higher incidence, 64.3%, than in previous studies, 27,28 whereas the lower incidence reported by Zieleskiewicz et al 27 may have been due to their smaller sample size. Ortner et al 28 enrolled women with late-onset pre-eclampsia as a large cohort of 95 pre-eclamptic women.…”