pre eclampsia manual

Prevention and management of pre-eclampsia and eclampsia A Reference Manual for Health Care Providers

Copyright © 2010, Jhpiego. All rights reserved. The material in this document may be freely used for educational or noncommercial purposes, provided that the material is accompanied by an acknowledgement line. Suggested citation: MCHIP. Prevention of eclampsia: A Reference Manual for Health Care Providers. Baltimore: Jhpiego; 2010.

Prevention and management of pre-eclampsia and eclampsia i

Prevention and management of pre-eclampsia and eclampsia

A Reference Manual for Health Care Providers

2010

Maternal and Child Health Integrated Project (MCHIP)

This manual is made possible through support provided to MCHIP by the Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, US Agency for International Development, under the terms of Subcontract No. __________, under Contract No. ______________. MCHIP is implemented by a collaborative effort between Jhpiego, Save the Children, John Snow, Inc (JSI), MACRO, Johns Hopkins University Institute for International Programs (IIP), Program for Appropriate Technology for Health (PATH), Broad Branch Associates (BBA), Population Services International (PSI), Collaborating Organizations: Communication Initiative (CI), CORE, and others.

ii Prevention and management of pre-eclampsia and eclampsia

Table of contents

Introduction ............................................................................................................ v Understanding pre-eclampsia and eclampsia ................................................................ 1

Key definitions ................................................................................................... 1 Pathophysiology ................................................................................................. 1 Epidemiology of pre-eclampsia and eclampsia ........................................................ 2 Morbidity and mortality associated with pre-eclampsia and eclampsia ........................ 3

Identifying pre-eclampsia .......................................................................................... 7 Key definitions ................................................................................................... 7 Introduction ...................................................................................................... 7 Screening ......................................................................................................... 7 Detecting hypertensive disorders in pregnancy ....................................................... 8 Differential diagnosis of hypertension in pregnancy/postpartum .............................. 13 Differential diagnosis of fits in pregnancy/postpartum ........................................... 14

Prevention ............................................................................................................. 17 Key definitions ................................................................................................. 17 Primary prevention of pre-eclampsia ................................................................... 17 Secondary prevention ....................................................................................... 18 Tertiary prevention ........................................................................................... 19 Overview of interventions to prevent pre-eclampsia and eclampsia.......................... 20

Management .......................................................................................................... 23 Gestational hypertension ................................................................................... 23 Mild pre-eclampsia - Gestation less than 37 weeks ................................................ 23 Mild pre-eclampsia - Gestation more than 37 complete weeks ................................ 24 Severe pre-eclampsia and eclampsia .................................................................. 24 Postpartum care .............................................................................................. 28 Referral for tertiary level care ............................................................................ 28 Complications of gestational hypertension ........................................................... 28

Managing obstetric emergencies ............................................................................... 29 General management for an obstetric emergency ................................................. 29 General management for shock .......................................................................... 30

Birth preparedness and complication readiness ........................................................... 33 Birth-preparedness plan .................................................................................... 33 Complication-readiness plan .............................................................................. 34

References ............................................................................................................. 37

Prevention and management of pre-eclampsia and eclampsia iii

Acknowledgements The writing team of ______________________________________________ is grateful to the following people, who provided invaluable assistance with this effort:

Contributing editors Reviewers Proofreader Illustrator .

About MCHIP

For more information or additional copies of this report, please contact:

iv Prevention and management of pre-eclampsia and eclampsia

Acronyms

USAID United States Agency for International Development WHO World Health Organization

Reference manual

Prevention and management of pre-eclampsia and eclampsia v

Introduction

Efforts such as the Safe Motherhood Initiative and the World Health Organization (WHO) Making Pregnancy Safer Division and strategies to meet the United Nations Millennium Development Goals are supporting worldwide activities to reduce maternal and newborn mortality. Despite these efforts, hundreds of thousands of women and babies die or become disabled due to complications of pregnancy and childbirth every year.1

Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labor.2 Pre-eclampsia may also occur in the immediate post-partum period. This is referred to as "postpartum pre-eclampsia." The most dangerous time for the mother is the 24�–48 hours postpartum and careful attention should be paid to pre-eclampsia signs and symptoms.3

Ten percent of all pregnancies are complicated by hypertension (HTN). Eclampsia and preeclampsia account for about half of these cases worldwide and have been recognized and described for years despite the general lack of understanding of the disease.4 The fetal mortality rate varies from 13-30% due to premature delivery and its complications. Placental infarcts, abruptio placentae, and intrauterine growth retardation also contribute to fetal demise.5 Maternal death risk is approximately 1.8%, in high resource settings, and up to 14% in settings with low resources and lack of facilities required for supportive management. Higher mortality rates are associated with patients who have multiple seizures outside the hospital and those without prenatal care.3

Fortunately, simple, low-cost interventions are available to prevent most cases of eclampsia and manage them should they occur. Providers at all levels must be able to identify pre-eclampsia and eclampsia and know how to respond. Timely diagnosis and effective initial management can reduce morbidity and the risk of maternal, fetal, and newborns deaths associated with severe pre-eclampsia and eclampsia. Once providers identify pre-eclampsia

vi Prevention and management of pre-eclampsia and eclampsia

and eclampsia, they must be competent to provide effective initial management and ensure timely referral for cases that cannot be managed at their level.

To facilitate access to important maternal technologies, countries must ensure that the following are in place:

National guidelines that reflect state-of-the art and evidence-based interventions for prevention, identification and management of pre-eclampsia and eclampsia

Policies that promote access to important technologies for prevention, identification and management of pre-eclampsia and eclampsia at all levels along the continuum of care

Training infrastructure that promotes training all health workers in prevention, identification and management of pre-eclampsia and eclampsia at all levels along the continuum of care

Logistics systems that ensure availability of necessary resources (equipment, supplies, and consumables for infection prevention and injection safety) are available

Supervision and monitoring systems to assure quality and ensure transfer of learning to the work site.

Ongoing research in various settings continues to identify the best approaches for preventing and managing eclampsia and its complications. By developing national guidelines, training health care providers, improving work environments, and supporting the development of improved access to care, more women will have access to life-saving interventions that reduce morbidity and mortality associated with pre-eclampsia and eclampsia.

About the learning materials MCHIP developed a learning package on the prevention and management of pre-eclampsia and eclampsia consisting of a reference manual, participant�’s notebook, and facilitator�’s guide. This learning package was developed for use by nurses, midwives, and doctors providing care during pregnancy, childbirth and the postpartum.

These documents comprise a set and should be used together. These resources are distinguished within the series by a corresponding icon located at the top of the right hand page:

Reference manual

Facilitator’s guide

Participant’s notebook

This course is designed to be utilized for in-service training, with the overall objective of providing updates about prevention and management of pre-eclampsia and eclampsia use to equip nurses, midwives, and clinical and health workers to carry out the following:

Reference manual

Prevention and management of pre-eclampsia and eclampsia vii

Provide safe, respectful, and friendly care to women, newborns, and their families. Women and families will then be more likely to utilize the health care system with confidence because they know they will receive competent, compassionate care.

Follow an evidence-based protocol for prevention, identification, and management of pre-eclampsia and eclampsia, including clear guidelines on when to refer women with complications, ensuring timely action is taken.

Provide greater protection from infection for their clients and themselves.

viii Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia 1

Understanding pre-eclampsia and eclampsia

Key definitions Avoidable factors: are factors causing or contributing to maternal death where there is departure from generally accepted standards of care.

Risk factors: are factors which make a condition more likely to happen or more dangerous

Pathophysiology Cause

Pre-eclampsia is a pregnancy-specific syndrome, recognized, even by Hippocrates, as a leading cause of maternal and perinatal mortality. The condition�’s former name, �“toxemia of pregnancy,�” was based on a theory that a toxin produced in a pregnant woman�’s body caused the disease. The cause of pre-eclampsia and eclampsia remains unknown, though multiple theories have been proposed to explain their cause, resulting in confusion and myths surrounding both etiology and management. The main etiologic theories include abnormal trophoblastic invasion, coagulation abnormalities, vascular endothelial damage, cardiovascular maladaptation, immunologic phenomena, genetic predisposition, and dietary deficiencies or excess.4

Pathophysiologic changes

In normal pregnancies, blood volume increases 30 to 50%, peripheral vascular resistance decreases, pregnancy-induced arterial dilatation occurs, fibrinogen is increased, and factor XIII (fibrin stabilizing factor) is decreased. The following pathophysiologic changes are associated with pre-eclampsia and eclampsia:

Blood pressure begins to rise after 20 weeks of pregnancy

Perfusion is decreased to virtually all organs, which is secondary to intense vasospasm due to an increased sensitivity of the vasculature to any pressor agent

Perfusion to the kidneys is decreased, resulting in sodium retention that leads to loss of intravascular plasma volume, increased extracellular volume (edema) and increased sensitivity to pressor agents

Loss of normal vasodilation of uterine arterioles results in decreased placental perfusion

Decreased intravascular volume results in increased viscosity of the blood and a corresponding rise in hematocrit, and activation of the coagulation cascade, especially platelets, with microthrombi formation

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome is sometimes associated with severe pre-eclampsia and results from activation of the coagulation cascade:

o Fibrin forms cross-linked networks in the small blood vessels.

o This leads to a microangiopathic hemolytic anemia: the mesh causes destruction of red blood cells as if they were being forced through a strainer.

o Additionally, platelets are consumed. As the liver appears to be the main site of this process, downstream liver cells suffer ischemia, leading to periportal necrosis. Other organs can be similarly affected.

2 Prevention and management of pre-eclampsia and eclampsia

o HELLP syndrome leads to a variant form of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding.

Disease progression

Pre-eclampsia and eclampsia are part of the same disorder with eclampsia being the severe form of the disease. Gestational hypertension may progress from a mild hypertensive disorder to a life-threatening condition, as follows:

hypertension without proteinuria or edema

mild pre-eclampsia

severe pre-eclampsia

eclampsia

While pre-eclampsia is usually a progressive disease, the rate of progression and the occurrence of catastrophic complications such as eclampsia, cerebrovascular accident, severe HELLP syndrome, pulmonary edema or renal failure are difficult to predict. In some cases, mild pre-eclampsia sometimes progresses to severe pre-eclampsia and eclampsia very suddenly with little or no warning. In other cases, hypertension or proteinuria are absent when a woman begins having eclamptic seizures. Eclampsia can occur during the antepartum, intrapartum, and postpartum periods; and ninety percent of eclampsia cases occur after 28 weeks' gestation.5

Epidemiology of pre-eclampsia and eclampsia Numerous maternal factors can predispose to the disorder; these may be genetic, behavioral, or environmental. Pre-eclampsia and therefore the risk of eclampsia is more common in:5, 6,7

Women with a family history of preeclampsia, prior preeclampsia and eclampsia

Women with a history of poor outcome of previous pregnancy, including intrauterine growth retardation, abruptio placentae, or fetal death

Preexisting medical condition - Obesity, chronic hypertension, renal disease, thrombophilias-antiphospholipid antibody syndrome, protein C deficiency and protein S deficiency, antithrombin deficiency, vascular and connective tissue disorders, gestational diabetes, and systemic lupus erythematosus

Multifetal gestations, hydatid mole, fetal hydrops, primigravida Teen pregnancy Primigravida Women who are older than 35 years Lower socioeconomic status primigravida (especially young teenagers and women over 35 years) primipaternity (first pregnancy with the male partner) obese women women with essential or renal hypertension multiple pregnancy black women women with

- diabetes


- hydatidiform mole - polyhydramnios - hydrops fetalis - increased insulin resistance - increased testosterone - increased blood homocysteine concentration.

Most traditional risk factors are associated with attributes of the woman or the pregnancy/fetus. One hypothesis on the causes of pre-eclampsia is immune maladaptation. Support for this hypothesis comes from epidemiological studies that show that:

the risk for developing pre-eclampsia decreases with the length of exposure to the sperm that will ultimately fertilize the woman�’s egg8

although pre-eclampsia is generally thought of as a disease of first pregnancies, the protective effect of multiparity is lost with change of partner9

men who fathered a pre-eclamptic pregnancy were nearly twice as likely to father a pre-eclamptic pregnancy in a different woman, regardless of whether she had already had a pre-eclamptic pregnancy or not9

�“Risk factors�” should not be used to predict complications. The system of risk categorization, or the �“risk approach�”, previously used for selecting women for specialized management is not useful, because evidence shows that many women categorized as �“high risk�” do not actually experience a complication, while many women categorized as �“low risk�” do. All pregnant women should therefore be considered �“at risk�” of developing a complication.

Morbidity and mortality associated with pre-eclampsia and eclampsia Factors influencing maternal and perinatal outcomes

Pre-eclampsia is a major obstetric problem leading to substantial maternal and perinatal morbidity and mortality worldwide, especially in low resource settings. Maternal and perinatal outcomes in pre-eclampsia depend on maternal, community, and health care factors.

Maternal factors5 influencing maternal and perinatal outcomes:

In general, maternal and perinatal outcomes are usually favorable in women with mild pre-eclampsia developing beyond 36 weeks�’ gestation who have no other pre-existing medical disorders.

By contrast, maternal and perinatal morbidities and mortalities are increased in women who develop the disorder before 33 weeks�’ gestation, in those with pre-existing medical disorders, and in those receiving care in low resource settings.

Community factors7 influencing maternal and perinatal outcomes:

Lack of awareness about symptoms of severe pre-eclampsia and eclampsia and the importance of early and regular antenatal care

Transportation problems

Low socioeconomic status

Financial hardship and inability to pay for transport and medical care


Community distrust of health care personnel

Health service factors7 influencing maternal and perinatal outcomes:

Failure to monitor blood pressure and urine during antenatal care

Failure to counsel women and families about dangerous symptoms of severe pre-eclampsia and the importance of regular antenatal care

Delay in referral of women with symptoms and signs of severe pre-eclampsia or eclampsia

Lack of a clear-cut management strategy/clinical protocols for dealing with pre-eclampsia and eclampsia

inadequately trained staff to treat women with severe eclampsia or eclampsia

Lack of proper equipment and drugs to treat eclampsia

Maternal and fetal complications in severe preeclampsia

Effects on the mother

These include:

Respiratory problems (asphyxia, aspiration of vomit, pulmonary edema, broncho-pneumonia)

Cardiac problems (heart failure)

Effects on the brain (hemorrhage, thrombosis, edema)

Renal complications (acute kidney failure)

Hepatic disease (liver failure or hemorrhage)

HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)

Coagulopathy (clotting/coagulation failure)

Visual disturbances (temporary blindness due to edema of the retina)

Injuries during convulsions (fractures)

Abruptio placentae

Stroke

Death

Long-term cardiovascular morbidity

The main causes of maternal death in eclampsia are intracerebral hemorrhage, pulmonary complications, kidney failure, liver failure and failure of more than one organ (e.g. heart + liver + kidney).

Effects on the fetus

These include:

Intrauterine growth retardation (IUGR)

Preterm delivery

Hypoxia

Neurologic injury

Perinatal death (1�–2%)


Long-term cardiovascular morbidity associated with low birthweight (fetal origin of adult disease)

Hypoxia may cause brain damage if severe or prolonged, and can result in physical or mental disability.


Identifying pre-eclampsia

Key definitions

Introduction Mild pre-eclampsia may progress to severe pre-eclampsia and eclampsia very suddenly with little or no warning. In addition, women with pre-eclampsia do not feel ill until the condition is severe and the disease is life threatening. Early detection by regular antenatal monitoring and careful follow-up of those with mild pre-eclampsia is therefore essential for the early diagnosis and treatment of severe eclampsia.

Screening Hypertensive disorders in pregnancy are a major contributor to maternal mortality world wide. With very careful antenatal care, providers can detect blood pressure elevation and the presence of proteinuria, ensure initiation of appropriate management at the appropriate level of care, and prevent many of these deaths. Improved detection and care should lead to a better outcome. If a woman develops hypertension, and/or proteinuria, providers will need to closely monitor her and encourage her to give birth in a health facility with skilled attendants.

Detecting proteinuria

The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to pre-eclampsia. Ruling out proteinuria is key for making a diagnosis of pre-eclampsia. Detection of proteinuria above the threshold in a pregnant woman with hypertension differentiates between relatively simple gestational hypertension and pre-eclampsia and dictates a considerable step-up in surveillance, often including admission. The social and financial repercussions of this for the woman and the economic consequences for the healthcare system are considerable. It is therefore important that tests for proteinuria are accurate.

Measurement of proteinuria differs from country to country and may vary by type of resources available at the facility. Methods to evaluate proteinuria include:

Quantitation of a timed collection: This has been the gold standard for many decades and is expressed as the amount of protein excreted in the urine per unit time. Twenty four-hour specimens have been traditionally used, but more recently 12-hour collections (and even 2-hour collections) have been validated.10

Urinary protein:creatinine ratio: This is used in some institutions instead of a timed protein collection. A review conducted by Côté et al showed that the spot protein:creatinine ratio is a reasonable �“rule-out�” test for proteinuria of 0.3 g/day or more, among otherwise healthy women with gestational hypertension with or without proteinuria on dipstick. However, they did not advocate use of the spot protein:creatinine ratio or spot albumin:creatinine ratio for monitoring or quantifying proteinuria in pregnancy.11

Urine dipsticks: Urinalysis by visual reagent strip tests is widely performed in antenatal clinics and in the community by various health professionals. A review by Waugh et al showed that significant proteinuria, with point-of-care urine dipstick analysis, cannot be accurately detected or excluded at the 1+ threshold and is not recommended for


diagnosing preeclampsia. Further research is necessary to determine the prediction of proteinuria using higher dipstick thresholds.12

While the measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia,13 it remains one of the criteria for the diagnosis of pre-eclampsia. Further work is needed to compare the different methods to evaluate proteinuria in the management of pregnant women with hypertension, particularly with respect to accuracy of diagnosis and the effect on inappropriate admissions and discharges.

Detecting hypertension Gestational blood pressure (BP) elevation is defined as a blood pressure >90 mm Hg diastolic in a woman who was normotensive before 20 weeks�’ gestation. In the absence of proteinuria the disease is highly suspected when increased blood pressure appears accompanied by the following symptoms: headache, blurred vision, and abdominal pain, or by abnormal laboratory test results, specifically low platelet counts and abnormal liver enzyme values.

The definition of hypertension has changed over the years:

In the past it has been recommended that an increment of 30 mm Hg systolic or 15 mm Hg diastolic blood pressure be used as a diagnostic criterion, even when absolute values remain <140/90 mm Hg

More recently, the diagnostic criteria for gestational hypertension include: Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, without proteinuria

Some use mean arterial pressure of 90mmHg or more in the second trimester. Mean arterial pressure is defined as: diastolic blood pressure+one third×(systolic blood pressure diastolic blood pressure; or automated mean arterial pressure readings. Mean arterial pressure appears to be a better predictor for pre-eclampsia than systolic BP, diastolic BP, or increased BP.14

BP readings are prone to inaccuracy due not only to observer and device error, but also to variability of blood pressure and to rise in BP caused by anxiety/fear due to the effects of attendance at the clinic (white-coat hypertension). 15

Detecting hypertensive disorders in pregnancy At every antenatal and postnatal visit:

1. Take a targeted symptom history. ASK the woman if she has had any of these symptoms: epigastric pain (heart burn), headaches, dizziness, or visual problems (double vision, partial vision, rings around lights). Note that these are the danger signs the pregnant / postpartum women should watch for.

2. Take the blood pressure at every visit.

Blood pressure should always be checked in the sitting position (BP will be highest in the sitting position, somewhat lower when she lies supine, and lowest when she lies on her side), with her feet supported or on the ground, and her arm at the level of the heart

Blood pressure measurements at the first antenatal visit for healthy normotensive women in the first and second trimester do not help predict pre-eclampsia.12


When BP is checked with the woman in left lateral recumbent, the superior arm has 10-12 mmHg lower BP than the inferior arm

- Measurements should be made with a mercury sphygmomanometer; in centers where the use of mercury has been banned for clinical purposes, the mercury sphygmomanometer will have to be replaced by an electronic device that has been validated for pregnancy.

- The sphygmomanometer should be regularly calibrated

- Remove all tight clothes from around the arm. Tight clothes may partially block the artery and give a false low reading.

- Wrap the cuff firmly around the upper arm. The cuff must be at least 2�–3 cm (1 inch) above the elbow and should encircle at least three�–fourths of the circumference of the arm; otherwise, a false high reading will be obtained.

- A wider cuff should be used when the diameter of the upper arm is more than 30 cm.

- Make sure that the woman is as relaxed and comfortable as possible, in a sitting position with arm supported or lying tilted to the left side. Lying on the back is not a good position because the weight of the gravid uterus exerts pressure on the inferior vena cava, thereby causing a drop in blood pressure.

- Do not kink or twist the tube on the cuff. Make sure that the stethoscope fits into your ears firmly and snugly. If a mercury blood pressure machine is used, it must be in the vertical position, and your eyes must be approximately at the same level as the top of the mercury column or the reading will not be accurate.

- Systolic blood pressure is taken at the point at which the arterial sound appears.

- Diastolic blood pressure is taken at the point at which the arterial sound disappears.

REMEMBER:

The normal BP is between 80/60 and 140/90 When the pre-pregnancy BP is not known, the BP taken before 20

weeks is considered the woman's normal BP Because of changes in cardiac output and blood volume, hormonal

changes which mediate a decrease in peripheral vascular resistance, smooth muscle-relaxing effect of progesterone, and heat production by the foetus, the BP will have some normal variations during pregnancy: - Systolic and diastolic BP begin to fall in the 1st trimester,

decreasing until mid-pregnancy and gradually return to non-pregnancy baseline by term

- There is a slight increase in pulse pressure: a slight fall in systolic and considerable decrease in diastolic later in gestation

- There is no change in venous pressures during pregnancy because of increased vascular capacity and compliance

3. If the diastolic BP is >90, have the woman lie on her left side for 20 minutes, then recheck it again with her sitting up

If the blood pressure is normal, educate the woman about danger signs and have her return in two weeks for a BP check


If the blood pressure is still elevated, check a midstream urine sample for protein.

4. If there is greater than 1+ protein in the urine:

Verify that the sample was a mid-stream/clean-catch sample

Proteinuria is defined as the presence of 300 mg or more of protein per liter in a clean catch, midstream specimen of urine. Usually proteinuria follows a rise in blood pressure, but occasionally it is the first sign of the disease.

Vaginal secretions and discharges are common in pregnancy and, if mixed with urine, give a positive test for protein. To avoid this, it is important that:

- The vulva is cleaned with water - The labia minor is spread - While urine is being passed, the middle part of the stream is caught in a clean

container.

Dipstick method:

- The end of the stick is dipped into the urine and excess shaken off by tapping the stick on the side of the container

- The result is then read by comparison with the color chart on the label at the time indicated on the dipstick container.

Boiling method:

- Boil the top half of the urine in a test tube - Compare the top half of the urine with the unboiled bottom half (the boiled part

may become cloudy) - Add 1�–2 drops of 2�–3% acetic acid. Do this even if the urine has not become

cloudy - If, after adding the acetic acid, the boiled part of the urine remains cloudy,

protein is present in the urine - If the boiled urine was not cloudy to begin with, but becomes cloudy when acetic

acid is added, this is another indication that protein is present - If cloudy urine becomes clear when acetic acid is added, protein is not present.

Rule-out pre-eclampsia: Check the biceps and/or patellar reflexes. If the reflexes are brisk (+3 or +4), refer her to a hospital/doctor.

Testing reflexes

Testing reflexes is part of an examination of the nervous system. It is very helpful for midwives to know how to test a few basic reflexes on adults. Hyper-reflexia can indicate many diseases of the nervous system or edema of the brain (cerebrum) in a pregnant woman. A woman with cerebral edema is at very likely to develop eclampsia (convulsions).

Using a Reflex Hammer

A reflex hammer is used to check the deep tendon reflexes. Once you are experienced, you may be able to use your fingers, the side of your hand, your knuckles, or the head of a stethoscope instead. For beginners (learners), it may be helpful to use a reflex (percussion) hammer.

1. Hold the hammer loosely between your thumb and index finger.

2. Bring the hammer down onto the tendon in a rapid, smooth movement.

3. Tap quickly and firmly.


4. Lift the hammer back up quickly.

5. Watch for how fast the response is. It is the speed of the response, not how far the limb moves, that tells you if her reflexes are normal.

Reflexes are usually given a grade of 0 to +4. The scale of grading is:

0 no response

+1 low but within normal response

+2 average or normal response

+3 brisker than average

+4 very brisk, hyperactive, abnormal, may have rhythmic tremors (clonus)

Checking Reflexes

When checking reflexes, always check both sides (both arms or both legs). Check that the response is similar on both sides. The biceps and patellar reflexes are the common ones to use when looking for pre-eclampsia in pregnant women.

Biceps Reflex

1. Bend the woman's arm about halfway. 2. With your fingers, feel for her tendon on the inside of her elbow (antecubital

fossa). If it is difficult to locate, move her arm up and down while feeling. You will notice a cord-like tendon.

3. If the woman is lying down, the bed will support her arm. If she is sitting up, you will need to support her arm on yours. Place your thumb on the tendon.

Figure XX. Testing Biceps Reflex

4. Strike your thumbnail, which is positioned over the tendon. This causes the biceps muscle to contract. You may or may not see the slight contraction at the woman's elbow.

5. You will be able to feel the response from the tendon through your thumb. You can grade the response by how fast you are able to feel the reflex response. You will need to check many reflexes before you develop an awareness of what is normal. Check your family, friends, and all of your clients to gain experience.

Patellar Reflex


1. Have the woman sit on the examining table or couch. Her legs should hang freely.

2. Feel for her tendon right below the kneecap (patella). If it is difficult to locate, move her lower leg a little while feeling at the same time.

Figure XX. Testing Patellar Reflex

3. Strike the tendon with a quick, firm tap and lift up immediately. You may also use the side of your hand or your knuckle to tap the tendon.

4. Tapping the tendon will cause the quadriceps muscle to contract, causing the lower leg to move.

5. The patellar reflex can also be tested with the woman lying in bed. Place one hand under the leg, supporting it, and tap.

6. If the woman is tense and contracting her muscles, you will not get an accurate test of her reflexes. You may need to talk to her and keep her attention away from what you are doing.

Remember: A woman with severe pre-eclampsia who has hyper-reflexia (+3 or +4) is very ill. She must be properly stabilised and transferred to a doctor/Level C facility as quickly as possible. Care of women with pre-eclampsia can save the lives of both the woman and foetus.

Rule-out anemia: Check haemoglobin (if there is a laboratory) or check for signs of anemia; if the woman has moderate anemia, treat appropriately, if the woman has severe anemia, refer her to a hospital/doctor.

Check for urinary tract infection or sexually transmitted infections (especially if the woman has abundant vaginal secretions). If the woman has an STI or a UTI, treat according to cause and following protocols.

REMEMBER: Because of changes in metabolism during pregnancy, the pregnant

woman will spill some protein in her urine and this is normal, as long as it does not exceed 1+.

Although proteinuria is most commonly associated with pre-


eclampsia or eclampsia, a woman's urine can test positive for protein if she is severely anemic, has kidney disease, or has a UTI, or if the urine has been contaminated by blood (or if she has schistosomiasis), vaginal discharge, or amniotic fluid.

Differential diagnosis of hypertension in pregnancy/postpartum There are many types of hypertensive disorders in pregnancy. It is important to understand them well, because their management differs. Table XX provides an overview of diagnostic criteria for the different hypertensive disorders in pregnancy.

Table XX. Differential diagnosis of hypertensive disorders in pregnancy

Chronic hypertension Diastolic BP 90 mm Hg or more prior to first 20 weeks of gestation

Preeclampsia superimposed on chronic hypertension (women with hypertension and no proteinuria early in pregnancy (<20 weeks�’ gestation))

In women with hypertension and proteinuria before 20 weeks�’ gestation any of the following are seen: New-onset proteinuria sudden increase in proteinuria, sudden increase in blood pressure in a

woman whose hypertension has previously been well controlled

Gestational hypertension: (1) transient hypertension of pregnancy if preeclampsia is not present at the time of delivery and blood pressure returns to normal by 12 weeks post partum (a retrospective diagnosis) or (2) chronic hypertension if the elevation persists.

Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, no proteinuria

Mild pre-eclampsia Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart, proteinuria up to 2+

Severe pre-eclampsia Diastolic BP 110 mm Hg or more, proteinuria 3+ or more

Eclampsia

A pregnant woman or a woman who has recently given birth is found unconscious or having convulsions (seizures), diastolic BP 110 mm Hg or more, proteinuria 2+ or more


Differential diagnosis of fits in pregnancy/postpartum There are many causes for convulsions in pregnancy. It is important to understand them well, because their management differs. Table XX provides an overview of diagnostic criteria for the different disorders in pregnancy that may lead to convulsions.

Table XX. Differential diagnosis of fits in pregnancy

Presenting symptom and other symptoms and signs typically present

Symptoms and signs sometimes present

Probable diagnosis

Convulsions Diastolic BP 90 mm Hg or more after 20 weeks gestation

Proteinuria 2+ or more

Coma (unconscious) Other signs and symptoms of severe pre-eclampsia - Headache (increasing frequency,

unrelieved by regular analgesics) - Blurred vision - Oliguria (passing less than 400 mL

in 24 hours) - Upper abdominal pain (epigastric

pain or pain in upper right quadrant)

- Pulmonary edema

Eclampsia

Trismus (difficulty opening mouth and chewing)

Spasms of face, neck, trunk Arched back Spontaneous violent spasms

Tetanus

Convulsions Past history of convulsions Normal blood pressure

Epilepsy

Fever Chills/rigor Headache Muscle/joint pain Coma Anemia

Convulsions Jaundice

Severe / complicated malaria

Headache Stiff neck Photophobia Fever

Convulsions Confusion Drowsiness Coma

Meningitis or Encephalitis

To make a differential diagnosis, carefully examine the woman and order tests / examinations to confirm a diagnosis. If a pregnant woman presents with fits / convulsions, it is best to begin treatment for eclampsia while you are waiting to rule out other causes.

The following table gives of an overview of tests to consider performing to rule out or confirm a diagnosis in a pregnant woman presenting with convulsions.

A small proportion of women with eclampsia have normal blood pressure. Treat all pregnant/postpartum women with convulsions as if they have eclampsia until another diagnosis is confirmed.


Eclampsia Epilepsy Cerebral malaria Meningitis

Blood pressure Usually raised in cases of eclampsia

Urine for protein

Will contain protein

Urine may show temporary proteinuria after a fit, but otherwise testing shows no abnormality.

Blood film to exclude malaria

In cerebral malaria, more than 5 per cent of circulating red cells will be parasitized

Liver enzymes and function tests

Will be elevated in Eclampsia indicating

liver damage

Platelet count Often low in pre-eclampsia/eclampsia

Coagulation studies (bedside clotting test)

Coagulation defects may be present in eclampsia

Renal function tests (plasma electrolytes, blood urea, creatinine and uric acid)

Urea may be elevated in eclampsia indicating kidney damage.

Creatinine clearance and serum proteins may be decreased

Blood urea is normal.

EEG (electro-encephalogram)

May show typical abnormalities

Examination of cerebrospinal fluid

The cerebro-spinal fluid (CSF) is under increased pressure

The fluid looks cloudy in coccal forms of meningitis but is clear in viral meningitis

The causal organism is usually found under bacteriological examination and the cell count is increased

Protein is increased, sugar and chlorides decreased.


Prevention

Key definitions

Primary prevention of pre-eclampsia By definition, primary prevention can help to avoid the development of a disease. Primary prevention will be difficult to achieve for pre-eclampsia because the cause is not really understood and most factors associated with it are difficult to avoid or manipulate. Nevertheless, there are certain interventions that can serve to prevent pre-eclampsia.

Family planning

Pre-eclampsia is associated with pregnancy, and adolescent and older (more than 35 years of age) women are at higher risk of pre-eclampsia, therefore prevention of pregnancy will prevent pre-eclampsia. Of course, women will want to have children and cannot indefinitely wait for pregnancy. However, family planning can help to delay the first pregnancy until the woman is at least 20 or 21 years of age; can limit pregnancies beyond 35 years of age if women no longer want to continue having children; and can ensure adequate spacing between pregnancies to allow the woman to recover between pregnancies.

Obesity and insulin resistance

Obesity is a definite risk for developing gestational hypertensive disorders, including pre-eclampsia. Obesity has a strong link with insulin resistance. The exact mechanisms by which obesity/insulin resistance are associated with an increased risk for pre-eclampsia are not completely understood. Prevention of or effective treatment of obesity, or both, could result in a substantial decrease in its frequency. Having a (too) low birthweight as a consequence of intrauterine growth restriction (IUGR) has also been identified as an important risk factor of the so-called insulin resistance syndrome in adult life. Prevention of IUGR could therefore, at least theoretically, contribute to primary prevention of pre-eclampsia (and IUGR) in the next generation.16

Smoking

Cigarette smoking is associated with a 30�–40% decrease in the risk of pre-eclampsia.17 However, this benefit is cancelled out by the substantial negative effect of smoking on fetal growth, risk for placental abruption, and general health. Understanding the mechanisms of the preventive effects of smoking on pre-eclampsia could help to unravel important aspects of its pathophysiology.

Sperm exposure, the paternal factor, and age

Findings from studies on sperm exposure, paternity, and maternal age suggest that it is better to:

Stay with the same partner if a first pregnancy was not complicated by pre-eclampsia Have pregnancies only with low-risk men, and Have children at an age when the endothelium is still able to cope with the inflammatory stress associated with the pregnant state.16

Health-care providers should realize that the antenatal care of a multiparous patient with a new partner should be the same as in a woman presenting with her first pregnancy, at least as far as the risk for pre-eclampsia is concerned.


Secondary prevention Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of pre-eclampsia. The ability to prevent eclampsia is limited by lack of knowledge of its underlying cause. Prevention has focused on identifying women at higher risk, followed by close clinical and laboratory monitoring to recognize the disease process in its early stages. These women can then be selected for more intensive monitoring or delivery. Although these measures do not prevent pre-eclampsia, they may be helpful in preventing some adverse maternal and fetal sequelae associated with symptoms and in preventing progression to eclampsia.

Antenatal care

Proper antenatal care is the most important part of secondary and tertiary prevention. The decrease in maternal mortality and serious resulted mainly from the screening and intervention (such as timed delivery) that comes with organized antenatal care. In order for antenatal care to be effective, however, health care providers must be adequately trained to identify, prevent, and manage pre-eclampsia and should have all of the essential equipment, commodities, and consumables. In addition, adequate systems must be in place to stabilize the woman and transfer her to the appropriate level of care.

Women, families, and communities need to understand danger signs and the importance of seeking early antenatal care. During antenatal care, health care providers can assist women and their families to develop a birth preparedness and complication readiness plan that will ensure that women access care in a timely manner.

Use of low-dose aspirin to prevent preeclampsia

Benefits of low-dose aspirin prophylaxis are unproven for most women, including nulliparous women. Despite earlier prospective studies that suggested that aspirin administration reduced the incidence of preeclampsia, it is not recommended to routinely give aspirin for prevention to women without risk factors. This opinion is based on the results of eight large trials in different populations around the world. Overall these trials, which included >27,000 pregnant women, demonstrated minimal to no reduction in the incidence of preeclampsia with low-dose aspirin therapy.18

Calcium supplementation

In a Cochrane review,19 calcium supplementation was associated with reduced hypertension and preeclampsia, particularly for those at high risk of the disease and with a low baseline dietary calcium intake (for those with an adequate calcium intake the difference was not significant). No side effects of calcium supplementation were recorded in the trials reviewed.

However, the reduction was not indicated in any overall effect on stillbirths or neonatal deaths. The data lend support to calcium supplementation for women at high risk of pre-eclampsia and in communities with low dietary calcium intake. The absence of convincing evidence of effectiveness from the largest trial (n=4589), which recorded no reduction in the rate or severity of pre-eclampsia or in the timing of onset, have discouraged the use of calcium supplementation in developed countries.

Other dietary supplements

Prophylactic magnesium supplementation has not been shown to be beneficial in preventing preeclampsia.20 Three randomized trials of fish oil supplementation for women at high risk for preeclampsia revealed no reduction in the incidence of preeclampsia. 16 A recent study showing the benefits of vitamins C and E to prevent preeclampsia was encouraging but needs further confirmation. 16


Tertiary prevention Tertiary prevention focuses on the prevention of complications in women with pre-eclampsia. Reduction of maternal and fetal/newborn mortality and serious morbidity depends on timely diagnosis and easy referral. The three major interventions for management of pre-eclampsia and eclampsia are anti-convulsant therapy, anti-hypertensive treatment, and timed delivery of the baby.

Anti-convulsant medications

Magnesium sulfate reduces the risk of eclampsia21 without any substantive effect on longer-term morbidity and mortality for the women or children.22, 23 Data from the Magpie study24

provide reassurance about the longer-term safety of magnesium sulfate when used for women with pre-eclampsia. There appears to be no substantive effect on women's subsequent fertility, or their use of health care services in the two years after the birth. Data from the main Magpie Trial follow up study demonstrated that magnesium sulfate has no clear effect on the child's risk of severe neurodevelopmental delay.23

For prevention of recurrent seizures in women with eclampsia, magnesium is more effective and has fewer risks than phenytoin and diazepam.25

Anti-hypertensive medications

The goal of treatment of hypertension in pregnancy is to reduce maternal risk without harming the fetus. Antihypertensive therapy is indicated for maternal benefit, but it may also permit prolongation of the pregnancy and thereby improve fetal maturity. Acute falls in maternal systemic blood pressure can result in fetal distress. Administration of a powerful vasodilator will result in a decreased intervillous blood flow unless the blood pressure decrease is accompanied by a (more or less specific) vasodilator response in the uteroplacental circulation. If antihypertensive treatment is chosen, there is no clear choice of drugs. By subgroup analysis, blockers could be less effective than calcium channel blockers. 26 Refer to Table XX for a broad overview of advantages and disadvantages of anti-hypertensive medications that may be used for management of pre-eclampsia/eclampsia.16, 18

Medication Advantages Disadvantages

Methyldopa

Stable uteroplacental blood flow and fetal hemodynamics

No long-term adverse effects on development among children exposed to methyldopa in utero

Causes somnolence in many individuals

Hydralazine (IV)

Associated with more maternal and perinatal adverse effects than other drugs

Should no longer be thought of as the drug of choice 26

Adrenergic receptor blocking agent (labetalol hydrochloride)

None of these agents has been associated with any consistent ill effects

-blockers

None of these agents has been associated with any consistent ill effects

blockers prescribed during early pregnancy, specifically atenolol, may be associated with growth restriction

Long-term follow-up studies are lacking

Calcium antagonists (nifedipine)

A multicenter prospective cohort study of first-trimester drug exposures reported no increase in major teratogenicity from these

Experience with calcium antagonists is limited


Medication Advantages Disadvantages agents

Diuretics

Contraindicated in pregnancy in settings in which uteroplacental perfusion is already reduced (preeclampsia and intrauterine growth restriction).

Angiotensin-converting enzyme inhibitors

Contraindicated during pregnancy because of associations with fetal growth restriction, neonatal renal failure, and neonatal death

Induction of labor

Apart from Cesarean operation or induction of labor (and therefore delivery of the placenta), there is no known cure for pre-eclampsia. A decision to induce labor will need to weigh benefits and risks for both the woman and fetus. The National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy recommends the following when considering delivering the baby to manage gestational hypertension:

“First, any therapy for preeclampsia other than delivery must have as its successful end point the reduction of perinatal morbidity and mortality.

Second, the cornerstone of obstetric management of pre-eclampsia is based on whether the fetus is more likely to survive without significant neonatal complications in utero or in the nursery.�”18

The decision to terminate pregnancy will depend upon:

1. Severity of the disease

2. Gestational age

3. Maternal and fetal condition

The WHO27 recommends the following for timing of delivery: In severe pre-eclampsia, delivery should occur within 24 hours of the onset of

symptoms. In eclampsia, delivery should occur within 12 hours of the onset of convulsions.

When the woman�’s hypertensive disease is mild, induction of labor is associated with improved maternal outcome and should be advised for women beyond 37 weeks�’ gestation.28

Overview of interventions to prevent pre-eclampsia and eclampsia


For an overview of preventive interventions, see Table XX.20

Reference manual


Management

Management protocols are copied from: WHO. MCPC. Geneva: WHO, 2003.

In order to detect early signs of pregnancy-induced hypertension and pre-eclampsia, regular antenatal visits are necessary, especially in the third trimester of pregnancy. At each antenatal visit, the woman�’s blood pressure must be measured and her urine should be checked for protein if diastolic blood pressure is more than 90mmHg. Pregnant women should be encouraged to come for antenatal care early in their pregnancy so that a baseline value for their blood pressure can be obtained.

If there is a rise in blood pressure, the woman should be closely monitored at frequent intervals. If proteinuria develops, she should be admitted to a health facility capable of coping with a woman who may develop eclampsia.

Gestational hypertension Diagnostic criteria

Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation

No proteinuria

Management

The woman is usually managed as an outpatient and followed up weekly at home or at a local clinic. Management on an outpatient basis at each visit:

Monitor blood pressure, urine (for proteinuria) and fetal condition (growth, movement, heart rate) weekly

Check if the woman has severe headache, visual disturbances or abdominal pain

Counsel the woman and her family about the danger signals of severe pre-eclampsia, ensuring that they know the importance of obtaining immediate medical help if any of the signs develop.

If the blood pressure decreases to normal levels and there are no other complications, the condition has stabilized and the woman should be allowed to proceed with normal labour and childbirth.

If the blood pressure rises, however, and/or proteinuria develops, or there is significant fetal growth restriction (signs of poor fetal growth) or fetal compromise (abnormal fetal

Mild pre-eclampsia - Gestation less than 37 weeks Diagnostic criteria


Proteinuria up to 2+

Management

If signs remain unchanged or normalize, follow up twice a week as an outpatient: Monitor blood pressure, urine (for proteinuria), reflexes and fetal condition.


Counsel the woman and her family about danger signals of severe pre-eclampsia or eclampsia.

Encourage additional periods of rest.

Encourage the woman to eat a normal diet (salt restriction should be discouraged).

Do not give anticonvulsants, anti-hypertensives, sedatives or tranquillizers.

If follow-up as an outpatient is not possible, admit the woman to the hospital:

- Provide a normal diet (salt restriction should be discouraged); - Monitor blood pressure (twice daily) and urine for proteinuria (daily); - Do not give anticonvulsants, anti-hypertensives, sedatives or tranquillizers unless

blood pressure or urinary protein level increases; - Do not give diuretics. Diuretics are harmful and only indicated for use in pre-

eclampsia with pulmonary edema or congestive heart failure; - If the diastolic pressure decreases to normal levels or her condition remains

stable, send the woman home: - Advise her to rest and to watch out for significant swelling or symptoms of severe

pre-eclampsia; - See her twice weekly to monitor blood pressure, urine (for proteinuria) and fetal

condition and to assess for symptoms and signs of severe pre-eclampsia; - If diastolic pressure rises again, readmit her; - If the signs remain unchanged, keep the woman in the hospital. Continue the

same management and monitor fetal growth by symphysis-fundal height; - If there are signs of growth restriction, consider early delivery. If not, continue

hospitalization until term.

If urinary protein level increases, manage as severe pre-eclampsia (see below).

Note: Symptoms and signs of pre-eclampsia do not completely disappear until after pregnancy ends.

Mild pre-eclampsia - Gestation more than 37 complete weeks Diagnostic criteria


Proteinuria up to 2+

Management

If there are signs of fetal compromise, assess the cervix and expedite delivery: If the cervix is favorable (soft, thin, partly dilated), rupture the membranes with an

amniotic hook or a Kocher clamp and induce labor using oxytocin or prostaglandins. If the cervix is unfavorable (firm, thick, closed), ripen the cervix using prostaglandins

or a Foley catheter or deliver by cesarean operation.

Severe pre-eclampsia and eclampsia Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery must occur within 12 hours of onset of convulsions in eclampsia. ALL cases of severe pre-

Reference manual


eclampsia should be managed actively. Symptoms and signs of �“impending eclampsia�” (blurred vision, hyperreflexia) are unreliable and expectant management is not recommended. Diagnostic criteria – severe pre-eclampsia

Diastolic BP 110 mm Hg or more


Diagnostic criteria –eclampsia

A pregnant woman or a woman who has recently given birth is found unconscious or having convulsions (seizures), diastolic BP 110 mm Hg or more


Management during a convulsion

Give anticonvulsive drugs (see below). Gather equipment (airway, suction, mask and bag, oxygen) and give oxygen at 4�–6 L

per minute. Protect the woman from injury but do not actively restrain her. Place the woman on her left side to reduce risk of aspiration of secretions, vomit and

blood. After the convulsion, aspirate the mouth and throat as necessary.

General management

If diastolic blood pressure remains above 110 mm Hg, give antihypertensive drugs (see below). Reduce the diastolic blood pressure to less than 100 mm Hg but not below 90 mm Hg.

Start an IV infusion and infuse IV fluids. Maintain a strict fluid balance chart and monitor the amount of fluids administered and

urine output to ensure that there is no fluid overload. Catheterize the bladder to monitor urine output and proteinuria. If urine output is less than 30 mL per hour:

- Withhold magnesium sulfate and infuse IV fluids (normal saline or Ringer�’s lactate) at 1 L in 8 hours;

- Monitor for the development of pulmonary edema. Never leave the woman alone. A convulsion followed by aspiration of vomit may

cause death of the woman and fetus. Observe vital signs, reflexes and fetal heart rate hourly. Auscultate the lung bases hourly for rales indicating pulmonary edema. If rales are

heard, withhold fluids and give furosemide 40 mg IV once. Assess clotting status with a bedside clotting test. Failure of a clot to form after 7

minutes or a soft clot that breaks down easily suggests coagulopathy.

Anticonvulsive drugs

A key factor in anticonvulsive therapy is adequate administration of anticonvulsive drugs. Convulsions in hospitalized women are most frequently caused by under-treatment. Magnesium sulfate is the drug of choice for preventing and treating convulsions in severe pre-eclampsia and eclampsia. Administration is outlined in Box 1.


BOX 1 Magnesium sulfate schedules for severe pre-eclampsia and eclampsia Loading dose Magnesium sulfate 20% solution, 4 g IV over 5 minutes. Follow promptly with 10 g of 50% magnesium sulfate solution, 5 g in each buttock as deep IM injection with 1 mL of 2% lignocaine in the same syringe. Ensure that aseptic technique is practiced when giving magnesium sulfate deep IM injection. Warn the woman that a feeling of warmth will be felt when magnesium sulfate is given. If convulsions recur after 15 minutes, give 2 g magnesium sulfate (50% solution) IV over 5 minutes.

Maintenance dose 5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2% IM every 4 hours into alternate buttocks.

Continue treatment with magnesium sulfate for 24 hours after delivery or the last convulsion, whichever occurs last.

Before repeat administration, ensure that: Respiratory rate is at least 16 per minute. Patellar reflexes are present. Urinary output is at least 30 mL per hour over 4 hours.

WITHHOLD OR DELAY DRUG IF: Respiratory rate falls below 16 per minute. Patellar reflexes are absent. Urinary output falls below 30 mL per hour over preceding 4 hours.

Keep antidote ready In case of respiratory arrest:

- Assist ventilation (mask and bag, anesthesia apparatus, intubation). Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly until respiration begins to antagonize the effects of magnesium sulfate.

If magnesium sulfate is not available, diazepam may be used although there is a greater risk for neonatal respiratory depression because diazepam passes the placenta freely. A single dose of diazepam to abort a convulsion seldom causes neonatal respiratory depression. Long-term continuous IV administration increases the risk of respiratory depression in babies who may already be suffering from the effects of utero-placental ischemia and preterm birth. The effect may last several days. Administration of diazepam is outlined in Box 2.

BOX 2 Diazepam schedules for severe pre-eclampsia and eclampsia Note: Use diazepam only if magnesium sulfate is not available. Intravenous administration Loading dose

Diazepam 10 mg IV slowly over 2 minutes. If convulsions recur, repeat loading dose.

Maintenance dose Diazepam 40 mg in 500 mL IV fluids (normal saline or Ringer�’s lactate) titrated to keep the woman sedated but rousable.

Maternal respiratory depression may occur when dose exceeds 30 mg in 1 hour: - Assist ventilation (mask and bag, anesthesia apparatus, intubation), if

necessary. - Do not give more than 100 mg in 24 hours.

Rectal administration Give diazepam rectally when IV access is not possible. The loading dose is 20 mg in a 10 mL syringe. Remove the needle, lubricate the barrel and insert the syringe

Reference manual


into the rectum to half its length. Discharge the contents and leave the syringe in place, holding the buttocks together for 10 minutes to prevent expulsion of the drug. Alternatively, the drug may be instilled in the rectum through a catheter.

If convulsions are not controlled within 10 minutes, administer an additional 10 mg per hour or more, depending on the size of the woman and her clinical response.

Antihypertensive drugs

If the diastolic pressure is 110 mm Hg or more, give antihypertensive drugs. The goal is to keep the diastolic pressure between 90 mm Hg and 100 mm Hg to prevent cerebral hemorrhage. Labetolol and nifedipine are the drugs of choice. Give labetolol 10 mg IV

- If response is inadequate (diastolic blood pressure remains above 110 mm Hg) after 10 minutes, give labetolol 20 mg IV;

- Increase the dose to 40 mg and then 80 mg if satisfactory response is not obtained after 10 minutes of each dose;

OR Give nifedipine 5 mg under the tongue:

- If response is inadequate (diastolic pressure remains above 110 mm Hg) after 10 minutes, give an additional 5 mg under the tongue.

Note: There is concern regarding a possibility for an interaction with magnesium sulfate that can lead to hypotension.

Delivery

Delivery should take place as soon as the woman�’s condition has stabilized. Delaying delivery to increase fetal maturity will risk the lives of both the woman and the fetus. Delivery should occur regardless of the gestational age.

In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms. In eclampsia, delivery should occur within 12 hours of the onset of convulsions.

Assess the cervix. If the cervix is favorable (soft, thin, partly dilated), rupture the membranes with an

amniotic hook or a Kocher clamp and induce labor using oxytocin or prostaglandins. If vaginal delivery is not anticipated within 12 hours (for eclampsia) or 24 hours (for

severe pre-eclampsia), deliver by cesarean operation. If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per

minute), deliver by cesarean operation. If the cervix is unfavorable (firm, thick, closed) and the fetus is alive, deliver by

cesarean operation. If safe anesthesia is not available for cesarean operation or if the fetus is dead

or too premature for survival: - Aim for vaginal delivery; - If the cervix is unfavorable (firm, thick, closed), ripen the cervix using

misoprostol, prostaglandins or a Foley catheter. Note: If cesarean operation is performed, ensure that: Coagulopathy has been ruled out;


Safe general anesthesia is available. Spinal anesthesia is associated with the risk of hypotension. This risk can be reduced if adequate IV fluids (500�–1 000 mL) are infused prior to administration of the anesthetic.

Do not use local anesthesia or ketamine in women with pre-eclampsia or eclampsia.

Postpartum care Anticonvulsive therapy should be maintained for 24 hours after delivery or the last

convulsion, whichever occurs last. Continue antihypertensive therapy as long as the diastolic pressure is 110 mm Hg or

more. Continue to monitor urine output. Ensure counseling about family planning in the postpartum period.

Referral for tertiary level care Consider referral of women who have: oliguria that persists for 48 hours after delivery; coagulation failure [e.g. coagulopathy or hemolysis, elevated liver enzymes and low

platelets (HELLP) syndrome]; persistent coma lasting more than 24 hours after convulsion.

Complications of gestational hypertension

Complications may cause adverse perinatal and maternal outcomes. Because complications are often difficult to treat, efforts should be made to prevent them by early diagnosis and proper management. Health care providers should be aware that management could also lead to complications. Manage complications as follows: If fetal growth restriction is severe, expedite delivery. If there is increasing drowsiness or coma, suspect cerebral hemorrhage:

- Reduce blood pressure slowly to reduce the risk of cerebral hemorrhage;

- Provide supportive therapy.

If heart, kidney or liver failure is suspected, provide supportive therapy and observe. If a clotting test shows failure of a clot to form after 7 minutes or a soft clot that breaks

down easily, suspect coagulopathy. If the woman has IV lines and catheters, she is prone to infection. Use proper infection

prevention techniques and closely monitor for signs of infection. If the woman is receiving IV fluids, she is at risk of circulatory overload. Maintain a strict

fluid balance chart and monitor the amount of fluids administered and urine output.

Reference manual


Managing obstetric emergencies

Management protocols are copied from: WHO. MCPC. Geneva: WHO, 2003.

General management for an obstetric emergency Emergencies can happen suddenly, as with a convulsion, or they can develop as a result of a complication that is not properly managed or monitored.

Preventing emergencies

Most emergencies can be prevented by:

careful planning;

following clinical guidelines;

Close monitoring of the woman.

Responding to an emergency

Responding to an emergency promptly and effectively requires that members of the clinical team know their roles and how the team should function to respond most effectively to emergencies. Team members should also know:

clinical situations and their diagnoses and treatments;

drugs and their use, administration and side effects;

Emergency equipment and how it functions.

Note: The ability of a facility to deal with emergencies should be assessed and reinforced by frequent practice emergency drills.

Initial management

In managing an emergency:

Stay calm. Think logically and focus on the needs of the woman.

Do not leave the woman unattended.

Take charge. Avoid confusion by having one person in charge.

SHOUT FOR HELP. Have one person go for help and have another person gather emergency equipment and supplies (e.g. oxygen cylinder, emergency kit).

If the woman is unconscious, assess the airway, breathing and circulation.

If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.

Position the woman lying down on her left side with her feet elevated. Loosen tight clothing.


Talk to the woman and help her to stay calm. Ask what happened and what symptoms she is experiencing.

Perform a quick examination including vital signs (blood pressure, pulse, respiration, temperature) and skin color.

Estimate the amount of blood lost and assess symptoms and signs.

General management for shock

Signs and symptoms usually seen in shock: Fast, weak pulse (110 per minute or more). Low blood pressure (systolic less than 90 mm Hg).

Other signs and symptoms of shock include:

Pallor (especially of inner eyelid, palms, or around the mouth). Sweaty or cold, clammy skin. Rapid breathing (rate of 30 breaths per minute or more). Anxiousness, confusion, or unconsciousness. Low urine output (less than 30 mL per hour).

Immediate management of shock

Shout for help. Urgently mobilize all available personnel. Evaluate vital signs (pulse, blood pressure, respiration, temperature). Turn the woman onto her side to reduce the risk of aspiration from vomiting and to

ensure an open airway. Keep the woman warm; however, avoid overheating which increases peripheral

circulation and reduces blood supply to the vital organs. Elevate the legs to increase return of blood to the heart (if possible, raise the foot

end of the bed).

Specific management

Start an IV infusion (or two if possible) using a large-bore cannula or needle (16 gauge or largest available). Collect blood to test hemoglobin; do an immediate cross-match and bedside clotting (see below) before infusion of fluids:

Rapidly infuse IV fluids (normal saline or Ringer�’s lactate) initially at the rate of 1 L in 15 to 20 minutes.

Note: Avoid using plasma substitutes (e.g., dextran) because there is no evidence that plasma substitutes are superior to normal saline in resuscitating a shocked woman. In addition, dextran can be harmful in large doses.

Give at least 2 L of these fluids in the first hour. (This amount is in addition to fluids given for lost blood.)

Reference manual


Note: Do not give fluids by mouth to a woman in shock. A quicker rate of infusion is needed in the management of shock from bleeding. Aim to replace 2 to 3 times the estimated fluid loss.

When finding a peripheral vein is not possible, do a venous cut-down. Continue to monitor vital signs and blood loss (every 15 minutes). Catheterize the bladder and monitor fluid intake and urine output. If available, give oxygen at 6 to 8 L per minute by mask or nasal cannula.

Bedside clotting test

Assess blood clotting status using this bedside clotting test: 1. Take 2 mL of venous blood into a small, dry, clean, plain glass test-tube

(approximately 10 mm x 75 mm). 2. Hold the tube in your closed fist to keep it warm (+37°C). 3. After four minutes, tip the tube slowly to see if a clot is forming. Then tip

it again every minute until the blood clots and the tube can be turned upside down.

4. If a clot does not form after seven minutes or a soft clot forms that breaks down easily, the woman may have a blood clotting disorder.

Decide and manage the cause of shock

After the woman is stabilized, determine the cause of shock and manage the condition accordingly.

Reference manual

Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor 33

Birth preparedness and complication readiness

When delays occur in recognizing problems and referring women to appropriate health care facilities, the result can lead to maternal and newborn deaths. One solution to combat these problems is to work with the pregnant woman and her family to develop two plans: a birth-preparedness plan and a complication-readiness plan.64

Birth-preparedness plan Having a birth plan can reduce delayed decision-making and increase the probability of timely care. A birth-preparedness plan is an action plan made by the woman, her family members, and the health care provider. Often this plan is not a written document, but instead is an ongoing discussion between all concerned parties to ensure that the woman receives the best care in a timely manner. Each family should have the opportunity to make a plan for the birth. Health care providers can help the woman and her family to develop birth-preparedness plans and discuss birth-related issues. Work with the woman to:

Make plans for the birth:

Discuss the idea of a birth plan and what to include during the first visit. Inquire about the birth-preparedness plan during the third or fourth antenatal visits. Ask if arrangements are made for a skilled birth attendant and the birth setting

during the antenatal visit in the eighth month. If planning a home delivery with a skilled birth attendant, discuss access to a safe

delivery kit consisting of 1) a piece of soap for cleaning the birth attendant�’s hands and the woman�’s perineum, 2) a plastic sheet about one square meter for use as a clean delivery surface, 3) clean string for tying the umbilical cord (usually two pieces), and 4) a clean razor blade for cutting the cord.

Make birth-related decisions:

Where to give birth. Who will be the skilled birth attendant. How to contact the provider. How to get to the place of birth. Who will be the birth companion. Who will take care of the family while the woman is absent. How much money is needed and how to access these funds.

Prepare for the birth:

Discuss items needed for the birth (perineal pads/cloths, soap, clean bed sheets, etc.) on the third antenatal visit.

Confirm necessary items are gathered near the due date.


Note: In some cultures, superstition surrounds buying items for an unborn baby. If this is not the case, families can prepare for the birth by buying baby supplies such as blankets, diapers, and clothes.

Save money: Discuss why and how to save money in preparation for the birth during the first visit. Discuss how to plan to make sure that any funds needed are available at birth. Check that the woman and her family have begun saving money or that they have

ways to access necessary funds.

Note: Encourage the family to save money so necessary funds are available for routine care during pregnancy and birth. Assess financial needs with the women as well as sources for accessing these funds so they are available before labor.

Complication-readiness plan The complication-readiness plan is an action plan that outlines steps that can be discussed and determined prior to an emergency. Developing this plan helps the family to be prepared for and respond quickly when the woman or newborn has a complication and needs medical care. It is important that a complication-readiness plan is prepared with the woman and her chosen family members. Unless others are involved, the woman may have difficulties putting the plan into action should complications occur for her or her baby.

Recognize danger signs

Women, family members, and community caregivers must know the signs of life-threatening complications. Many hours can be lost from the time a complication is recognized until the time arrangements are made for the woman to reach help. For PPH, the time from the start of bleeding to death can be as little as two hours. In too many cases, families of women who died in pregnancy, birth, or postpartum, did not recognize the problem in time. It is critical to reduce the time needed to recognize problems and make arrangements to receive care at the most appropriate level of care. Women, family members, and community caregivers must know the signs of life-threatening complications.

Maternal danger signs include:

Vaginal bleeding (any vaginal bleeding during pregnancy; heavy vaginal bleeding or a sudden increase in vaginal bleeding during the postpartum period).

Breathing difficulties. Fever. Severe abdominal pain. Severe headache/blurred vision. Convulsions or loss of consciousness. Foul-smelling discharge from vagina, tears, and incisions. Calf pain with or without swelling. Night blindness. Verbalization or behavior indicating she may hurt the baby or herself. Hallucinations.

Reference manual


Newborn danger signs include:

Breathing problems. Feeding difficulties or not sucking. Feels cold or has fever. Redness, swelling, or pus from eyes or around the cord or umbilicus. Convulsions or fits. Jaundice (yellow skin).

Save money

Similar to the birth preparedness plan, the family should be encouraged to save money so necessary funds are available for emergencies. In many situations, women either do not seek or receive care because they lack funding to pay for services.

Choose a decision-maker in case of emergency

In many families, one person is the primary decision-maker. Too often, other members of the family do not feel they can make decisions if that person is absent. This can result in death when an emergency occurs and the primary decision-maker is absent. It is important to discuss how the family can make emergency decisions without disrupting or offending cultural and family values. If possible, find out which family member can make a decision in the absence of the chief decision-maker.

Have an emergency transportation plan

Too many women and newborns die because they suffer serious complications and do not have access to transportation to the type of health care facility that can provide needed care. Each family should develop a transportation plan during the woman�’s early pregnancy in case the woman experiences complications and urgently needs a higher level of care. This plan should be prepared during pregnancy and after giving birth, either before discharge from the health facility or immediately after returning home. The plan should address the following:

Where to go if complications arise. How to get to the next level of care in case of an emergency. Who in the family will accompany the woman.

Have an emergency blood donation plan

Many health care facilities lack an inadequate, safe blood supply for transfusions. After birth, women are more likely to need blood transfusions because the complications they experience from birth lead to blood loss. For these reasons, it is extremely important that the woman and her family determine blood donors that can be available if needed.

Reference manual


References

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38 Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor

21 Magpie Trial Collaborative Group: Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002, 359(9321):1877-90. 22 Th Magpie Trial Follow-up Study Collaborative Group: The Magpie Trial: a randomised trial comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for children at 18 months. BJOG 2007, 114(3):289-299. 23 The Magpie Trial Follow-up Study Collaborative Group: The Magpie Trial : a randomised trial comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for women at two years. BJOG 2007, 114(3):300-309 24 Smyth, 2009 25 Duley L, Carroli G, Belizan J, et al. Which anticonvulsant for women with eclampsia: evidence from the collaborative eclampsia trial. Lancet 1995; 345: 1455�–63. 26 Magee LA, Ornstein MP, von Dadelszen P. Management of hypertension in pregnancy. BMJ 1999; 318: 1332�–36. 27 WHO. MCPC. 28 Corine M Koopmans, Denise Bijlenga, Henk Groen, Sylvia M C Vijgen, Jan G Aarnoudse, Dick J Bekedam, Paul P van den Berg, Karin de Boer, Jan M Burggraaff , Kitty W M Bloemenkamp, Addy P Drogtrop, Arie Franx, Christianne J M de Groot, Anjoke J M Huisjes, Anneke Kwee, Aren J van Loon, Annemiek Lub, Dimitri N M Papatsonis, Joris A M van der Post, Frans J M E Roumen, Hubertina C J Scheepers, Christine Willekes, Ben W J Mol, Maria G van Pampus, for the HYPITAT study group* 64 JHPIEGO and Maternal and Neonatal Health (MNH). Birth Preparedness and Complication Readiness. Baltimore, MD: JHPIEGO/MNH; 2001.

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