Pre-eclampsia: diagnosis and
management
An e-learning course for
for midwives and health professionals
E-learning course objectives
On completion of the course, you will have a clear understanding of the following:
1.
The definition of pre-eclampsia, and where it fits with other manifestations of
hypertension in pregnancy
2.
A brief history of the condition
3.
Who is most at risk
4.
How to spot early symptoms and enable a timely diagnosis
5.
How to provide effective immediate and long term medical and emotional
support
6.
Where you can access information, help and support as a healthcare
professional
Outcomes for you as a health professional:
Increased knowledge and greater confidence in dealing with pre-eclampsia.
Assessment
• At the end of the module there will be a test on the subjects
covered.
• A pass mark of 75% or more is required in order for you to be
accredited with a certificate from Action on Pre-eclampsia
(APEC).
Pre-eclampsia: definition
Pre-eclampsia is defined by NICE (2010) as:
‘New hypertension presenting after 20 weeks
with significant proteinuria’.
Pre-eclampsia: other useful
definitions to consider
•
Chronic hypertension:
‘Hypertension present at the booking visit or
before 20 weeks, or being treated at
the time of referral to the maternity services’
•
Gestational hypertension:
‘ New hypertension presenting after 20
weeks without significant proteinuria’
National Institute for Health and
Clinical Excellence (NICE) (2010)
A short history of eclampsia and preeclampsia
220BC:
First references to eclampsia were found in ancient
Egypt
1843:
Association of fits with protein in the urine was made
by Lever. Eclampsia described by Victorian doctors as
‘toxaemia of pregnancy’, still occasionally referred to
as pre-eclampsia toxaemia (PET) today
1872:
A survey found 25% of maternal deaths were due to
eclampsia. Doctors began to use induction of labour
to ‘cure’ eclampsia
Early 20th C:
Caesarean section was used to deliver babies early to
prevent maternal deaths, but midwives had little, if
any, training on the condition.
A 1950’s experience
A 1950’s account of eclampsia and pre-eclampsia
“Margaret was admitted in the sixth month of her pregnancy.
…She was deeply unconscious on admission, her blood
pressure was 200/190, heart rate 140 bpm. So heavy was
the deposit of protein that upon boiling the urine turned solid
like egg white. The baby was dead on delivery (by
caesarean section).
Margaret never regained consciousness. She was kept
under heavy sedation in the darkened room, she had
repeated convulsions that were terrifying to see. A slight
twitching was followed by vigorous contractions of all the
muscles of the body. Her whole body became rigid, and the
muscular spasm bent her body backwards, so that for about
twenty seconds only her feet and head rested on the bed.
Respiration ceased, she became blue with asphyxia. Quite
quickly the rigidity passed followed by violent movements
and spasm of all her limbs…With violent movements of the
jaw she bit her tongue to pieces. She salivated profusely and
foamed at the mouth….”
Extract from ‘Call the midwife’ by Jennifer Worth
What has changed since then?
•
The birth of the NHS after the second world war, the advent of routine
antenatal care and advances in medicine have radically improved the outlook
for women with pre-eclampsia in recent decades
•
Studies have shown that from the 1930’s to the 1980’s the incidence of
eclampsia fell by almost 90%
•
However, pre-eclampsia still remains a significant cause of maternal and infant
death in the UK and the developing world
•
Pre-eclampsia and eclampsia have been found to be the second most
common cause of maternal death in the UK
•
From 2006 - 2008 22 women died from
pre-eclampsia in the UK. (CMACE 2011)
•
Of these deaths 20 demonstrated substandard
care; in 14 of these deaths this was classed as
major – these were avoidable deaths.
Risk Factors
One or more of the following could be a risk factor:
•
Multiple fetus pregnancy
•
Previous pre-eclampsia
•
High blood pressure before pregnancy or a booking diastolic blood pressure of
90mmHg or more
•
Diabetes
•
Renal disease before pregnancy or 1+ or proteinuria on at least two occasions in
early pregnancy
•
Antiphospholipid antibodies
•
First pregnancy
•
Age of 40 or more
•
BMI of 35 or more, weight of 100kg or more at booking
•
10 years or more since last baby
•
Mother or sister had pre-eclampsia
•
Booking diastolic of 80mmHg-89mmHg
Signs/symptoms
Pre-eclampsia can be symptomless but presents itself with the following signs:
•
Hypertension
•
Proteinuria
Maternal symptoms:
•
Headaches
•
Visual disturbances (described as light in front of
the eyes)
•
Epigastric pain
•
Reduced or absent fetal movement or suspected small for gestational age
fetus
Antenatal screening for pre-eclampsia
•
Regular antenatal check-ups are the best way to screen all women for the
signs and symptoms of pre-eclampsia. Ensuring all women know about
symptoms and who to contact if they are worried in between appointments,
is an important self-help aspect of this screening
•
Accurate measurements of BP and checks for proteinuria must be taken at
every appointment. Always listen to any concerns the woman expresses
•
Antenatal check ups should occur every three weeks from 20 weeks to 34
weeks; then every two weeks from 34 weeks onwards (see NICE
Antenatal Care Guideline 2008 for further details).
Antenatal screening for pre-eclampsia
•
At the first antenatal visit all women should be assessed for their risk factors for
pre-eclampsia, preferably using the PRECOG (2004) Guideline
•
A small proportion of women will have hypertension before they become
pregnant (chronic hypertension) - these are more likely to develop preeclampsia
•
Others will have hypertension diagnosed in the first trimester when it is not
thought to be due to the pregnancy
•
Screening for pre-eclampsia should start at the booking visit and continue at
every subsequent antenatal appointment. Although pre-eclampsia does not
occur in the first half of pregnancy, these initial readings give the baseline for all
future recordings and are vital for later accurate diagnosis
•
Blood pressure and urine analysis results should recorded accurately – do not
‘round up’ BP readings, i.e. if it is 122/73 record it as such.
Changes in blood pressure could be a
vital sign something is wrong…
• Hypertensive disorders in
pregnancy (including preeclampsia) can affect 1015% of all pregnancies
• Hypertensive disorders
cause 1 in 50 stillbirths and
10% of all preterm births
Hypertensive Disorders of Pregnancy
The NICE guidelines describe the different conditions associated with
blood pressure as ‘Hypertensive Disorders of Pregnancy.’
These include: pre-eclampsia, chronic hypertension. gestational
hypertension and eclampsia.
A final diagnosis of the condition can be made, through observations,
urine and blood tests.
REMEMBER a hypertensive disorder can develop into preeclampsia, but once a woman has pre-eclampsia it will not resolve
until the baby is born.
All of these conditions require careful monitoring as women are at risk
of:
– Cerebral haemorrhage
– Intra-uterine growth restriction (IUGR)
So, regarding hypertension, what is
abnormal?
Mild Hypertension
– Systolic blood pressure 140-149 mm Hg
– Diastolic blood pressure 90-99 mm Hg
Moderate Hypertension
– Systolic blood pressure 150-159 mm Hg
– Diastolic blood pressure 100-109 mm Hg
Severe Hypertension
– Systolic blood pressure 160 mm Hg or higher
– Diastolic blood pressure greater than 110 mm Hg
(NICE 2010)
Talking with women about pre-eclampsia
It is important to ensure the following:
• The woman is given information about pre-eclampsia and
time to discuss it, to help her understand the condition
• She knows that she has not caused her pre-eclampsia, and
by the same token there is nothing she can do to alter the
outcome
• She is aware of the importance of controlling the signs of
pre-eclampsia
• She understands the criteria as to why an early birth might
achieve the best outcome for mother and baby
• If the baby may be born preterm or unwell, that she meets
the neonatal team and has a good understanding about
what will happen at delivery and what to expect on the
neonatal unit.
Coping with the emotional aspects of
pre-eclampsia
The diagnosis of any medical condition can precipitate a whole cascade of
emotions in the woman and in her family.
Common themes to be aware of:
• Grief
• Anger
• Fear
• Uncertainty
• Guilt
Diagnosis of pre-eclampsia
New hypertension (140/90 or above) presenting after the 20th* week of pregnancy
with:
•
300mg or more of protein in a 24 hour urine collection
(equivalent to +++ protein on a dipstick)
OR
• more than 30mg/mmol in a spot urinary protein:
creatinine sample
Serious features of pre-eclampsia
Pre-eclampsia (as described in previous slide) becomes more serious with one
or more of the following present themselves:
• severe hypertension (160/110 or above)
• headache
• epigastric pain
• visual disturbances
• abnormal blood results.
What are the risks of pre-eclampsia to
mother and baby?
The mother is at risk of:
• Eclampsia (seizures)
• Cerebral haemorrhage
• Placental abruption
• Renal failure
• Pulmonary oedema, acute respiratory failure
• Disseminated intravascular coagulopathy – failure of clotting system
• HELLP syndrome, liver haemorrhage and rupture
• Thromboembolism – blood clots
The baby is at risk of:
• Intrauterine growth restriction
• Intrauterine death
• Prematurity as a result of an early birth to manage pre-eclampsia
When pre-eclampsia becomes
eclampsia…
Eclampsia is an obstetric emergency!
•
Defined by NICE (2010) as
‘A convulsive condition associated with pre-eclampsia’.
•
It occurs in 1-2% of pre-eclamptic pregnancies
•
Beware: It may occur as the initial presentation without hypertension and
proteinuria
•
Fits can occur:
a. Antenatally (38%)
b. Intrapartum (18%)
c. Postnatally (44%)
What is HELLP syndrome?
HELLP syndrome is a serious complication of pre-eclampsia.
The term "HELLP" is an abbreviation of the three main features of the syndrome:
H
haemolysis – destruction of red blood cells
EL
elevated liver enzymes
LP
low platelets
It is estimated to occur in 5-20% of pre-eclamptic
pregnancies (Collins et al 2008)
Can anything be done to prevent
pre-eclampsia?
There are some medications that have been
shown to help reduce the risk of preeclampsia.
These include:
• Low-dose aspirin
• Calcium supplements
Women at high risk of developing pre-eclampsia should be referred to an
obstetrician specialising in medical problems in pregnancy. They should be
given low dose (75mgs per day) of Aspirin from the 12th week of pregnancy or
earlier if possible - (APEC medical experts recommend from conception.) These
are available over the counter at pharmacies, but it is important that women
understand that the advised dosage for pregnancy should not be exceeded. A
pre-eclampsia specialist may also advocate calcium supplements and advise on
dosage.
Is there a cure for pre-eclampsia?
The only ‘cure’ for pre-eclampsia is to for the baby
to be born along with delivery of the placenta.
However, there are many things health
professionals can and should do when caring for
all pregnant women:
• Health professionals can screen women for the risk factors
• They can monitor blood pressure and urine for the signs of the disease
• They can manage signs such as high blood pressure when it occurs
• Once pre-eclampsia has been diagnosed, the aim of management is to control
the signs of the disease and plan for safe birth of the baby
• Providing information, psychological support and listening to women can
help to reduce the emotional impact during and after pregnancy.
Medical management following a
diagnosis
The aim of management of pre-eclampsia is to:
•
Monitor blood pressure, urine, and biochemical markers through blood tests
•
Control potentially dangerous hypertension with medication
•
Ensure regular monitoring of the fetus and placenta with cardiotocography
(CTG) and ultrasound
•
Plan for a safe delivery.
Depending on severity, pre-eclampsia can be
managed as:
•
An in-patient on the antenatal ward
•
An emergency on the labour ward
Examination of women with preeclampsia
On examining a pregnant woman, the doctor will be looking at the following:
• What the woman is saying – how she feels, whether she has a headache,
visual disturbances or any vaginal bleeding suggestive of placental abruption
• Blood pressure, pulse, result of urine analysis
• Respiratory system – fine inspiratory crepitations which may indicate
pulmonary oedema
• Abdominal examination – right upper quadrant pain, or epigastric tenderness,
symphysis-fundal height, fetal presentation, liquor volume and fetal heart beat
• Neurological examination – pre-eclamptic women can have brisker than usual
reflexes.
Tests for pre-eclampsia
For the mother:
• Urine dipstick to look for protein (an automated reading is more accurate)
• Protein: creatinine ratio or 24-hour urine collection to quantify the amount of
protein in the urine
• Full blood count, urea and electrolytes, liver function tests and uric acid
For the baby:
• Ultrasound scan to assess:
−fetal growth
−liquor volume
−umbilical artery and Doppler flow velocity
– Cardiotocograph
Understanding the blood tests
Full blood count (FBC)
• Haemoglobin – should be a good level for safe delivery; also a low level can
indicate HELLP syndrome.
• Platelets – a low level or rapid fall in platelets may indicate the development
of HELLP syndrome
Urea, electrolytes and uric acid (U and E’s)
• Raised amounts of waste products such as creatinine, urea and uric acid in
the blood are evidence that the kidneys are being affected by pre-eclampsia.
Liver Function (LFT)
• Rising alanine amniotranferase (ALT) or aspartate aminotransferease (AST)
are features of HELLP syndrome and suggest liver involvement
Understanding the urine tests
These are performed to quantify the amount of protein in the urine, (although
quantification is not necessary after diagnosis.)
Protein : creatinine ratio
• Abnormal if this is a ratio of more than 30mg/mmol
24 hour urine collection
• Abnormal if there is more than 300mg of protein over 24 hours
Management of Pre-eclampsia (1)
Mild hypertension
(BP 140/90 - 144/99 mmHg)
• Perform initial assessment and tests
• Refer to obstetric care
• Admit to hospital
• Measure blood pressure four times a day
• Monitor kidney function, electrolytes, full blood
count and liver function twice a week
• Thromboprophylaxis – TED stockings and blood thinners
• Ensure regular monitoring of the fetus and placenta with cardiotocography
(CTG) and ultrasound
Management of Pre-eclampsia (2)
Moderate hypertension
(BP 150/100 to 159/109 mmHg)
Management is the same as for mild hypertension and also:
– Treat hypertension with oral Labetalol and aim to keep blood pressure
between 80-100/<150 mmHg
– Monitor bloods: FBC, U and E, LFTs three times a week
Management of Pre-eclampsia (3)
Severe hypertension
(BP > 160/110 mmHg)
The aim is to treat the hypertension and reduce the risk of eclamptic seizures.
Perform assessment and tests as for mild and moderate pre-eclampsia
Blood should be taken for cross matching if delivery is anticipated
Treat blood pressure - aim for diastolic 80-100 mmHg and systolic <150 mmHg
Strict fluid balance all intake and output should be recorded
Monitor BP according to the clinical situation
Manage on labour ward or high dependency unit
These women need one-to -one care in a consultant led team
Controlling high blood pressure
in severe pre-eclampsia
•
Intravenous medication can be used if oral anti-hypertensives are not
controlling blood pressure
•
These medications include:
- Labetalol
- Hydralazine
These are normally administered by a
doctor
•
The incidence of eclamptic fits can be
reduced with an intravenous infusion
of maganesium sulphate
Why is early induction sometimes
necessary for the pre-eclamptic woman?
• Severe hypertension which is unresponsive to
medication
• Deteriorating kidney function indicated by low urine
output, raised urea and creatinine
• Falling platelet count
• Rising or profoundly elevated liver function tests
ALT and AST
• Persistent symptoms
Why do some babies need to be
born early because of preeclampsia?
•
Evidence of intrauterine growth restriction on
ultrasound
•
Suspected fetal distress identified on CTG
•
Threat to maternal survival if pregnancy allowed to
continue.
Managing problems with babies who
need to be born before 34 weeks
•
Babies’ lungs aren’t fully matured before 34 weeks of pregnancy
•
Antenatal steroids can be given to the mother to help develop the baby’s
lungs should they need to be delivered before 34 weeks
•
It is important to arrange for the neonatal team to meet with the parents
before the birth to discuss the prognosis and potential problems that may be
faced by a baby who has to be born early
•
Occasionally women with severe pre-eclampsia may need to be transferred to
a hospital with available cots on the neonatal unit
Method of birth
This depends on:
• Severity of the pre-eclampsia
• Gestation of the pregnancy
• The woman’s previous obstetric
history
•The views and needs of the parents must
always be considered sympathetically.
Management of pre-eclampsia in labour
•
Keep the woman informed and as involved in decision-making as possible,
aiming to reduce stress and anxiety
•
Regular blood pressure monitoring
•
Women should continue anti-hypertensive medication in labour
•
A magnesium sulphate infusion may be needed to protect against eclampic fits
•
Continuous CTG monitoring
•
Fluid balance should be strictly monitored and intake may need to be limited
•
Intravenous access
•
Active management of the third stage with intramuscular syntocinon and/or
Syntocinon infusion to prevent postpartum haemorrhage
•
Ergometrine/Syntometrine should be avoided as these can increase blood
pressure
•
Don’t forget the birth partner, who will benefit from good communication too.
Eclampsia
•
Always manage eclampsia as an obstetric emergency
•
You should be familiar with your labour ward’s eclampsia drill
Immediate action:
•
Call for help
•
Ensure woman is safe and put into left lateral position
•
Assess airway, breathing and circulation – resuscitate as necessary
•
Multi-disciplinary management by doctors, midwives and anaesthetic team aims to:
• - stabilise the condition – bring down blood pressure, start magnesium sulphate
• - assess maternal condition – catheterise, send bloods
• - if eclampsia occurs prior to delivery assess fetal condition and plan for
delivery
Postnatal care
•
Some women may need to continue to take
anti-hypertensive medication
•
All women should have their blood pressure
checked between day 3 and 5
•
Women who still have hypertension and/or
proteinuria at the six-week check should be
referred for further investigation
•
All women with gestational hypertension and
pre-eclampsia should be told that they have an
increased risk of these conditions occurring in
future pregnancies
•
They should also be told that they are at
increased risk of developing high blood
pressure later on in life.
What midwives and doctors can provide
following pre-eclampsia
Women who have had pre-eclampsia want to know:
“Will I get it again?”
“How will I be looked after in my next pregnancy?”
“Where can I find support now and in the future?”
Providing emotional support for
women is as important as medical
support.
•
Grief may be as simple as mourning the loss of a chance to have a home
birth or as complicated as mourning the death of a much wanted baby.
•
Anger can be directed outwards at the medical
staff or inwards at the woman herself who may
feel guilty that she has some how caused her
condition.
•
It is very hard to give women with preeclampsia any certainties, and this can lead to
fear and anxiety.
Practical advice and guidance for
women after pre-eclampsia
•
All women should be offered a de-briefing session with a senior doctor after
a pregnancy complicated by severe pre-eclampsia
•
They should be given an estimated risk of recurrence of pre-eclampsia. The
statistics are laid out in the NICE (2010) Hypertension in pregnancy guidance
•
They should be given a plan as to how their antenatal care will be managed
during their next pregnancy
•
They should be given information about where to get immediate and ongoing
emotional support.
About Action on Pre-eclampsia (APEC)
APEC is a UK based charity that aims to:
• Educate, inform and advise the public and health professionals about
the prevalence, nature and risks of pre-eclampsia
• Campaign for greater public awareness of the disease and for action to
improve methods of detection and treatment
• Support affected women and their families
• Promote research into the causes of the disease and the development
of appropriate screening techniques and treatment methods
• Provide information about pre-eclampsia to pregnant women, affected
families and health professionals involved in maternity care
• Provide professional education about pre-eclampsia with a
programme of conferences and study days.
Sources of information and support
Action on Pre-eclampsia (APEC)
Bliss
Helpline on 0208 427 4217, information leaflets,
Premature and sick babies
Expert referral service, study days for midwives.
www.bliss.org
www.apec.org.uk
Tommy’s
Pregnancy and birth problems
www. tommys.org
Sands
Stillbirth & neonatal deaths
www. uk-sands.org
References
Centre for Maternal and Child Enquiries (CMACE) (2011) Saving mothers lives. BJOG
Suppl 1
Chamberlain G (2007) From Witchcraft to Wisdom, a history of Obstetrics and
Gynaecology in the British Isles. London: RCOG Press.
Collins S, Arulkumaran S et al. (2008) Oxford handbook of Obsetrics and Gynaecology.,
Oxford University Press.
Leitch C R, Cameron A D , Walker J J (2005) The changing pattern of eclampsia over a
60-year period. BJOG 104:8 917-992
Nelson-Piercy C (2007), A handbook of Obstetric Medicine. London: Taylor Francis.
NICE (2008) Antenatal Care www.nice.org.uk
NICE (2010) Hypertension in pregnancy. www.nice.org.uk
Pre-eclampsia Community Guideline (PRECOG) 2004 Available at www.apec.org.uk
Redman C, Walker I (1992), Pre-eclampsia - the facts. Oxford: Oxford University Press.
Worth J (2002) Call the midwife: A true story of the East End in the 1950’s. London:
Orion.
Further reading
Bewley C (2010) Hypertensive disorders of pregnancy. In Macdonald S and MagillCuerden J (Editors), Mayes Midwifery. London: Bailliere Tindall 787-798.
Bothamley J, Boyle M (2009). The renal system, hypertension and pre-eclampsia. In
Medical conditions affecting pregnancy and childbirth, Radcliffe Publishing,109-137.
Boyle M, McDonald S (2011) Pre-eclampsia and eclampsia. In Emergencies around
childbirth: a handbook for midwives. Boyle M (Editor), Radcliffe Publishing, 55-69.
Heazell A, Norwitz E R, Kenny L, Baker P N (Editors), 2010. Hypertension in pregnancy
Cambridge: Cambridge University Press.
Lloyd C (2009 ) Hypertensive disorders of pregnancy. In: Fraser D M and Cooper M A
(Editors) Myles Textbook for Midwives. London: Elsevier 397-413
Pre-eclampsia Community Guideline Group (PRECOG). The Pre-eclampsia Community
Guideline (2004); The Day Assessment Unit Guideline (2009); Guideline for the
Management of Postpartum Hypertension (2009). Available as free downloads from
Action on Pre eclampsia (APEC) at www.apec.org.uk
And finally...
• Take the APEC quiz to earn your elearning
certificate for your portfolio:
• Please go to the link to take the short quiz
here: http://action-on-preeclampsia.org.uk/htmlforms/e-learning.html
• You will also be directed to an evalutation
form – we would be very grateful if you could
take 5 minutes to complete this and help us to
improve our package.