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Pre-eclampsia: diagnosis and management An e-learning course for for midwives and health professionals

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Title: Pre-eclampsia: diagnosis and management An e-learning course for for midwives and health professionals


1
Pre-eclampsia diagnosis and managementAn
e-learning course forfor midwives and health
professionals
2
E-learning course objectives
  • On completion of the course, you will have a
    clear understanding of the following
  • The definition of pre-eclampsia, and where it
    fits with other manifestations of hypertension in
    pregnancy
  • A brief history of the condition
  • Who is most at risk
  • How to spot early symptoms and enable a timely
    diagnosis
  • How to provide effective immediate and long term
    medical and emotional support
  • 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.

3
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).

4
Pre-eclampsia definition
Pre-eclampsia is defined by NICE (2010) as
New hypertension presenting after 20
weeks with significant
proteinuria.
5
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)

6
A short history of eclampsia and pre-eclampsia
  • 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.

7
A 1950s experience
A 1950s 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 limbsWith 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
8
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 1930s to the
    1980s 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.

9
Who may be at risk?
  • One or more of the following features warrants
    close attention
  • Extremes of maternal age teenagers and women
    over 40
  • First pregnancy
  • Interval of more than 10 years since last
    pregnancy
  • Body mass index (BMI) of more than 35
  • Family history of pre-eclampsia
  • Multiple pregnancies
  • Pregnancies conceived through assisted
    reproduction techniques
  • Women with a history of previous pre-eclampsia
  • Women with a history of chronic renal disease
  • Women with a history of diabetes mellitus
  • Women with a history of antiphospholipid
    antibodies
  • Women with pre-pregnancy hypertension
  • REMEMBER some women will have no risk factors and
    will have been fit and well in early pregnancy,
    but still develop pre-eclampsia.

10
Signs/symptoms
  • Pre-eclampsia can be symptomless but presents
    itself with the following signs
  • Hypertension
  • Proteinuria
  • Women may also experience the following symptoms
  • Headache
  • Visual disturbances (described as light in front
    of
  • the eyes)
  • Nausea and vomiting
  • Oedema, particularly rapid onset oedema of the
    hands or feet (and associated weight gain water
    is very heavy)
  • General malaise, sometimes accompanied by a
    feeling of unease
  • Reduced or absent fetal movement

11
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).

12
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
    pre-eclampsia
  • 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.

13
Changes in blood pressure could be a vital sign
something is wrong
  • Hypertensive disorders in pregnancy (including
    pre-eclampsia) can affect 10-15 of all
    pregnancies
  • Hypertensive disorders cause 1 in 50 stillbirths
    and 10 of all preterm births

14
What is pregnancy induced hypertension?
  • This is a term which incorporates both
    gestational hypertension and pre-eclampsia. It is
    useful to consider each womans diagnosis under
    this heading before a final diagnosis of one or
    the other can be made, usually through serial
    urine and blood tests.
  • REMEMBER gestational hypertension can develop
    into pre-eclampsia, but once a woman has
    pre-eclampsia it will not resolve until the baby
    is born.
  • Both of these conditions require careful
    monitoring as women are at risk of
  • Cerebral haemorrhage
  • Intra-uterine growth restriction (IUGR)

15
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)

16
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
    symptoms of pre-eclampsia
  • She understands the criteria as to why an early
    delivery 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.

17
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

18
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

19
When is severe pre-eclampsia diagnosed?
  • Pre-eclampsia (as described in previous slide)
    with one or more of the following
  • severe hypertension (160/110 or above)
  • headache
  • epigastric pain
  • visual disturbances
  • abnormal blood results.

20
What are the risks of severe 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 delivery to
    manage pre-eclampsia

21
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
  • Antenatally (38)
  • Intrapartum (18)
  • Postnatally (44)

22
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)

23
Can anything be done to prevent pre-eclampsia?
  • There are some medications that have been shown
    to help reduce the risk of pre-eclampsia.
  • 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. 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.
24
Is there a cure for pre-eclampsia?
  • Unfortunately the only cure for pre-eclampsia
    is to deliver the baby and 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 symptoms such as high blood
    pressure when it occurs
  • Once pre-eclampsia has been diagnosed, the aim of
    management is to control the symptoms of the
    disease and plan for safe delivery of the baby
  • Providing information, psychological support and
    listening to women can help to reduce the
    emotional impact during and after pregnancy.

25
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

26
Examination of women with pre-eclampsia
  • 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
  • General appearance facial oedema and jaundice
  • Blood pressure, pulse, general oedema, 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.

27
Tests for pre-eclampsia
  • For the mother
  • Urine dipstick to look for protein (an automated
    reading is more accurate)
  • Proteincreatine 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
  • Cardiotocograph
  • Ultrasound scan to assess
  • fetal growth
  • liquor volume
  • umbilical artery and Doppler flow velocity

28
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 Es)
  • Raised amounts of waste products such as
    creatine, 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

29
Understanding the urine tests
  • These are performed to quantify the amount of
    protein in the urine
  • 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

30
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
  • Regular cardiotocography (CTGs )

31
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/lt150 mmHg
  • Monitor bloods FBC, U and E, LFTs three times a
    week

32
Management of Pre-eclampsia (3)
Severe hypertension (BP gt 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 lt150
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
33
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

34
Why do women with pre-eclampsia sometimes have to
be delivered early?
Maternal indications
  • 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

35
Why do some babies need to be delivered early
because of pre-eclampsia?
  • Evidence of intrauterine growth restriction on
    ultrasound
  • Suspected fetal distress identified on CTG
  • Threat to maternal survival if pregnancy allowed
    to continue.

36
Managing problems with babies who need to be
delivered before 34 weeks
  • Babies lungs arent fully matured before 34
    weeks of pregnancy
  • Antenatal steroids can be given to the mother to
    help develop the babys 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

37
Method of delivery
  • This depends on
  • Severity of the pre-eclampsia
  • Gestation of the pregnancy
  • The womans previous obstetric
  • history

38
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
  • Dont forget the birth partner, who will benefit
    from good communication too.

39
Eclampsia
  • Always manage eclampsia as an obstetric emergency
  • You should be familiar with your labour wards
    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

40
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.

41
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?
42
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 pre-eclampsia
    any certainties, and this can led to fear and
    anxiety.

43
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.

44
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.

45
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
  • Tommys
  • Pregnancy and birth problems
  • www. tommys.org
  • Sands
  • Stillbirth neonatal deaths
  • www. uk-sands.org

46
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 1048 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 1950s. London Orion.

47
Further reading
  • Bewley C (2010) Hypertensive disorders of
    pregnancy. In Macdonald S and Magill-Cuerden 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

48
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-pre-eclampsia.org.uk/htmlf
    orms/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.
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