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Brief on New WHO PEE Guidelines

Brief on New WHO PEE Guidelines

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Published by: Dhaka2012 on May 06, 2012
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 1
WHO Recommendations for Prevention andTreatment of Pre-Eclampsia and Eclampsia:
Implications and Actions
 
Background
Nearly one-tenth of maternal deaths in Asia and Africa and one-quarter of maternal deathsin Latin America are associated with hypertensive disorders of pregnancy. Among thehypertensive disorders, pre-eclampsia and eclampsia have the greatest impact on maternaland newborn morbidity and mortality. Yet the majority of deaths related to pre-eclampsiaand eclampsia could be avoided if women received timely and effective care, deliveredaccording to evidence-based standards.
Criteria for Diagnosis of Pre-eclampsia and Eclampsia
Pre-eclampsia:
Onset of a new episode of hypertension during pregnancy, characterized by:
 
Persistent hypertension (diastolic blood pressure
90 mm Hg)
and
 
 
Substantial proteinuria (> 0.3 g/24 hours).
Eclampsia:
 
Generalized seizures, generally in addition to pre-eclampsia criteria
 
The primary goal of the
WHO Recommendations for Preventionand Treatment of Pre-eclampsia and Eclampsia
is to improvethe quality of care and outcomes for pregnant women whodevelop the two most dangerous hypertensive disorders. Whilethe recommendations are not intended to be comprehensive,they are intended to promote proven, evidence-based clinicalpractices in the management of women with pre-eclampsia andeclampsia.
Guideline Content and Development Process
WHO’s guidelines were developed in accordance with the
WHO Handbook for Guideline Development
, through a processinvolving: (1) identification of critical questions and criticaloutcomes; (2) retrieval of evidence; (3) assessment, grading,and synthesis of the evidence; (4) formulation of recommendations; and (5) planning fordissemination, implementation, impact evaluation, and updating. In addition to staff fromthe WHO Departments of Reproductive Health and Research, Making Pregnancy Safer, andNutrition for Health and Development, many international stakeholders and externalexperts, including 173 participants in an online consultation and 25 experts at a technicalconsultation, were involved in the guideline development process. Evidence related to eachspecific question, drawn primarily from Cochrane reviews, was rigorously examined andgraded according to its strength. Likewise, the strength of each recommendation wasdetermined based on the grade of the evidence as well as the magnitude of the effect, thebalance of advantages versus disadvantages, resource use, and feasibility.
 
2
CLINICAL PRACTICE RECOMMENDATIONS FOR THE PREVENTION AND MANAGEMENT OFPRE-ECLAMPSIA AND ECLAMPSIA
1
 During Antenatal CarePractices
RecommendedPractices
NOT RecommendedPractice Implication
-
Calcium supplementation during pregnancy in areas where calciumintake is low
- Vitamin D supplementationduring pregnancy
- Calcium supplementationduring pregnancy in areaswhere calcium deficiency is notpresentProvide calcium to all women andacetylsalicylic acid to selectedgroups for the prevention of PE/E.While vitamin supplementationcan be useful for other healthconditions, do not provideVitamins C, D, or E, to pregnantwomen as part of a strategy forprevention of PE/E.
-
Low-dose acetylsalicylic acid(aspirin, 75 mg) for the prevention of pre-eclampsia in women at high riskof developing the condition
- Individual or combinedvitamin C and vitamin Esupplementation
-
Antihypertensive drugs forpregnant women with severehypertension
- Use of diuretics, particularlythiazides, for prevention of pre-eclampsia and itscomplicationsGive antihypertensive drugs, butnot diuretics, to pregnant womenwith severe hypertension.
- Advice to rest at homeDo not advise rest or dietary saltrestriction for pregnant women toprevent pre-eclampsia or itscomplications.
- Strict bed rest for pregnantwomen with hypertension (withor without proteinuria)
- Restriction in dietary saltintake
-
In women with severe pre-eclampsia, if there is a viable fetusand the pregnancy is less than 36(plus 6 days) weeks of gestation,expectant management can beconsidered, provided thatuncontrolled maternal hypertension,increasing maternal organdysfunction, and fetal distress do notoccur and the conditions can bemonitored.For a woman with pre-eclampsiaduring a preterm pregnancy (< 37weeks), clinicians can monitor thewoman if: (1) her blood pressure isunder control, (2) there is no fetaldistress, and (3) there are no signsof maternal organ dysfunction.Continuous monitoring isnecessary during this period of expectant management.
During Labor and Birth
 
Recommended Practices
 
Practice Implication
-
Induction of labor for women with severe pre-eclampsia at a gestational age when the fetus is notviable or is unlikely to achieve viability within one ortwo weeksConduct an expedited delivery for women withsevere pre-eclampsia remote from term, whether ornot the fetus is viable.
-
Expedited delivery for women with severe pre-eclampsia at term
1
A full report of the recommendations can be found in
WHO Recommendations for Prevention and Treatment of Pre-eclampsia andEclampsia
(http://whqlibdoc.who.int/publications/2011/9789241548335_eng.pdf), and a full listing of the evidence supporting these recommendations can be found in
WHO Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia:Evidence Base
http://whqlibdoc.who.int/hq/2011/WHO_RHR_11.25_eng.pdf).
 
3
CLINICAL PRACTICE RECOMMENDATIONS FOR THE PREVENTION AND MANAGEMENT OFPRE-ECLAMPSIA AND ECLAMPSIA
1
 Recommended Practices
 
Practice Implication
-
Magnesium sulfate, in preference to otheranticonvulsants, for the prevention of eclampsia inwomen with severe pre-eclampsiaMagnesium sulfate is the anticonvulsant of choicefor women with severe pre-eclampsia or eclampsia.If possible, give a full regimen of magnesium sulfateto women with eclampsia or severe pre-eclampsia. If the administration of a full regimen is not possible,these women should be given the loading dose of magnesium sulfate and should immediatelytransferred to a higher-level health care facility forfurther treatment.
-
Magnesium sulfate, in preference to otheranticonvulsants, for treatment of women witheclampsia
-
The full intravenous or intramuscular magnesiumsulfate regimen for the prevention and treatment of eclampsia
-
For women with severe pre-eclampsia oreclampsia, in settings where it is not possible toadminister the full magnesium sulfate regimen, usethe magnesium sulfate loading dose followed byimmediate transfer to a higher-level health carefacility
During Postpartum CareRecommended Practices
 
Practice Implication
-
Continued antihypertensive drugs during thepostpartum period for women treated withantihypertensive drugs during the antenatal periodcareTreat women with antihypertensive drugs during thepostpartum if they: (1) have severe postpartumhypertension, or (2) were treated withantihypertensive drugs during pregnancy.
-
Antihypertensive drugs for women with severepostpartum hypertension
Program Actions
The ultimate goal of these guidelines is to improve the quality of care and health outcomesrelated to pre-eclampsia and eclampsia. The recommendations, especially those thatrepresent a change from previous practice, will require actions at the national, district, andlocal levels. The following actions are needed:
1.
 
Revise national guidelines or protocols to include evidence-based practices.
Each country’s approach to promoting the use of the recommendations should be tailoredto the specific national and local context. The revision of existing national guidelinesshould be a well-planned and participatory, consensus-driven process, and anymodifications should be made in an explicit and transparent manner and based on clear justification. The revision process should include these steps:
 
Convene a national working group of recognized clinical experts from governmentagencies, medical and nursing/midwifery educational institutions, professionalorganizations, key nongovernmental organizations (NGOs), and other experts to reviewthe WHO recommendations and consider what adaptations are necessary for the localcontext.
 
Develop clear and practical clinical protocols that reflect the recommendations.
 
Develop clear and practical guidance for community health workers.
 
Ensure that policy, including job descriptions, reflect the new recommendations.
 
Ensure that all skilled birth attendants are authorized to give magnesium sulfateand antihypertensives for severe pre-eclampsia and eclampsia.
 
Ensure that trained community health workers are authorized to counsel andprovide calcium in areas of calcium deficiency.

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