Professional Documents
Culture Documents
Pre Eklamsi Diagnosis
Pre Eklamsi Diagnosis
Version 1.0
Guideline No. 3
Date of publication September 2011
Revision date September 2013
Table of Contents
Key Recommendations............................................................................................................. 3
1.0 Purpose and Scope ............................................................................................................ 3
2.0 Background and Introduction .............................................................................................. 3
3.0 Methodology ....................................................................................................................... 3
4.0 Clinical Guideline ................................................................................................................ 4
4.1 Diagnosis and Classification .......................................................................................................................... 4
4.1.1 Classification of Hypertensive Disorders of Pregnancy ............................................ 4
4.1.2 Measurement of Blood Pressure .............................................................................. 4
4.1.3 Diagnosis of Hypertension ........................................................................................ 4
- Measurement of Proteinuria ............................................................................................ 5
4.1.5 Diagnosis of Clinically Significant Proteinuria ........................................................... 5
4.2 Management of non-severe pre-eclampsia ..................................................................... 6
4.2.1 Place of Care ............................................................................................................ 6
4.2.2 Initial evaluation ........................................................................................................ 6
4.2.3 Treatment of non-proteinuric gestational hypertension and non-severe preeclampsia .......................................................................................................................... 6
4.2.4 Delivery..................................................................................................................... 7
4.3 Management of Severe Pre-eclampsia ........................................................................... 8
4.3.1 Entry criteria .......................................................................................................... 8
4.3.2 General Measures ................................................................................................ 8
4.3.3 Basic Investigations .............................................................................................. 9
4.3.4 Monitoring ............................................................................................................. 9
4.3.5 Fluid Management ................................................................................................ 9
4.3.6 Thromboprophylaxis............................................................................................ 10
4.3.7 The treatment of severe hypertension................................................................. 10
4.3.8 The Treatment and Prevention of Eclampsia.......................................................... 12
4.3.9 The Timing and Mode of Delivery of Women with Pre-eclampsia .......................... 14
4.3.10 Stabilisation before Transfer ................................................................................. 14
4.3.11 Anaesthesia and fluid administration .................................................................... 15
4.3.12 Postpartum fluid management .............................................................................. 15
4.3.13
HELLP syndrome............................................................................................. 16
4.3.14 Immediate post natal care .................................................................................... 17
4.3.15
Postnatal review .............................................................................................. 17
5.0 References and further reading .................................................................................... 18
6.0 Implementation Strategy .................................................................................................. 19
7.0 Key Performance Indicators ............................................................................................. 19
8.0 Qualifying Statement ........................................................................................................ 19
Appendix 1 .............................................................................................................................. 20
Appendix 2 .............................................................................................................................. 21
Appendix 3 .............................................................................................................................. 22
Appendix 4 .............................................................................................................................. 23
Appendix 5 .............................................................................................................................. 24
Key Recommendations
1. An appropriately sized cuff should be used to measure blood pressure. If the
mid-arm circumference is > 33 cm, a large cuff should be used.
2. All pregnant women should be assessed for proteinuria.
3. Nifedipine is a potent antihypertensive and should never be given sublingually.
4. Cases of severe pre-eclampsia should be given magnesium sulphate to
prevent seizures.
5. Following delivery the patient should be fluid restricted in order to wait for the
natural diuresis.
6. Corticosteroids may be considered for patients with a platelet count of < 50 x
109 ml.
7. A platelet transfusion is recommended prior to caesarean section or vaginal
delivery when the platelet count is < 20 x 109 ml.
8. Methyldopa should be avoided postnatally.
9. It is not necessary to perform a clotting profile in cases of non-severe preeclampsia and gestational hypertension if the platelet count is normal.
3.0 Methodology
The literature reviewed during the development of this guideline included current local and
national guidelines and their reference lists from the UK, Canada, USA, Australia and New
Zealand. In addition, Medline and the Cochrane Library were searched for literature published
between 2000 and 2010. Articles were restricted to those published in English.
The guideline was developed by Dr Clare O'Loughlin and Professor Louise Kenny, Consultant
Obstetrician and Gynecologist at Cork University Maternity Hospital, Cork, Ireland.
The guideline was peer reviewed by: Dr Joe Clarke (GP), Mr Brian Cleary (Pharmacist), Ms
Fiona Dunlevy (Coombe), Dr Maeve Eogan (Rotunda), Dr Chris Fitzpatrick (Coombe),
Professor Richard Greene, (Cork), Professor John Higgins (Cork), Ms Marguerite Hogan
3
Elevations of both systolic and diastolic blood pressures have been associated with adverse
fetal outcome and therefore both are important.
Detecting a rise in blood pressure from booking or preconception blood pressure, rather than
relying on an absolute value, has in the past been considered useful in diagnosing preeclampsia in women who do not reach blood pressure of 140 or 90 mmHg. Available evidence
does not suggest that these women have an increased risk of adverse outcome. However,
such a rise may be significant in women with other complications such as proteinuria and
closer monitoring of such women is recommended.
Severe hypertension should be defined as a systolic BP of >160 mmHg or a diastolic BP of
>110 mmHg. For severe hypertension, a repeat measurement should be taken for
confirmation no more than 15 minutes later.
- Measurement of Proteinuria
All pregnant women should be assessed for proteinuria.
Urinary dipstick testing may be used for screening for proteinuria when the suspicion of
preeclampsia is low.
Approximate equivalence is:
1+ = 0.3 g/l
2+ = 1 g/l
3+ = 3 g/l
There is considerable observer error with visual dipstick assessment. This can be overcome
by the use of automated dipstick readers, which significantly improve both false positive and
negative rates.
In the presence of hypertension, a reading of 1+ or more should prompt further
evaluation.
4.1.5 Diagnosis of Clinically Significant Proteinuria
The upper limit of a normal 24-hour urine protein excretion is 0.3g and is based on a 95% CI
for urinary protein in pregnancy. However, there is considerable variation between laboratory
assays for the quantification of proteinuria. This, combined with unknown errors and the delay
associated with obtaining a 24-hour collection means that newer tests have potential
advantages. An elevated protein creatinine ratio of greater than 30 mg/mmol correlates with a
24-hour urine excretion greater than 300mg and should be used to check for significant
proteinuria.
For women without underlying medical problems, antihypertensive drug therapy should be
used to keep systolic blood pressure at 130-155 mmHg and diastolic blood pressure at 80105 mmHg. For women with underlying medical problems, such as diabetes or renal disease,
there is some evidence that tighter control is beneficial and therapy should be used to keep
systolic blood pressure at 130-139 mmHg and diastolic blood pressure at 80-89mmHg.
There are several medications currently used for the treatment of moderate to severe
hypertension. A Cochrane review of pharmacological agents used in the treatment of
gestational hypertension found insufficient evidence to recommend one agent over another
and the selection of a drug of first choice is at the clinicians discretion (Duley et al. 2002).
Methyldopa is a centrally acting antihypertensive which does not appear to have any
adverse effect on the uteroplacental circulation. Methyldopa is given at a dose of
250mg three times per day increasing to a maximum of 1g three times a day.
Methyldopa is not suitable for the rapid control of hypertension as it requires 24 hours
to achieve therapeutic levels. As the dose of methyldopa increases the adverse effects,
particularly sedation and depression increase.
If the initial dose of any antihypertensive drug fails to adequately control blood pressure, the
dose should be increased incrementally until the maximum dose is reached. If adequate
control of blood pressure has still not been achieved, a second antihypertensive agent may be
introduced. This drug should be prescribed in addition to and not instead of the first agent.
4.2.4 Delivery
The ultimate treatment for pre-eclampsia is delivery of the baby. After 37 completed weeks
gestation consideration should be given to induction of labour. A clinical assessment should
include the womans symptoms, the severity of the pre-eclampsia, the well-being of the fetus
and the favourability of the cervix. If the cervix is unfavourable and the pre-eclampsia is mild,
for example, induction of labour may be deferred especially in a woman with a single prior
caesarean section. Particular caution is also required in the obese parturient. In some clinical
circumstances it may be necessary to proceed to an elective caesarean section.
7
Evidence from the HYPITAT Trial (Koopmans et al. 2009) suggests that in women with
gestational hypertension and non-severe pre-eclampsia, induction of labour after 37 weeks
gestation is associated with a significant reduction in adverse maternal outcome including
progression to pre-eclampsia, without a difference in neonatal outcomes or an increase in
Caesarean section rates. Consideration should be given to induction of labour in this situation.
Eclampsia
Severe hypertension e.g. a systolic blood pressure over 160mmHg with at least +
proteinuria
Moderate hypertension e.g. a systolic blood pressure over 140 mmHg and/or diastolic
blood pressure over 90 mmHg with significant proteinuria and any of:
severe headache with visual disturbance
epigastric pain
signs of clonus
liver tenderness
platelet count falling to below 100 x 10 9/l
alanine amino transferase rising to above 50iu/l
creatinine >100mmol/l
Serum electrolytes
Clotting
Blood pressure and pulse should be measured every 15 minutes until stabilised and
then half hourly.
An indwelling catheter should be inserted and urine output measured hourly whenever
intravenous fluids are given.
Oxygen saturation should be measured continuously and charted with the blood
pressure. If saturation falls below 95% then medical review is essential.
Fluid balance should be monitored very carefully. Detailed input and output recordings
should be charted.
Respiratory rate should be measured hourly.
Temperature should be measured four hourly.
When present, Central Venous Pressure (CVP) and arterial lines should be measured
continuously and charted with the blood pressure.
Neurological assessment should be performed hourly using either AVPU or GCS (see
Appendix for details regarding these scales)
Fetal well-being should be assessed carefully. In the initial stages this will be with a
cardiotocograph but consideration should be given to assessing the fetus with a growth
scan, liquor assessment and umbilical artery doppler flow velocity waveforms.
Blood tests should be repeated every 12 hours whilst on the protocol. In the event of
haemorrhage more frequent blood tests should be taken. In the presence of abnormal
or deteriorating haematological and/or biochemical parameters, more frequent testing
may be required e.g. every 4-8 hours.
4.3.6 Thromboprophylaxis
Prior to delivery:
Women with pre-eclampsia are at increased risk of thrombo emobolic disease. All
patients should have anti-embolic stockings and/or flowtrons and/or heparin whilst
immobile.
Following delivery:
Low molecular weight heparin (dose adjusted on early pregnancy weight) should be
given daily until the patient is fully mobile (7 days if delivered by Caesarean section).
Low molecular weight heparin should not be given until 4-6 hours after spinal
anaesthesia.
An epidural catheter should be left in place for at least 12 hours after low molecular
weight heparin administration. Following removal of an epidural catheter low molecular
weight heparin should not be given for 4-6 hours.
doubled every half hour to a maximum of 32ml/hour (160mg)/hour until the blood pressure
has dropped and then stabilised at an acceptable level.
Contraindication: severe asthma, use with caution in women with pre-existing cardiac disease.
If intravenous labetalol has not reduced BP <160/105mmHg after 60-90 minutes or BP is
>160mmHg despite a maximal labetalol infusion, then a second line agent should be
considered. In such cases it is normally appropriate to continue the first drug i.e. labetalol
while administering the second. The use of a second line antihypertensive should always be
discussed with a senior obstetrician.
SECOND CHOICE AGENTS:
The choice of second line agent should be determined by the clinical situation (i.e. suitability
of oral or IV therapy, proximity of delivery) and the preference of the senior obstetrician.
CAUTION: The use of a second line agent (hydralazine or nifedipine) can cause precipitate
drops in blood pressure, particularly if magnesium sulphate therapy is also being
administered.
HYDRALAZINE
If labetalol is contraindicated or fails to control the blood pressure then Hydralazine is an
alternative agent.
Hydralazine is given as a bolus infusion 2.5 mg over 5 minutes measuring the blood pressure
every 5 minutes. This can be repeated every 20 minutes to a maximum dose of 20 mgs. This
may be followed by an infusion of 40mg of hydralazine in 40 mls of normal saline, which
should run at 1-5ml/hr (1-5mg/hr). However, if the labetalol infusion is continued a hydralazine
infusion may not be required as the blood pressure will probably settle with bolus doses.
NIFEDIPINE
Nifedipine should NOT be given sublingually to a woman with hypertension. Profound
hypotension can occur with concomitant use of nifedipine and parenteral magnesium
sulphate and therefore nifedipine should be prescribed with caution in women with
severe pre-eclampsia.
Oral nifedipine is currently available in 3 different preparations; capsules, modified release (12
hour twice daily dose) and modified release (24 hours, once daily dose) tablets.
NB the proprietary brands of nifedipine vary, check the drug information carefully before
prescribing.
Oral nifedipine can be considered if labetalol and/or hydrallazine has not adequately
controlled blood pressure.
11
A modified release 12 hour preparation (e.g. Adalat Retard) or 24 hour (e.g. Adalat LA)
may be considered in women where a more sustained preparation may be beneficial (such as
women post delivery who have discontinued magnesium sulphate).
4.3.8 The Treatment and Prevention of Eclampsia
It is appropriate to treat cases of severe pre-eclampsia with Magnesium Sulphate to
prevent seizures. No other agents are appropriate for prophylaxis (Duley et al, 2010).
Continuous pulse oximetry (alert Anaesthetist if O2 sat<95%) and three lead ECG
monitoring if available
12
ii)
iv)
13
1.
2.
3.
4.
restriction will usually be continued for the duration of magnesium sulphate treatment;
however, increased fluid intake may be allowed by a consultant obstetrician at an earlier time
point in the presence of significant diuresis.
Urine output should be recorded hourly and each 4 hour block should be summated and
recorded on the chart. Each 4 hour block should total in excess of 80 ml. If two consecutive
blocks fail to achieve 80 ml then further action is appropriate:
A.
If total input is more than 750 ml in excess of output in the last 24 hours (or since
starting the regime) then 20 mg of iv furosemide should be given. Colloid should then be given
as below if a diuresis of >200mls in the next hour occurs.
or
B.
If total input is less than 750 ml in excess of output in the last 24 hours (or since
starting the regime) then an infusion of 250ml of colloid over 20 minutes should be given. The
urine output should then be watched until the end of the next four hour block. If the urine
output is still low then 20mg of iv furosemide - furosemide should be given. If a diuresis in
excess of 200 ml occurs in the next hour the fluid should be replaced with 250ml of colloid
over 1 hour in addition to baseline fluids.
If the urine output fails to respond to furosemide in either situation then a discussion with a
Renal Physician or a recognized specialist would be appropriate.
If persisting oliguria requiring fluid challenge or frusemide occurs then the electrolytes need to
be carefully assessed and checked six hourly. If there is concern over a rising creatinine and
or potassium the case should be discussed with a Renal Physician or a recognized specialist.
If the woman has a falling oxygen saturation, this is most likely to be due to fluid overload.
Input and output should be assessed together with either clinical or invasive assessment of
the fluid balance. However the most appropriate treatment is likely to be furosemide and
oxygen. If there is no diuresis and the oxygen saturation does not rise, then renal referral
should be considered.
4.3.13 HELLP syndrome
Prophylactic transfusion of platelets is not recommended, even prior to Caesarean section,
when platelet count >50 x 109/L and there is no excessive bleeding or platelet dysfunction.
Consideration should be given to ordering blood products, including platelets, when the
platelet count is <50 x 109/L, when the platelet count is falling, and/or there is coagulopathy.
Platelet transfusion is recommended prior to Caesarean section or vaginal delivery
when platelet count is <20 x 109/L.
16
Corticosteroids may be considered for women with a platelet count <50 x 10 9/L.
Dexamethasone intravenously at 12 hourly intervals over 36 hours [10 mg, 10 mg, 5 mg, 5
mg] may expedite improvement of laboratory parameters.
risk factors such as obesity and limited interventions such as aspirin therapy which may
improve outcomes in subsequent pregnancies.
5.0
Distribution of guideline to all members of the Institute and to all maternity units.
Implementation through HSE Obstetrics and Gynaecology programme local
implementation boards.
Distribution to other interested parties and professional bodies.
Discuss care with women in an environment that is appropriate and which enables
respectful confidential discussion.
Advise women of their choices and ensure informed consent is obtained.
Meet all legislative requirements and maintain standards of professional conduct.
Apply standard precautions and additional precautions as necessary, when delivering
care.
Document all care in accordance with local and mandatory requirements.
19
Appendix 1
Neurological monitoring
The Glasgow coma score is a quantitative assessment of the level of consciousness. It is the
sum of the three responses of eye opening, verbal response and motor response:
Response
Points
Eye opening
Spontaneous
Eye opening to speech on request
Eye opening to painful stimulus
No eye opening
4
3
2
1
Verbal response
Orientated
Confused
Inappropriate words
Incomprehensible sounds
No verbal response
5
4
3
2
1
Motor response
Obeys commands
Localises to pain
Withdraws fro painful stimulus
Abnormal flexion, decorticate posture
Extensor response, decerebrate posture
No movement to stimulus
6
5
4
3
2
1
The AVPU score is a simplified and quick neurological assessment where the patient can be
A
Alert
V
Responds to voice
P
Responds to pain
U
Unresponsive
20
Appendix 2
21
Appendix 3
PRESCRIPTION DOCUMENT
FOR INTRAVENOUS LABETALOL
Date _____________
Bolus doses
Yes
No
o Give bolus dose of 50mg (10ml of labetalol 5mg/ml) over at least 5 minutes.
o Can be repeated in doses of 50mg at 10 minute intervals up to a maximum dose of 200mg.
Prescribed by _____________________
Dose
Dose
Time
Time
Administered by
Administered by
Dose
Dose
Time
Time
Administered by
Administered by
Maintenance dose
Following a response to bolus doses, or as initial treatment in moderate hypertension, a labetalol infusion should
be commenced:
o
o
o
Draw up 300mg of labetalol in 60ml from three 20 ml ampoules containing 100 mg of labetalol each
(5mg/ml).
Start an infusion of labetalol 5mg/ml at a rate of 4ml/hour (20mg/hour) preferably via a syringe pump.
The infusion rate should be doubled every half hour to a maximum of 32ml/hour (160mg)/hour until the
blood pressure has dropped and then stabilised at an acceptable level.
Prescribed by _____________________
Date commenced
Prepared by
_____________________
Checked by
_____________________
Commenced by
_____________________
Time commenced
__________
________
_____________________
22
Appendix 4
PRESCRIPTION DOCUMENT
FOR INTRAVENOUS HYDRALAZINE
Date _____________
Bolus doses
o
o
o
o
Prescribed by _____________________
Dose
Dose
Time
Time
Administered by
Administered by
Dose
Dose
Time
Time
Administered by
Administered by
Dose
Dose
Time
Time
Administered by
Administered by
Dose
Dose
Time
Time
Administered by
Administered by
Maintenance dose
Administration of intravenous maintenance hydralazine.
o Reconstitute 2 ampoules (40mg) with 1ml of water for injections each.
o Add 40 mg of reconstituted hydralazine solution in 2 ml of water of injection to 38 ml of 0.9% normal
saline (1mg/ml).
o Administer infusion at a rate of 1-5 mg/hour (i.e. 1-5 ml/hour).
Prescribed by _____________________
Prepared by
______________
Checked by
______________
Commenced by
________________
________
Discontinued by
_________________
23
Appendix 5
Infuse pre-mixed loading dose bag over ten minutes (i.e. at a rate of 300ml per hour) followed by
maintenance infusion.
Time
______________
Date
______________
Prescribed by
______________
Administered by
______________
Maintenance dose
o
Infuse pre-mixed maintenance dose bag at 1g per hour (i.e. at a rate of 25ml per hour).
Time
______________
Prescribed by ______________
Date ______________
Bag #1
Prepared by _______________
Checked by
_______________
Time commenced ____________
Commenced by _____________
Date commenced _____________
Bag #2
Prepared by _______________
Checked by
_______________
Time commenced ____________
Commenced by _____________
Date commenced _____________
Bag #3
Prepared by _______________
Checked by
_______________
Time commenced ____________
Commenced by _____________
Date commenced _____________
24