Copyright © 2011, 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: Participant’s Notebook. Baltimore: Jhpiego; 2011.
Participant’s notebook /Prevention and management of pre-eclampsia and eclampsia
Participant’s Notebook
2011
Maternal and Child Health Integrated Project (MCHIP)
This project 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 Cooperative Agreement No. GHS-A-00-08-00002-00. 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.
Prevention and management of pre-eclampsia and eclampsia1
Version 4.0 / 10 January 2011
Participant’s notebook /Table of contents
Key definitions
Understanding pre-eclampsia and eclampsia
Summary of the session
Learning objectives for the session
Learning activities - Classroom
Learning activities - Individual
Identifying pre-eclampsia
Summary of the session
Learning objectives for the session
Job aid
Learning activities
Prevention of pre-eclampsia and/or eclampsia
Summary of the session
Learning objectives for the session
Job aid
Learning activities
Management of pre-eclampsia and eclampsia
Summary of the session
Learning objectives for the session
Job aids
Learning activities – classroom
Clinical simulation: Management of headache, high blood pressure, blurred vision, loss of consciousness
Learning activities – individual
Management during a convulsion / fit
Summary of the session
Learning objectives for the session
Job aids
Learning activities - Classroom
Learning activities - Individual
Birth preparedness and complication readiness
Summary of the session
Learning objectives for the session
Learning activities
Suggested answers for learning activities
Understanding pre-eclampsia and eclampsia
Identifying pre-eclampsia
Prevention of pre-eclampsia and/or eclampsia
Management of pre-eclampsia and eclampsia
Managing convulsions
Birth preparedness and complication readiness
Learning guides
Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but < 110 mm Hg
Learning guide: Management of severe pre-eclampsia / eclampsia
Learning guide: Administering magnesium sulfate
Learning guide: Management during and after an eclamptic fit/seizure
Checklists
Checklist for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but < 110 mm Hg
Checklist: Management of severe pre-eclampsia / eclampsia
Checklist: Administering loading dose of magnesium sulfate
Checklist: Administering maintenance dose of magnesium sulfate
Checklist: Management during and after an eclamptic fit/seizure
Final Evaluation Form
Acknowledgements
Susheela Engelbrecht led development of the learning materials, with technical assistance and feedback from members of the MCHIP Training and Quality Assurance TaskForce, one of the five Task Forces formed under the Pre-Eclampsia/Eclampsia Technical Working Group. Members of the task force includePatricia Gomez, Diane Sawchuck, Peter von Dadelszen,Abdelhadi Eltahir,FrancesGanges, Ann Davenport, Deborah Armbruster, Nahed Matta,Jeffrey Smith, Annette Briley, and Bridget Lynch. The writing team is grateful to the following people, who provided invaluable assistance with this effort:
- Contributing editors
- Reviewers: Ahmet Metin Gulmezoglu
- Proofreader
- Illustrator .
About MCHIP
For more information or additional copies of this manual, please contact:
Acronyms
BP / blood pressureBPP / birth preparedness plan
CRP / complication readiness plan
dBP / diastolic blood pressure
DIC / disseminated intravascular coagulation
HELLP / Hemolysis,ELevated Liver enzymes, and low Platelet count syndrome
HIP / hypertension in pregnancy
IUGR / intrauterine growth restriction
Magpie Trial / magnesium sulfate for prevention of eclampsia trial
MAP / mean arterial pressure
MCHIP / maternal and child health integrated project
RCT / randomized controlled trial
sBP / systolic blood pressure
STI / sexually transmitted infections
UTI / urinary tract infection
USAID / United States Agency for International Development
WHO / World Health Organization
Prevention and management of pre-eclampsia and eclampsia1
Version 4.0 / 10January 2011
Participant’s notebook /Key definitions
Albumin: Also known as "albumen" when pertaining to egg whites, refers generally to any protein that is water soluble, which is moderately soluble in concentrated salt solutions, and experiences heat coagulation (protein denaturation).
Avoidable factors: Factors causing or contributing to maternal death where there is departure from generally accepted standards of care.
Chronic Hypertension: Refers to pre- existing hypertension or hypertension diagnosed in the first half of pregnancy. If associated with proteinuria and other features of pre-eclampsia in the second half of pregnancy, it is called chronic hypertension with superimposed pre-eclampsia.
Coagulation cascade: Coagulation is an important part of hemostasis (the cessation of blood loss from a damaged vessel), wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel. The coagulation cascade leads to fibrin formation. Normally, the coagulation cascade happens as a result of injury and is essential for stopping bleeding; in the case of severe pre-eclampsia, it may be part of the disease process.
Creatinine: Creatinine is a breakdown product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body (depending on muscle mass). Creatinine is chiefly filtered out of the blood by the kidneys. If the filtering of the kidney is deficient, blood levels rise.
Disseminated intravascular coagulation (DIC):A pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood vessels throughout the body. As the small clots consume coagulation proteins and platelets, normal coagulation is disrupted and abnormal bleeding occurs. The small clots also disrupt normal blood flow to organs (such as the kidneys), which may malfunction as a result.
Fetal compromise: Suboptimal blood flow to the fetus during the antepartum period (before labor) or intrapartum period (birth process) may result in fetal compromise. During the antenatal period, this may result in restricted growth; during labor and childbirth, this is usually referred to as “fetal distress.”
Fibrinogen: A protein present in blood plasma that converts to fibrin when blood clots.
Gestational hypertension: Formerly known as “pregnancy induced hypertension.” Defined as hypertension in the second half of pregnancy (20 weeks and above) without proteinuria.
HELLP (Hemolysis,ELevated Liver enzymes, and low Platelet count) syndrome: 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:
- Fibrin forms cross-linked networks in the small blood vessels.
- This leads to destruction of red blood cells because of narrowing or obstruction of small blood vessels (microangiopathic hemolytic anemia): the mesh causes destruction of red blood cells as if they were being forced through a strainer.
- Additionally, platelets are consumed. As the liver appears to be the main site of this process, downstream liver cells suffer from lack of adequate blood flow to support the normal functioning (ischemia), leading to the localized death of living cells situated around the portal vein of the liver (periportal necrosis). Other organs can be similarly affected.
- HELLP syndrome leads to a form of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding.
Hypertension in pregnancy (HIP): Defined as a diastolic blood pressure of ≥90 mmHg measured on 2 separate occasions more than 6 hours apart OR a single reading at any stage of pregnancy of a diastolic BP of ≥110mmHg.
Insulin resistance: A physiological condition in which the natural hormone, insulin, becomes less effective in lowering blood sugars. The resulting increase in blood glucose may raise levels outside the normal range and cause adverse health effects.
Intervillous space: "inter" means between, and "villous" means vessels, so the intervillous space is the "space between the vessels" of the mother and the embryo.
Mean arterial pressure: Term used to describe an average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle.
Neuro-Developmental Delay: Describes the omission or arrest of a stage of early development. The brain develops in stages, beginning with lower levels of function. Optimal function of each stage is dependent upon complete development of the preceding levels. If there is a disruption or delay in early development, the higher brain cannot function at its potential and this can result in difficulties, particularly with learning.
Normotensive: Having normal blood pressure.
Perinatal:The period occurring "around the time of birth", specifically from 22 completed weeks (154 days) of gestation (the time when birth weight is normally 500 g) to seven completed days after birth.Legal regulations in different countries include gestation age beginning from 16 to 28 weeks (7 months) before birth or from 500 to 1,000 g birthweight.
Pre-eclampsia:A condition that can occur after the 20th week of pregnancy, which includes high blood pressure and protein in the urine. This condition is accompanied by metabolic disturbances that can threaten the health of the pregnancy as well as the lives of the fetus and pregnant woman.
Pressor agent:Any agent that causesa narrowing of an opening of a blood vessel.
Proteinuria: Means the presence of an excess of serumproteins in the urine.
Randomized controlled trial (RCT): A type of scientific experiment most commonly used in testing the efficacy or effectiveness of healthcare services (such as medicine or nursing) or health technologies (such as pharmaceuticals, medical devices or surgery). RCTs involve the random allocation of different interventions (treatments or conditions) to subjects. The most important advantage of proper randomization is that "it eliminates selection bias, balancing both known and unknown prognostic factors, in the assignment of treatments."
Risk factors: Factors which make a condition more likely to happen or more dangerous
Trophoblast:The tissue of the developing embryo responsible for implantation and formation of the placenta.
Trophoblastic invasion: The invasion of a specific type of trophoblast (extravillous trophoblast) into the maternal uterus is a vital stage in the establishment of pregnancy. A theory about the etiology of pre-eclampsia is the failure of the trophoblast to invade sufficiently. If there is too firm an attachment, it may lead to placenta accreta.
Vasodilation: Refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When vessels dilate, the flow of blood is increased due to a decrease in vascular resistance. Therefore, dilation of arterial blood vessels (mainly arterioles) leads to a decrease in blood pressure.
Vasospasm: Refers to a condition in which blood vessels spasm, leading to vasoconstriction. This can lead to tissue ischemia and death (necrosis).
Understanding pre-eclampsia and eclampsia
Summary of the session
During this session, you will review: 1) the evolution of pre-eclampsia and eclampsia, 2) epidemiology of pre-eclampsia and eclampsia, 3) the pathophysiology of pre-eclampsia and eclampsia,4) factors that influence the survival of women with pre-eclampsia/eclampsia and their fetuses/newborn,and 5) morbidity and mortality associated with severe pre-eclampsia and eclampsia.
Learning objectives for the session
At the end of the session, participants will be able to:
- Describe the progression of gestational hypertension into severe pre-eclampsia or eclampsia
- List factors that may predispose some women to the disease
- Describe the pathophysiology of pre-eclampsia and eclampsia
- List maternal, community, and health service factors that influence the survival of women and their newborns
- List maternal and fetal complications associated with severe pre-eclampsia or eclampsia
Learning activities - Classroom
- List the factors that influence maternal and perinatal outcomes.
- Mark the factors that are avoidable or can be anticipated.
- State the steps that must be taken to prevent these avoidable factors, or to reduce the risk.
One example is provided for each category of factors.
Maternal factors
Predisposing factors / Avoidable? Yes / No / Steps to avoid occurrencePre-existing medical conditions / May be avoidable /
- Prevent pregnancy until condition is stable or avoid pregnancy
Community factors
Predisposing factors / Avoidable? Yes / No / Steps to avoid occurrenceLack of awareness about signs and symptoms of pre-eclampsia, severe pre-eclampsia and eclampsia and the importance of early and regular antenatal care / Yes /
- Good antenatal care
- Birth preparedness and complication readiness plans
- Community sensitization
Health service factors
Predisposing factors / Avoidable? Yes / No / Steps to avoid occurrenceInadequate availability and access to antenatal care / Yes /
- Political commitment to increase access to care
- Create alternatives to traditional health care system
Learning activities - Individual
Instructions: Complete the following phrases with the appropriate word or words.
1.In normal pregnancies:
- Blood volume ______
- Peripheral vascular resistance ______
- Progesterone induced arterial ______ occurs
- Fibrinogen is ______
- Factor XIII (fibrin stabilizing factor) is ______.
2.The following pathophysiologic changes are associated with pre-eclampsia and eclampsia:
- Blood pressure begins to ______ after 20 weeks of pregnancy
- Perfusion is ______ to virtually all organs,which is secondary to intense ______ due to an increased sensitivity of the vasculature to any pressor agent
- Perfusion to the kidneys is ______, resulting in sodium retention that leads to ______ of intravascular plasma volume,______ extracellular volume (edema) and increased ______ to pressor agents
- Loss of normal ______ of uterine arterioles results in decreased ______ perfusion
- ______ intravascular volume results in increased ______ of the blood and a corresponding rise in hematocrit, and activation of the ______.
3.The system of risk categorization, or the “risk approach,______ useful for predicting which women will suffer from pre-eclampsia.
4.Maternal and perinatal outcomes in pre-eclampsia depend on ______,______, and ______ factors.
5.The main causes of maternal death in eclampsia are:
- ______
- ______ complications
- ______ failure
- ______ failure
- failure of ______one organ.
Identifying pre-eclampsia
Summary of the session
During this session, you will review 1) screening for pre-eclampsia,2) diagnosing hypertensive disorders of pregnancy,and 3) the differential diagnosis of hypertensive disorders in pregnancy and the postpartum.
Learning objectives for the session
At the end of the session, participants will be able to:
- Describe routine screening for hypertensive disorders during pregnancy and the postpartum
- Correctly measure protein in the urine
- Correctly measure blood pressure
- Make a differential diagnosis of hypertensive disorders in pregnancy and the postpartum
- Test reflexes in women with elevated blood pressure
Job aid
Differential diagnosis of hypertensive disorders in pregnancy
Diagnosis / Diagnostic criteriaChronic hypertension / Diastolic BP 90 mm Hg or more prior to first 20 weeks of gestation
Preeclampsia superimposed on chronic hypertension /
- Women with chronic hypertension
- Any of the following are seen after 20 weeks’ gestation:
-Sudden increase in BP in a woman whose hypertension has previously been well controlled
-One or more adverse conditions associated with pre-eclampsia and/or eclampsia
Gestational hypertension /
- Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, no proteinuria.
- Postpartum:
-Chronic hypertension if the elevation persists beyond 12 weeks postpartum.
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 (fits), diastolic BP 110 mm Hg or more, proteinuria 2+ or more
Learning activities
Instructions: Complete the following phrases with the appropriate word or words.
- Methods to evaluate proteinuria include:
- ______
- ______
- ______
- ______
- Gestational hypertension is a ______diagnosis made ______ weeks post partum if diastolic blood pressure was greater than 90 mmHg but ______ was not present at the time of delivery and blood pressure returned to ______.
- BP readings are prone to inaccuracy due not only to observer error, but also to variability of blood pressure and to:
- ______
- ______
- ______
- ______
- When testing reflexes,it is the______of the response, not how______ the limb moves, that tells you if her reflexes are normal.
- When the pre-pregnancy BP is not known, the BP taken before ______ weeks is considered the woman's normal BP
- The measure of proteinuria is a ______ predictor of either maternal or fetal complications in women with pre-eclampsia.
- Although proteinuria is most commonly associated with pre-eclampsia or eclampsia, a woman's urine can test positive for protein if:
- ______
- ______
- ______
- ______
- Read the signs and symptoms in the first column and then write the diagnosis in the second column:
Diagnostic criteria / Diagnosis
Diastolic BP 110 mm Hg or more, proteinuria 3+ or more
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
Diastolic BP 90 mm Hg or more prior to first 20 weeks of gestation
Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart, proteinuria up to 2+
Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, no proteinuria
A pregnant woman or a woman who has recently given birth is found unconscious or having convulsions (fits), diastolic BP 110 mm Hg or more, proteinuria 2+ or more
Prevention of pre-eclampsia and/or eclampsia
Summary of the session
During this session, you will review interventions for 1) primary, 2) secondary, and 3) tertiary prevention of pre-eclampsia and/or eclampsia.
Learning objectives for the session
At the end of the session, participants will be able to:
- Define the different levels of prevention
- Describe evidence-based interventions to promote for primary prevention of pre-eclampsia/eclampsia
- Describe evidence-based interventions to promote for secondary prevention of pre-eclampsia/eclampsia
- Describe evidence-based interventions to promote for tertiary prevention of pre-eclampsia/eclampsia
Job aid