Powys Teaching Local Health Board
Directorate: Women and Children’s Service
Author: Lewis, Owen and Revell / Title: Guidelines for management of pre-eclampsia and eclampsia in the community
Code: PtHB/MAT 0022

Guidelines for management of pre-eclampsia and eclampsia in the community

Document
Code
/
Date
/ Version Number / Planned Review Date
PtHB Mat 0022 / Jan 2006
Jan 2012 / 1st Issue
2nd Issue / Jan 2015
Document Owner / Approved by / Date
Women and Children’s Directorate / Women’s and Children’s Directorate
Clinical Effectiveness committee / 29/03/2012
16/04/2012
Document Type / Guidelines

Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys

Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

Guidelines on the Management of Pre-eclampsia and eclampsia in the community

Contents / Page
Validation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Definitions / 5
Responsibilities / 5
Process / 5
References / 0
Appendices
Mental Health Screening Flow Chart / 10

For Reviewed / Updated Policies Only:

Relevant Changes – / Date
Revised to include updated guidance from NICE 2010 / Jan 2012

VALIDATION FORM

To be completed by the Author – no policy, procedure or guidance will be accepted without completion of this section which must remain part of the policy

Title: Guidelines for management of pre-eclampsia and eclampsia in the community
Author:Marie Lewis, Practice Development Midwife, Donna Owen, Lead Midwife North Powys, Denise Revell, Integrated Midwife
Directorate:Women and Children’s Service
Reviewed/Updated by: Marie Lewis, Practice Development Midwife, Donna Owen, Lead Midwife North Powys, Denise Revell, Integrated Midwife
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
If yes, please include below:
National Institute of Clinical Excellence (2010) Hypertension in pregnancy, the management of hypertensive disorders during pregnancy, NICE, London
Action on Pre-eclampsia (2011).
Consultation
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives
Supervisor of Midwives – Powys
Practice Development Midwife,
Lead Midwives
Agreed by Head of Midwifery / 20.12.2011
Agreed by Women and Childrens Directorate / 22.12.2011
Health Visitors and School Nursing team
Implications
Please state any training implications as a result of implementing the policy / procedure.
  • None.
Please state any resource implications associated with the implementation.
  • None
Please state any other implications which may arise from the implementation of this policy/procedure.
  • None

Equality Assessment StatementPlease complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all.

Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X / Woman focused midwifery policy
Race / X
Religion/ Belief / x
Sexual Orientation / X
Welsh Language / X
Human Rights / X
Are there any new or additional risks arising from the implementation of this policy?
None
Do you believe that they are adequately controlled?
N/A.

Risk Assessment

Guideline forthe Management of Gestational Hypertension, Pre-Eclampsia and Eclampsia inthe Community

Relevant to:

Local guideline for all midwives working in Powys.

Purpose

Hypertension is the most frequent medical condition in pregnancy, and pre-eclampsia is the most common of the serious complications in pregnancy. Pre-eclampsia occurs in approximately 10% of primigravida women, with severe pre-eclampsia affecting 1-2 women per 100 pregnancies (APEC 2005).Most hypertensive disorders that occur during pregnancy develop for the first time in the second half of pregnancy: new hypertension can occur without significant proteinuria [Gestational hypertension] or with significant proteinuria [pre-eclampsia] (NICE 2010). Pre-eclampsia and eclampsia remains the second highest cause of direct deaths in the UK. During the triennium 2006-2008, 107 women died as a direct cause of their pregnancy. (11.39 per 100,000 maternities) 19 of these women were as a direct result of pre-eclampsia or eclampsia (incidence 0.83 per 100,000 maternities)(CMACE 2011).

Sadly, a high proportion of the maternal deaths were associated with sub-standard care both in the hospital and the community. The main causes were from failure to identify the severity of the problem and prescribe appropriate antihypertensive drugs, along with delayed referral to a clinical specialist (CMACE 2011).

Hypertensive disorders carry a risk for the baby in terms of higher rates of Perinatal mortality, pre term birth and low birth weight [NICE 2010].

The following guidelines are based upon APEC (2004) Pre-eclampsia Community Guideline (PRECOG), and NICE (2010) The Management of Hypertensive Disorders during Pregnancy Guideline.

Responsibilities

The overall aim must be to ensure safe and effective care is provided to mother and baby.

Qualifications/Training

All midwives working in Powys hold a recognised midwifery qualification. No additional qualifications are required to carry out this policy.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the completion of Datix reporting form.

Process:

Reducing error in blood pressure measurement

  • Use accurate equipment (manual non mercury sphygmomanometer.)
  • Use sitting or semi-reclining position so that the arm to be used is at the level of the heart.
  • Do not take the blood pressure in the upper arm with the woman on her side as this will give falsely lower readings.
  • Use appropriate size of cuff: standard size (13x23cm) for an arm circumference of up to 33cm, a large size (33 x 15 cm) for an arm circumference between 33 and 41cm) and a thigh cuff (18x36cm) for an arm circumference of 41cm or more. There is less error introduced by using too large a cuff than by too small a cuff.
  • Deflate the cuff slowly, at a rate of 2 mmHg to 3 mmHg per second, taking at least 30 seconds to complete the whole deflation.
  • Use Korotkoff V (disappearance of heart sounds) for measurement of diastolic pressure, as this is subject to less intra-observer and inter-observer variation than Korotkoff IV (muffling of heart sounds) and seems to correlate best with intra-arterial pressure in pregnancy. In the 15% of pregnant women whose diastolic pressure falls to zero before the last sound is heard, then both phase IV and phase V readings should be recorded (e.g. 148/84/0 mmHg).
  • Measure to the nearest 2 mmHg to avoid digit preference.
  • Obtain an estimated systolic pressure by palpation, to avoid auscultatory gap.
  • If two readings are necessary, use the average of the readings and not just the lowest reading. This will minimize threshold avoidance (the tendency to repeat a reading until one that is below a known threshold is recorded that requires no action).

Definitions

Chronic hypertension: Hypertension present at booking visit or before 20 weeks, or that is being treated at time of referral to maternity services. Can be primary or secondary in aetiology.

Degrees of hypertension

  • Mild:Diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg.
  • Moderate:Diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg.
  • Severe:Diastolic blood pressure ≥ 110 mmHg, systolic blood pressure ≥ 160 mmHg.

Eclampsia: Convulsive condition associated with pre-eclampsia.

Gestational hypertension: New hypertension presenting after 20 weeks without significant proteinuria.

Pre-eclampsia: New hypertension presenting after 20 weeks with significant proteinuria.

Severe pre-eclampsia: Pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.

Identify the presence of any one of the following factors that may predispose a woman in a given pregnancy to pre-eclampsia. (NICE 2010)

MODERATE RISK FACTORS
First Pregnancy
Multiparous with:
  • ten years or more since last baby

Age 40 years or more
Body mass index of 35 or more
Family history of pre-eclampsia (in mother or sister)
Multiple pregnancy
HIGH RISK FACTORS
Hypertensive disease in any previous pregnancy
Certain underlying medical conditions:
  • pre-existing hypertension
  • pre-existing renal disease
  • pre-existing diabetes (Type 1 or 2)
  • Auto immune diseases e.g. antiphospholipid antibodies

In the event of two or more Moderate risk factors or one high risk factor for pre-eclampsia are present, offer referral to obstetric team for further investigation and clarification of risk.

Women with a moderate to high risk of pre-eclampsia should be offered an early referral to an obstetrician (prior to 12 weeks), and advised to commence 75mg aspirin daily from 12 weeks gestation until birth (NICE 2010).

All pregnant women should be aware that after 20 weeks gestation pre-eclampsia may develop between antenatal assessment, and that it is appropriate for them to self refer at any time. (PRECOG Recommendation 3b)

Signs and Symptoms

New hypertension.

New and/or significant proteinuria.

Headache and/or visual disturbance.

  • Severe pounding headache, partial loss of visual acuity, bright/ flashing visual disturbances. Migraines can continue during pregnancy and any migraine can be excruciating without being life threatening or associated with signs of pre-eclampsia.
  • A headache of sufficient severity to seek medical advice.

Epigastric pain and/or vomiting.

  • Epigastric pain, especially if severe or associated with vomiting. The most sinister epigastric pain is described by the sufferer as severe and is associated with definite tenderness to deep epigastric palpation (the woman winces)
  • new epigastric pain

Reduced fetal movements, small for gestational age infant.

Thresholds for Further Action

Description / Definition / Action by midwife
New hypertension without proteinuria after 20 weeks. / Diastolic BP 90 and < 100 mmHg / Refer to hospital assessment within 48 hours
Diastolic BP 90 and < 100 mmHg with significant symptoms / Refer for same day hospital assessment
Systolic BP 160 mmHg / Refer for same day hospital assessment
Diastolic BP 100 mmHg / Refer for same day hospital assessment
New hypertension and proteinuria after 20 weeks / Diastolic BP 90 mmHg and new proteinuria 1+ on dipstick / Refer for same day hospital assessment
Diastolic BP 100 mmHg and new proteinuria 1+ on dipstick / Immediate hospital admission
Systolic BP 170 mmHg and new proteinuria 1+ on dipstick / Immediate hospital admission
Diastolic BP 90 mmHg and new proteinuria 1+ on dipstick and significant symptoms / Immediate hospital admission
New proteinuria without hypertension after 20 weeks / 1+ on dipstick / Re-assess 1 week (visual testing on dip stick is adequate for community setting)
2+ or more on dipstick / Refer to hospital assessment within 48 hours
Automated reading of proteinuria is recommended in a secondary care setting (NICE 2010)
1+ on dipstick with significant symptoms / Refer for same day hospital assessment
Maternal symptoms or fetal signs and symptoms without new hypertension or proteinuria / Headache and or visual disturbances with diastolic BP < 90 mmHg and a trace or no protein / Follow local protocols for investigation.
Consider reducing interval before next visit.
Epigastric pain with diastolic BP < 90 mmHg and a trace or no protein / Refer for same day hospital assessment
Reduced movements or small for gestational age infant with diastolic BP < than 90 mmHg and a trace or no protein / Refer for same day hospital assessment

Management of Women with Gestational Hypertension (NICE Guidelines 2010)

Women should be offered an integrated care package covering admission to hospital, measurement of blood pressure, testing for proteinuria and blood tests as indicated on the table below.

Degree of Hypertension / Mild Hypertension
(140/90 to
149/99 mmHg) / Moderate Hypertension
(150/100 to
159/109 mmHg) / Severe Hypertension
(160/110 mmHg or higher)
Admit To Hospital / No / No / Yes (until blood pressure is 159/109 mmHg or lower)
Treat / NO / With oral labetalol asfirst-line treatment to
keep:
• diastolic blood
pressure between
80–100 mmHg
• systolic blood
pressure less than 150 mmHg / With oral labetalol as first-line treatment to
keep:
• diastolic blood
pressure between 80–
100 mmHg
• systolic blood pressure
less than 150 mmHg
Measure Blood Pressure / Not more than once a week / At least twice a week / At least four times a day
Test for Proteinuria / At each visit using
automated reagent strip
reading device or
urinary
protein : creatinine ratio / At each visit using
automated reagent-strip
reading device or
urinary
protein : creatinine ratio / Daily using automated
reagent-strip reading device or urinary protein : creatinine ratio
Blood Test / Only those for routine antenatal care / Test kidney function,
electrolytes, full blood
count, transaminases,
bilirubin
Do not carry out further
blood tests if no
proteinuria at
subsequent visits / Test at presentation and then monitor weekly:
• kidney function,
electrolytes, full blood
count, transaminases, bilirubin

IN CASE OF ECLAMPTIC FIT

  • Call for help.
  • Gently turn the woman on to her left side.
  • Clear and maintain airway.
  • Administer oxygen once airways are clear and breathing restarts.
  • Insert No. 2 airway as soon as jaw muscle begins to relax.
  • Continue to take and record vital signs as above.
  • If possible, insert one or two grey Venflons (16 g) in readiness for IV drug therapy at DGH. DO NOT give IV fluids.
  • GP (if present)or paramedic to administer drugs if appropriately trained.
  • Liaise with nearest DGH for transfer using SBAR form
  • Transfer by blue light to DGH as soon as possible.
  • Maternity records/Transfer SBAR form to be completed as accurately as possible and sent with the transferring midwife. Include copy of this Policy with Maternity Records labelled with mother’s details signed and dated by midwife to support documentation of the actions taken.
  • Complete Datix form.
  • Inform Supervisor of Midwives (using SBAR).

Postnatal Care

In women with hypertensive disorders in pregnancy who have given birth, measure blood pressure:

As per DGH management plan or at least:

•daily for the first 2 days after birth

•at least once between day 3 and day 5 after birth

•as clinically indicated if antihypertensive treatment is changed after birth.

•Women should be encouraged to attend for a six-eight week postnatal assessment with their GP.

For women with gestational hypertension who did not take antihypertensive treatment and have given birth refer to GP if their blood pressure is higher than 149/99 mmHg.

If women are breastfeeding, assess clinical well being of baby, especially adequacy of feeding, at least daily for the first two days after birth. Also, offer women advice on safety of drugs for babies receiving breast milk. (No identified risks associated with women taking labetalol, nifedipine, enalapril, captopril, atenolol, and metoprolol)

Remember to write management plan in postnatal notes to include:

•Frequency of blood pressure monitoring.

•Indications for medical review of blood pressure.

•Who will provide follow-up care on discharge from maternity services.

•Discussion around long term health risks including further hypertension, cardiac disease, risk of cardiovascular accident (CVA) and thromboembolism.

•Advice regarding keeping body mass index (BMI) between 18.5-24.9kg/m.

Also refer to the following Policies:-

  • Antenatal Care
  • Postnatal care
  • Assistance in an Emergency
  • All Wales Birth Centre Guidelines
  • Cardio Pulmonary Resuscitation

References

APEC (2004) Pre-eclampsia community guideline, APEC: London.

CMACE (2011) Saving Mothers’ Lives, Reviewing maternal deaths to make motherhood safer: 2006-2008, The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.

National Institute of Clinical Excellence (2010) Hypertension in pregnancy, the management of hypertensive disorders during pregnancy, NICE, London

Action on Pre-eclampsia (2011).

Issue Date: 2006
Status: Final / Page 1 of 12 / Review Date: 2015
Approved by: