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Suggested citation: MCHIP. Prevention of eclampsia: A Reference Manual for Health Care Providers. Baltimore: Jhpiego; 2011.
Prevention and management of pre-eclampsia and eclampsia
A Reference Manual for Health Care Providers
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.
Table of contents
Introduction 1
Understanding pre-eclampsia and eclampsia 5
Pathophysiology 5
Epidemiology of pre-eclampsia and eclampsia 6
Factors influencing maternal and perinatal outcomes 7
Morbidity and mortality associated with pre-eclampsia and eclampsia 8
Identifying pre-eclampsia 11
Introduction 11
Definition 11
Screening 12
Detecting hypertensive disorders in pregnancy 16
Prevention of pre-eclampsia and/or eclampsia 21
Primary prevention of pre-eclampsia 21
Secondary prevention (screening and detection) 22
Tertiary prevention (management of severe pre-eclampsia and eclampsia) 23
Overview of interventions to prevent pre-eclampsia and eclampsia 27
Management of pre-eclampsia and eclampsia 29
Introduction 29
Gestational hypertension 29
Mild pre-eclampsia - Gestation less than 37 weeks 30
Mild pre-eclampsia - Gestation of 37 complete weeks or more 31
Severe pre-eclampsia and eclampsia 31
Postpartum care 38
Referral for tertiary level care 39
Management during a convulsion / fit 41
Stages of an eclamptic fit 41
Management during a convulsion 42
Differential diagnosis of convulsions 43
Birth preparedness and complication readiness 46
Birth-preparedness plan 46
Complication-readiness plan 47
References 50
Acknowledgements
Susheela Engelbrecht led development of the learning materials, with technical assistance and feedback from members of the MCHIP Training and Quality Assurance Task Force, one of the five Task Forces formed under the Pre-Eclampsia/Eclampsia Technical Working Group. Members of the task force include Patricia Gomez, Diane Sawchuck, Peter von Dadelszen, Abdelhadi Eltahir, Frances Ganges, Ann Davenport, Deborah Armbruster, Nahed Matta, Jeffrey Smith, Annette Briley, and Bridget Lynch. The writing team is grateful to Ahmet Metin Gulmezoglu for review of this draft.
About MCHIP
Acronyms
BPP / 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
MDG / Millennium Development Goals
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 eclampsia v
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Reference manual /Introduction
Efforts such as the Safe Motherhood Initiative and the World Health Organization (WHO) Making Pregnancy Safer Division and strategies to meet the United Nations Millennium Development Goals (MDG) are supporting worldwide activities to reduce maternal and newborn mortality. Despite these efforts, hundreds of thousands of women and babies die or become disabled due to complications of pregnancy and childbirth every year (WHO, 1994).
Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major causes are severe bleeding (mostly postpartum hemorrhage), infections (also mostly in the immediate postpartum), hypertensive disorders in pregnancy (eclampsia), and obstructed labor. New estimates show that the leading causes of maternal deaths are hemorrhage and hypertension, which together account for more than half of maternal deaths (figure xx) (WHO and UNICEF, 2010). Indirect causes, which include deaths due to conditions such as malaria, HIV/AIDS and cardiac diseases, account for about one fifth of maternal deaths. Regional estimates show that hemorrhage and hypertension are among the top three causes of deaths in both South Asia and Sub-Saharan Africa, where the majority of maternal deaths occur (WHO and UNICEF, 2010). Pre-eclampsia and eclampsia may also occur in the immediate post-partum period and is referred to as "postpartum pre-eclampsia." The most dangerous time for the woman is the 24–48 hours postpartum and careful attention should be paid to pre-eclampsia signs and symptoms (Manjuluri et al, 2005).
Figure xx. Global estimates of the causes of maternal deaths, 1997-2007
Ten percent of all pregnancies are complicated by hypertension (HTN) (Craici et al, 2008). Pre-eclampsia and eclampsia account for about half of these cases worldwide and have been recognized and described for years despite the general lack of understanding of the disease (Roberts et al, 2001). The fetal mortality rate associated with pre-eclampsia and eclampsia varies from 13-30%, primarily due to premature delivery and its complications (Gabbe, 2007). Placental infarcts, abruptio placentae, and intrauterine growth restriction also contribute to fetal demise (Gabbe, 2007). Maternal death risk associated with pre-eclampsia and eclampsia is approximately 1.8%, inhigh resource settings, and up to 14% in settings with low resources and lack of facilities required for supportive management.Higher mortality rates are associated with women who have multiple convulsions/fits outside the hospital and those without antenatal care (Rivers, 1996).
Fortunately, simple, low-cost interventions are available to prevent most cases of eclampsia and to manage them when they occur. Providers at all levels must be able to identify pre-eclampsia and eclampsia and know how to respond. Timely diagnosis and effective initial management can reduce morbidity and the risk of maternal, fetal, and newborns deaths associated with severe pre-eclampsia and eclampsia. Once providers identify pre-eclampsia and eclampsia, they must be competent to provide effective initial management and ensure timely referral for cases that cannot be managed at their facility level.
To facilitate access to important maternal technologies, countries must have the political will and ensure that the following are in place:
§ National guidelines that reflect state-of-the-art and evidence-based interventions for prevention, identification and management of pre-eclampsia and eclampsia
§ Policies that promote access to important technologies for prevention, identification and management of pre-eclampsia and eclampsia at all levels along the continuum of care
§ Training infrastructure that promotes pre-service education and periodic updates and refresher training for all health workers in prevention, identification and management of pre-eclampsia and eclampsia at all levels along the continuum of care
§ Service delivery systems that ensure quality and promptness of response for women with severe pre-eclampsia/ eclampsia
§ Logistics systems that ensure availability of necessary resources (equipment, supplies, medications - magnesium sulphate and calcium gluconate) and consumables for infection prevention and injection safety
§ Supervision and monitoring systems that assure quality and ensure transfer of learning to the work site
§ A service delivery model that promotes education and knowledge sharing with women, families and communities about the risks, signs and symptoms, and how to respond when the woman presents with signs or symptoms of pre-eclampsia and eclampsia
§ Links between communities and health care facilities that ensure that the woman receives timely and appropriate care
Ongoing research in various settings continues to identify the best approaches for preventing and managing eclampsia and its complications. By developing national guidelines, training health care providers, improving work environments, and supporting the development of improved access to care, more women will have access to life-saving interventions that reduce morbidity and mortality associated with pre-eclampsia and eclampsia.
About the learning materials
MCHIP developed a learning package on the prevention and management of pre-eclampsia and eclampsia consisting of a reference manual, participant’s notebook, and facilitator’s guide. This learning package was developed for use by clinical health workers, nurses, midwives, and physicians providing care during pregnancy, childbirth and the postpartum.
These documents comprise a set and should be used together. These resources are distinguished within the series by a corresponding icon located at the top of the right hand page:
Reference manual /Facilitator’s guide /
Participant’s notebook /
This course is designed to be utilized for in-service training, with the overall objective of providing updates about prevention and management of pre-eclampsia and eclampsia use to equip nurses, midwives, physicians, trainers and clinical health workers to carry out the following:
§ Provide safe, respectful, culturally sensitive, and friendly care to women, newborns, and their families. Women and families will then be more likely to utilize the health care system with confidence because they know they will receive competent, compassionate care.
§ Follow an evidence-based protocol for prevention, identification, and management of pre-eclampsia and eclampsia, including clear guidelines on when to refer women with complications, ensuring timely action is taken.
§ Provide greater protection from infection for their clients and exercise of universal precautions for themselves.
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Understanding pre-eclampsia and eclampsia
Pathophysiology
Cause
Pre-eclampsia is a pregnancy-specific syndrome, recognized, even by Hippocrates, as a leading cause of maternal and perinatal mortality. The condition’s former name, “toxemia of pregnancy,” was based on a theory that a toxin produced in a pregnant woman’s body caused the disease. The cause of pre-eclampsia and eclampsia remains unknown, though experts have proposed multiple theories to explain their cause, resulting in confusion and myths surrounding both etiology and management. Themain etiologic theories includeabnormal trophoblastic invasion, coagulation abnormalities, vascular endothelial damage, cardiovascular maladaptation, immunologic phenomena, genetic predisposition, and dietary deficiencies or excess (Craici et al, 2008).
Pathophysiologic changes
In normal pregnancies, blood volume increases 30 to 50%, peripheral vascular resistance decreases, progesterone induced arterial dilatation occurs, fibrinogen is increased, and factor XIII (fibrin stabilizing factor) is decreased. The following pathophysiologic changes are associated with pre-eclampsia and eclampsia:
· Blood pressure begins to rise after 20 weeks of pregnancy
· Perfusion is decreased to virtually all organs, which is secondary to intense vasospasm due to an increased sensitivity of the vasculature to any pressor agent
· Perfusion to the kidneys is decreased, resulting in sodium retention that leads to loss of intravascular plasma volume, increased extracellular volume (edema) and increased sensitivity to pressor agents
· Loss of normal vasodilation of uterine arterioles results in decreased placental perfusion
· Decreased intravascular volume results in increased viscosity of the blood and a corresponding rise in hematocrit, and activation of the coagulation cascade, especially platelets, with microthrombi formation
· 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.
Disease progression
Pre-eclampsia and eclampsia are part of the same disorder with eclampsia being the severe form of the syndrome. Gestational hypertension may progress from a mild hypertensive disorder to a life-threatening condition, as follows:
· hypertension without proteinuria or edema
· mild pre-eclampsia
· severe pre-eclampsia
· eclampsia
While pre-eclampsia is usually a progressive disease, the rate of progression and the occurrence of catastrophic complications such as eclampsia, cerebrovascular accident, severe HELLP syndrome, pulmonary edema or renal failure are difficult to predict. In some cases, mild pre-eclampsia sometimes progresses to severe pre-eclampsia and eclampsia very suddenly with little or no warning. In other cases, hypertension or proteinuria are absent when a woman begins having eclamptic convulsions/fits. Eclampsia can occur during the antepartum, intrapartum, and postpartum periods; and ninety percent ofeclampsia cases occur after 28 weeks' gestation (Gabbe, 2007).
HELLP syndrome is a group of symptoms that occur in pregnant women who have:
· H -- hemolysis
· EL -- elevated liver enzymes
· LP -- low platelet count
HELLP syndrome occurs in approximately 10% of pregnant women with pre-eclampsia or eclampsia. Many women have high blood pressure and are diagnosed with pre-eclampsia before they develop HELLP syndrome. However, in some cases, HELLP symptoms are the first warning of pre-eclampsia and the condition is misdiagnosed as hepatitis, gallbladder disease, idiopathic thrombocytopenic purpura, or thrombotic thrombocytopenic purpura.
The exact cause of HELLP is unknown, but general activation of the coagulation cascade is considered the main underlying problem. Fibrin forms cross-linked networks in the small blood vessels. This leads to a 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 ischemia, leading to periportal necrosis. Other organs can be similarly affected. HELLP syndrome leads to a variant form of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding, which can make emergency surgery a serious challenge.
Symptoms include:
· Headache
· Nausea and vomiting that continues to get worse
· Upper abdominal pain / upper abdominal tenderness on palpation
· Vision problems
The woman's liver may hemorrhage and permanent liver damage may occur if delivery is delayed. Such damage can lead to death. Up to thirty-five percent of women with HELLP die. The death rate among babies born to mothers with HELLP syndrome varies and depends on birth weight and the development of the baby's organs, especially the lungs.