1. Pre-eclampsia: diagnosis and management An e-learning course for for midwives and health professionals

2. E-learning course objectives
On completion of the course, you will have a clear understanding of the following:
The definition of pre-eclampsia, and where it fits with other manifestations of hypertension in pregnancy
A brief history of the condition
Who is most at risk
How to spot early symptoms and enable a timely diagnosis
How to provide effective immediate and long term medical and emotional support
Where you can access information, help and support as a healthcare professional
Outcomes for you as a health professional:
Increased knowledge and greater confidence in dealing with pre-eclampsia.

3. Assessment
At the end of the module there will be a test on the subjects covered.
A pass mark of 75% or more is required in order for you to be accredited with a certificate from Action on Pre-eclampsia (APEC).

4. Pre-eclampsia: definition
Pre-eclampsia is defined by NICE (2010) as:
‘New hypertension presenting after 20 weeks
with significant proteinuria’.

5. Pre-eclampsia: other useful definitions to consider
Chronic hypertension:
‘Hypertension present at the booking visit or
before 20 weeks, or being treated at
the time of referral to the maternity services’
Gestational hypertension:
‘ New hypertension presenting after 20
weeks without significant proteinuria’
National Institute for Health and
Clinical Excellence (NICE) (2010)

6. A short history of eclampsia and pre-eclampsia
220BC: First references to eclampsia were found in ancient Egypt
1843: Association of fits with protein in the urine was made by Lever. Eclampsia described by Victorian doctors as ‘toxaemia of pregnancy’, still occasionally referred to as pre-eclampsia toxaemia (PET) today
1872: A survey found 25% of maternal deaths were due to eclampsia. Doctors began to use induction of labour to ‘cure’ eclampsia
Early 20th C: Caesarean section was used to deliver babies early to prevent maternal deaths, but midwives had little, if any, training on the condition.

7. A 1950’s experience A 1950’s account of eclampsia and pre-eclampsia
“Margaret was admitted in the sixth month of her pregnancy. …She was deeply unconscious on admission, her blood pressure was 200/190, heart rate 140 bpm. So heavy was the deposit of protein that upon boiling the urine turned solid like egg white. The baby was dead on delivery (by caesarean section).
Margaret never regained consciousness. She was kept under heavy sedation in the darkened room, she had repeated convulsions that were terrifying to see. A slight twitching was followed by vigorous contractions of all the muscles of the body. Her whole body became rigid, and the muscular spasm bent her body backwards, so that for about twenty seconds only her feet and head rested on the bed. Respiration ceased, she became blue with asphyxia. Quite quickly the rigidity passed followed by violent movements and spasm of all her limbs…With violent movements of the jaw she bit her tongue to pieces. She salivated profusely and foamed at the mouth….”
Extract from ‘Call the midwife’ by Jennifer Worth

8. What has changed since then?
The birth of the NHS after the second world war, the advent of routine antenatal care and advances in medicine have radically improved the outlook for women with pre-eclampsia in recent decades
Studies have shown that from the 1930’s to the 1980’s the incidence of eclampsia fell by almost 90%
However, pre-eclampsia still remains a significant cause of maternal and infant death in the UK and the developing world
Pre-eclampsia and eclampsia have been found to be the second most common cause of maternal death in the UK
From women died from
pre-eclampsia in the UK. (CMACE 2011)
Of these deaths 20 demonstrated substandard
care; in 14 of these deaths this was classed as
major – these were avoidable deaths.

9. Who may be at risk?
One or more of the following features warrants close attention:
Extremes of maternal age – teenagers and women over 40
First pregnancy
Interval of more than 10 years since last pregnancy
Body mass index (BMI) of more than 35
Family history of pre-eclampsia
Multiple pregnancies
Pregnancies conceived through assisted reproduction techniques
Women with a history of previous pre-eclampsia
Women with a history of chronic renal disease
Women with a history of diabetes mellitus
Women with a history of antiphospholipid antibodies
Women with pre-pregnancy hypertension
REMEMBER some women will have no risk factors and will have been fit and well in early pregnancy, but still develop pre-eclampsia.

10. Signs/symptoms
Pre-eclampsia can be symptomless but presents itself with the following signs:
Hypertension
Proteinuria
Women may also experience the following symptoms:
Headache
Visual disturbances (described as light in front of
the eyes)
Nausea and vomiting
Oedema, particularly rapid onset oedema of the hands or feet (and associated weight gain – water is very heavy)
General malaise, sometimes accompanied by a feeling of unease
Reduced or absent fetal movement

11. Antenatal screening for pre-eclampsia
Regular antenatal check-ups are the best way to screen all women for the signs and symptoms of pre-eclampsia. Ensuring all women know about symptoms and who to contact if they are worried in between appointments, is an important self-help aspect of this screening
Accurate measurements of BP and checks for proteinuria must be taken at every appointment. Always listen to any concerns the woman expresses
Antenatal check ups should occur every three weeks from 20 weeks to 34 weeks; then every two weeks from 34 weeks onwards (see NICE Antenatal Care Guideline 2008 for further details).

12. Antenatal screening for pre-eclampsia
At the first antenatal visit all women should be assessed for their risk factors for pre-eclampsia, preferably using the PRECOG (2004) Guideline
A small proportion of women will have hypertension before they become pregnant (chronic hypertension) - these are more likely to develop pre- eclampsia
Others will have hypertension diagnosed in the first trimester when it is not thought to be due to the pregnancy
Screening for pre-eclampsia should start at the booking visit and continue at every subsequent antenatal appointment. Although pre-eclampsia does not occur in the first half of pregnancy, these initial readings give the baseline for all future recordings and are vital for later accurate diagnosis
Blood pressure and urine analysis results should recorded accurately – do not ‘round up’ BP readings, i.e. if it is 122/73 record it as such.

13. Changes in blood pressure could be a vital sign something is wrong…
Hypertensive disorders in pregnancy (including pre- eclampsia) can affect % of all pregnancies
Hypertensive disorders cause 1 in 50 stillbirths and 10% of all preterm births

14. What is pregnancy induced hypertension?
This is a term which incorporates both gestational hypertension and pre-eclampsia. It is useful to consider each woman’s diagnosis under this heading before a final diagnosis of one or the other can be made, usually through serial urine and blood tests.
REMEMBER gestational hypertension can develop into pre- eclampsia, but once a woman has pre-eclampsia it will not resolve until the baby is born.
Both of these conditions require careful monitoring as women are at risk of:
Cerebral haemorrhage
Intra-uterine growth restriction (IUGR)

15. So, regarding hypertension, what is abnormal?
Mild Hypertension
Systolic blood pressure mm Hg
Diastolic blood pressure mm Hg
Moderate Hypertension
Systolic blood pressure mm Hg
Diastolic blood pressure mm Hg
Severe Hypertension
Systolic blood pressure 160 mm Hg or higher
Diastolic blood pressure greater than 110 mm Hg
(NICE 2010)

16. Talking with women about pre-eclampsia
It is important to ensure the following:
The woman is given information about pre-eclampsia and time to discuss it, to help her understand the condition
She knows that she has not caused her pre-eclampsia, and by the same token there is nothing she can do to alter the outcome
She is aware of the importance of controlling the symptoms of pre-eclampsia
She understands the criteria as to why an early delivery might achieve the best outcome for mother and baby
If the baby may be born preterm or unwell, that she meets the neonatal team and has a good understanding about what will happen at delivery and what to expect on the neonatal unit.

17. Coping with the emotional aspects of pre-eclampsia
The diagnosis of any medical condition can precipitate a whole cascade of emotions in the woman and in her family.
Common themes to be aware of:
Grief
Anger
Fear
Uncertainty
Guilt

18. Diagnosis of pre-eclampsia
New hypertension (140/90 or above) presenting after the 20th* week of pregnancy with:
300mg or more of protein in a 24 hour urine collection
(equivalent to +++ protein on a dipstick) OR
more than 30mg/mmol in a spot urinary protein:
creatinine sample

19. When is severe pre-eclampsia diagnosed?
Pre-eclampsia (as described in previous slide) with one or more of the following:
severe hypertension (160/110 or above)
headache
epigastric pain
visual disturbances
abnormal blood results.

20. What are the risks of severe pre-eclampsia to mother and baby?
The mother is at risk of:
Eclampsia (seizures)
Cerebral haemorrhage
Placental abruption
Renal failure
Pulmonary oedema, acute respiratory failure
Disseminated intravascular coagulopathy – failure of clotting system
HELLP syndrome, liver haemorrhage and rupture
Thromboembolism – blood clots
The baby is at risk of:
Intrauterine growth restriction
Intrauterine death
Prematurity as a result of an early delivery to manage pre-eclampsia

21. When pre-eclampsia becomes eclampsia…
Eclampsia is an obstetric emergency!
Defined by NICE (2010) as
‘A convulsive condition associated with pre-eclampsia’.
It occurs in 1-2% of pre-eclamptic pregnancies
Beware: It may occur as the initial presentation without hypertension and proteinuria
Fits can occur:
Antenatally (38%)
Intrapartum (18%)
Postnatally (44%)

22. What is HELLP syndrome?
HELLP syndrome is a serious complication of pre-eclampsia.
The term "HELLP" is an abbreviation of the three main features of the syndrome:
H haemolysis – destruction of red blood cells
EL elevated liver enzymes
LP low platelets
It is estimated to occur in 5-20% of pre-eclamptic
pregnancies (Collins et al 2008)

23. Can anything be done to prevent pre-eclampsia?
There are some medications that have been shown to help reduce the risk of pre- eclampsia.
These include:
Low-dose aspirin
Calcium supplements
Women at high risk of developing pre-eclampsia should be referred to an obstetrician specialising in medical problems in pregnancy. They should be given low dose (75mgs per day) of Aspirin from the 12th week of pregnancy or earlier if possible. These are available over the counter at pharmacies, but it is important that women understand that the advised dosage for pregnancy should not be exceeded. A pre-eclampsia specialist may also advocate calcium supplements and advise on dosage.

24. Is there a cure for pre-eclampsia?
Unfortunately the only ‘cure’ for pre-eclampsia is to deliver the baby and placenta. However, there are many things health professionals can and should do when caring for all pregnant women:
Health professionals can screen women for the risk factors
They can monitor blood pressure and urine for the signs of the disease
They can manage symptoms such as high blood pressure when it occurs
Once pre-eclampsia has been diagnosed, the aim of management is to control the symptoms of the disease and plan for safe delivery of the baby
Providing information, psychological support and listening to women can help to reduce the emotional impact during and after pregnancy.

25. Medical management following a diagnosis
The aim of management of pre-eclampsia is to:
Monitor blood pressure, urine, and biochemical markers through blood tests
Control potentially dangerous hypertension with medication
Ensure regular monitoring of the fetus and placenta with cardiotocography (CTG) and ultrasound
Plan for a safe delivery.
Depending on severity, pre-eclampsia can be
managed as:
An in-patient on the antenatal ward
An emergency on the labour ward

26. Examination of women with pre-eclampsia
On examining a pregnant woman, the doctor will be looking at the following:
What the woman is saying – how she feels, whether she has a headache, visual disturbances or any vaginal bleeding suggestive of placental abruption
General appearance – facial oedema and jaundice
Blood pressure, pulse, general oedema, result of urine analysis
Respiratory system – fine inspiratory crepitations which may indicate pulmonary oedema
Abdominal examination – right upper quadrant pain, or epigastric tenderness, symphysis-fundal height, fetal presentation, liquor volume and fetal heart beat
Neurological examination – pre-eclamptic women can have brisker than usual reflexes.

27. Tests for pre-eclampsia
For the mother:
Urine dipstick to look for protein (an automated reading is more accurate)
Protein:creatine ratio or 24-hour urine collection to quantify the amount of protein in the urine
Full blood count, urea and electrolytes, liver function tests and uric acid
For the baby:
Cardiotocograph
Ultrasound scan to assess:
fetal growth
liquor volume
umbilical artery and Doppler flow velocity

28. Understanding the blood tests
Full blood count (FBC)
Haemoglobin – should be a good level for safe delivery; also a low level can indicate HELLP syndrome.
Platelets – a low level or rapid fall in platelets may indicate the development of HELLP syndrome
Urea, electrolytes and uric acid (U and E’s)
Raised amounts of waste products such as creatine, urea and uric acid in the blood are evidence that the kidneys are being affected by pre-eclampsia.
Liver Function (LFT)
Rising Alanine amniotranferase (ALT) or aspartate aminotransferease (AST) are features of HELLP syndrome and suggest liver involvement

29. Understanding the urine tests
These are performed to quantify the amount of protein in the urine:
Protein : creatinine ratio
Abnormal if this is a ratio of more than 30mg/mmol
24 hour urine collection
Abnormal if there is more than 300mg of protein over 24 hours

30. Management of Pre-eclampsia (1)
Mild hypertension
(BP 140/ /99 mmHg)
Perform initial assessment and tests
Refer to obstetric care
Admit to hospital
Measure blood pressure four times a day
Monitor kidney function, electrolytes, full blood
count and liver function twice a week
Thromboprophylaxis – TED stockings and blood thinners
Regular cardiotocography (CTGs )

31. Management of Pre-eclampsia (2)
Moderate hypertension
(BP 150/100 to 159/109 mmHg)
Management is the same as for mild hypertension and also:
Treat hypertension with oral Labetalol and aim to keep blood pressure between /<150 mmHg
Monitor bloods: FBC, U and E, LFTs three times a week

32. Management of Pre-eclampsia (3)
Severe hypertension
(BP > 160/110 mmHg)
The aim is to treat the hypertension and reduce the risk of eclamptic seizures.
Perform assessment and tests as for mild and moderate pre-eclampsia
Blood should be taken for cross matching if delivery is anticipated
Treat blood pressure - aim for diastolic mmHg and systolic <150 mmHg
Strict fluid balance all intake and output should be recorded
Monitor BP according to the clinical situation
Manage on labour ward or high dependency unit
These women need one-to -one care in a consultant led team

33. Controlling high blood pressure in severe pre-eclampsia
Intravenous medication can be used if oral anti-hypertensives are not controlling blood pressure
These medications include:
- Labetalol
- Hydralazine
These are normally administered by a
doctor
The incidence of eclamptic fits can be
reduced with an intravenous infusion
of maganesium sulphate

34. Why do women with pre-eclampsia sometimes have to be delivered early?
Maternal indications
Severe hypertension which is unresponsive to medication
Deteriorating kidney function indicated by low urine output, raised urea and creatinine
Falling platelet count
Rising or profoundly elevated liver function tests ALT and AST
Persistent symptoms

35. Why do some babies need to be delivered early because of pre-eclampsia?
Evidence of intrauterine growth restriction on ultrasound
Suspected fetal distress identified on CTG
Threat to maternal survival if pregnancy allowed to continue.

36. Managing problems with babies who need to be delivered before 34 weeks
Babies’ lungs aren’t fully matured before 34 weeks of pregnancy
Antenatal steroids can be given to the mother to help develop the baby’s lungs should they need to be delivered before 34 weeks
It is important to arrange for the neonatal team to meet with the parents before the birth to discuss the prognosis and potential problems that may be faced by a baby who has to be born early
Occasionally women with severe pre-eclampsia may need to be transferred to a hospital with available cots on the neonatal unit

37. Method of delivery This depends on: Severity of the pre-eclampsia
Gestation of the pregnancy
The woman’s previous obstetric
history

38. Management of pre-eclampsia in labour
Keep the woman informed and as involved in decision-making as possible, aiming to reduce stress and anxiety
Regular blood pressure monitoring
Women should continue anti-hypertensive medication in labour
A magnesium sulphate infusion may be needed to protect against eclampic fits
Continuous CTG monitoring
Fluid balance should be strictly monitored and intake may need to be limited
Intravenous access
Active management of the third stage with intramuscular syntocinon and/or Syntocinon infusion to prevent postpartum haemorrhage
Ergometrine/Syntometrine should be avoided as these can increase blood pressure
Don’t forget the birth partner, who will benefit from good communication too.

39. Eclampsia Always manage eclampsia as an obstetric emergency
You should be familiar with your labour ward’s eclampsia drill
Immediate action:
Call for help
Ensure woman is safe and put into left lateral position
Assess airway, breathing and circulation – resuscitate as necessary
Multi-disciplinary management by doctors, midwives and anaesthetic team aims to:
- stabilise the condition – bring down blood pressure, start magnesium sulphate
- assess maternal condition – catheterise, send bloods
- if eclampsia occurs prior to delivery assess fetal condition and plan for delivery

40. Postnatal care
Some women may need to continue to take anti-hypertensive medication
All women should have their blood pressure checked between day 3 and 5
Women who still have hypertension and/or proteinuria at the six-week check should be referred for further investigation
All women with gestational hypertension and pre-eclampsia should be told that they have an increased risk of these conditions occurring in future pregnancies
They should also be told that they are at increased risk of developing high blood pressure later on in life.

41. What midwives and doctors can provide following pre-eclampsia
Women who have had pre-eclampsia want to know:
“Will I get it again?”
“How will I be looked after in my next pregnancy?”
“Where can I find support now and in the future?”

42. Providing emotional support for women is as important as medical support.
Grief may be as simple as mourning the loss of a chance to have a home birth or as complicated as mourning the death of a much wanted baby.
Anger can be directed outwards at the medical staff or inwards at the woman herself who may feel guilty that she has some how caused her condition.
It is very hard to give women with pre- eclampsia any certainties, and this can led to fear and anxiety.

43. Practical advice and guidance for women after pre-eclampsia
All women should be offered a de-briefing session with a senior doctor after a pregnancy complicated by severe pre-eclampsia
They should be given an estimated risk of recurrence of pre-eclampsia. The statistics are laid out in the NICE (2010) Hypertension in pregnancy guidance
They should be given a plan as to how their antenatal care will be managed during their next pregnancy
They should be given information about where to get immediate and ongoing emotional support.

44. About Action on Pre-Eclampsia (APEC)
APEC is a UK based charity that aims to:
Educate, inform and advise the public and health professionals about the prevalence, nature and risks of pre-eclampsia
Campaign for greater public awareness of the disease and for action to improve methods of detection and treatment
Support affected women and their families
Promote research into the causes of the disease and the development of appropriate screening techniques and treatment methods
Provide information about pre-eclampsia to pregnant women, affected families and health professionals involved in maternity care
Provide professional education about pre-eclampsia with a programme of conferences and study days.

45. Sources of information and support
Action on Pre-Eclampsia (APEC) Bliss Helpline on , information leaflets, Premature and sick babies Expert referral service, study days for midwives. Tommy’s Pregnancy and birth problems www. tommys.org Sands Stillbirth & neonatal deaths www. uk-sands.org

46. References
Centre for Maternal and Child Enquiries (CMACE) (2011) Saving mothers lives. BJOG Suppl 1 Chamberlain G (2007) From Witchcraft to Wisdom, a history of Obstetrics and Gynaecology in the British Isles. London: RCOG Press. Collins S, Arulkumaran S et al. (2008) Oxford handbook of Obsetrics and Gynaecology., Oxford University Press. Leitch C R, Cameron A D , Walker J J (2005) The changing pattern of eclampsia over a 60-year period. BJOG 104: Nelson-Piercy C (2007), A handbook of Obstetric Medicine. London: Taylor Francis. NICE (2008) Antenatal Care NICE (2010) Hypertension in pregnancy. Pre-eclampsia Community Guideline (PRECOG) 2004 Available at Redman C, Walker I (1992), Pre-eclampsia - the facts. Oxford: Oxford University Press. Worth J (2002) Call the midwife: A true story of the East End in the 1950’s. London: Orion.

47. Further reading
Bewley C (2010) Hypertensive disorders of pregnancy. In Macdonald S and Magill- Cuerden J (Editors), Mayes Midwifery. London: Bailliere Tindall
Bothamley J, Boyle M (2009). The renal system, hypertension and pre-eclampsia. In Medical conditions affecting pregnancy and childbirth, Radcliffe Publishing,
Boyle M, McDonald S (2011) Pre-eclampsia and eclampsia. In Emergencies around childbirth: a handbook for midwives. Boyle M (Editor), Radcliffe Publishing,
Heazell A, Norwitz E R, Kenny L, Baker P N (Editors), Hypertension in pregnancy Cambridge: Cambridge University Press.
Lloyd C (2009 ) Hypertensive disorders of pregnancy. In: Fraser D M and Cooper M A (Editors) Myles Textbook for Midwives. London: Elsevier
Pre-eclampsia Community Guideline Group (PRECOG). The Pre-eclampsia Community Guideline (2004); The Day Assessment Unit Guideline (2009); Guideline for the Management of Postpartum Hypertension (2009). Available as free downloads from Action on Pre eclampsia (APEC) at

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