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Pre Eclampsia and Eclampsia - Severe UHL Obstetric Guideline of 19 Author: Paul Bosio, Consultant Obstetrician – updated by Hypertension Team Written: February 2001 Contact: Julia Austin Consultant Midwife Last Review 17/12/19 Approved by: Maternity Service Governance Group Next Review 01/12/2022 Guideline Register No: C3 / 2001

Pre Eclampsia and Eclampsia - Severe UHL Obstetric Guideline

Trust Reference C3/2001 Maternity

1. Introduction and who the guideline applies to:

This guideline is intended for use when any woman with severe proteinuric hypertension is transferred to Delivery Suite for intensive monitoring after discussion with senior staff, and where one of the following criteria is met:

1.

Hypertension (greater or equal to 140/90 mmHg) with proteinuria (greater or equal to 0.3g/day or more than or equal to 2+) AND at least one or more of the following:

a) Headache not relieved with simple analgesia

b) Clonus (3 beats) Hyper reflexia c) Platelet count less than 100 x 109, ALT greater than 70 iu/L

(consider HELLP) d) Epigastric pain, vomiting, visual disturbances

2.

Severe hypertension (Systolic Blood Pressure greater or equal to 160 mmHg or Diastolic Blood Pressure greater or equal to 110 mmHg) with proteinuria (greater or equal to 0.3g/day or more than or equal to 2+)

3.

Eclampsia (convulsions associated with pre-eclampsia)

Related UHL documents:

Enhanced Maternity Care

Fetal Heart Rate Monitoring in Labour

Maternity Early Obstetric Warning Scoring System

2. Recommendations:

1.

If the condition of a woman necessitates following the guideline, the following clinicians should be informed:


1. Consultant on call 2. Anaesthetist on call for Delivery Suite 3. At the LRI inform the Obstetric senior registrar on call At the LGH inform the Obstetric registrar on call i.e. the team directly responsible for on-site management of patient 4. Neonatal team, particularly in the presence of prematurity or concerns about

fetal condition

2.

In women who meet the criteria for severe hypertension requiring intravenous therapy the first drug of choice is arbitrarily intravenous Labetalol. Intravenous Hydralazine may be used as an alternative, especially if Labetalol is contra-indicated OR maximum dose of Labetalol not controlling hypertension.

3. Magnesium sulphate should be considered for all women with severe pre-eclampsia.

4.

Magnesium sulphate should be used for the treatment and subsequent prophylaxis of eclamptic seizures.

5. In the presence of signs of toxicity, magnesium levels should be ascertained.

6.

Transfer to the Intensive Therapy Unit should be considered in the following situations:

- Recurrent seizures - Mean arterial pressure greater than 125 mmHg despite intravenous

Labetalol and / or Hydralazine - Persistent oliguria with normal / high Central Venous Pressure - Pulmonary oedema with oliguria - Compromised myocardial function

7.

Mode and timing of delivery should be discussed with the consultant on call in all cases of Eclampsia (Antenatal or Postnatal) and in severe Pre Eclampsia where labour is not established or not progressing adequately.

8 Above 28 weeks a continuous CTG should be commenced unless otherwise stated in the intrapartum care plan. Less than 28 weeks, the method of fetal monitoring should be discussed with the consultant.

9

If the platelet count is less than 50 x 109/L a platelet transfusion should be considered for operative delivery, in consultation with a Haematologist.

10

Observations should be recorded on a high dependency chart by the midwife caring for the woman.

11

Postnatal monitoring should be continued once patient warded and discharge care plan put in place, including referral to the Hypertension in Pregnancy Team where appropriate.


Recommendation One:

If the condition of a woman necessitates following the guideline, the following clinicians should be informed:

1. Consultant Obstetrician and Consultant Anaesthetist on call for Delivery Suite

2. Obstetric senior registrar on call – directly responsible for on-site management of patient

3. Neonatal team, particularly in the presence of prematurity or concerns about fetal condition

The Core Staff in charge of Delivery Suite is responsible for ensuring the specified clinicians are informed.

The Hypertensive Pregnancy Team (LRI) or relevant Consultant (LGH) should be informed of the case at the earliest possible opportunity.

Recommendation Two:

Observations should be recorded on a high dependency chart by the midwife caring for the woman.

- Commence MEOWS (Modified Early Obstetric Warning Scoring System) monitoring

- Patient should be fasted - Consider omeprazole 40mg orally on admission and then 20mg Omeprazole

every 24 hours until delivery.

- Where women are undergoing category 1, 2 or 3 Caesarean section and they have only had one dose of 40mg Omeprazole, a further dose of 20mg omeprazole can be given If the last dose given was more than 12 hours previously. Alternatively, the Anaesthetist may choose to administer an IV infusion of ranitidine/ omeprazole for women who are at particularly high risk of aspiration.

- Use anti-embolic stockings - Continuous CTG of women who are 28 weeks or above. In women who are less

than 28 weeks the fetal heart should be auscultated on admission, subsequent fetal monitoring should be discussed with the on call obstetric consultant (see recommendation 8).


Blood pressure measurements:

- Automated devices should be used.15 (Please note:

automated devices may underestimate blood pressure so recheck with a manual device)

- Record blood pressure every 15 minutes on HDU chart.

- Inform the Senior Registrar or Consultant if the systolic blood pressure exceeds 160mm Hg or if the Mean Arterial Pressure is greater than 125 mmHg on two readings, or one reading greater than 140 mmHg. Treatment is recommended (see recommendation three).

Fluid intake:

- The standard intravenous regime is 85 ml/hr (this includes syntocinon administration)

Urine Output:

- All patients to be catheterised, draining into an hourly measurement catheter bag.

- Inform the Senior Registrar if the output is less than 30 ml in a one hour period.

Central Venous Pressure (CVP):

- Record hourly.

- The anaesthetist is responsible for the insertion and subsequent care of the CVP line.

- Inform anaesthetist of any concerns. If the CVP is greater than 8 mmHg inform the Senior Registrar or the Obstetric Consultant and the Obstetric Anaesthetist.

Bloods:

- 6 hourly to include full blood count, (and coagulation screen if platelet count less than 100), Urea and Electrolytes, Liver Function Tests, and Group and Save.

- Blood film and LDH for haemolysis should be carried out once daily / on admission to exclude HELLP.

Delivery:

- Ergometrine not to be given - use intravenous Oxytocin (Syntocinon®).

- Take cord gases (arterial & venous) and record in notes.


Recommendation Three: In women who meet the criteria for severe hypertension requiring intravenous therapy (see flow charts on pages 6 and 7) the first drug of choice is arbitrarily intravenous Labetalol. Intravenous Hydralazine may be used as an alternative, especially if Labetalol is contra-indicated OR maximum dose of Labetalol not controlling hypertension.

There is no evidence that intravenous Labetalol is superior to intravenous hydralazine.1,2,3

Labetalol is contra-indicated in asthmatics. For full contra-indications refer to Trandate® SPC or BNF.

Both drugs can precipitate fetal distress and therefore continuous fetal heart rate monitoring is mandatory.

Women receiving intravenous Labetalol should be in the left lateral position during the infusion and for 3 hours afterwards.

Labetalol Maintenance Therapy:

Draw up 40 ml Labetalol (5 mg/ml). Start infusion at 20 mg/hr, and double every 30 minutes, until a satisfactory response (Mean Arterial Pressure (MAP) less than 120 mmHg), to a maximum infusion rate of 160 mg/hr. Aim for a MAP of 100 mmHg.

If MAP is between 70 and 100 mmHg, reduce the infusion by 20 mg/hr every 30 minutes, until the MAP stabilises at 100 mmHg.

If the MAP is less than 70 mmHg discontinue the infusion and inform the Obstetric Anaesthetist and Senior Registrar.

Intravenous Hydralazine If Labetalol is contra-indicated or maximum dose of labetalol is not controlling hypertension: Fluids - Consider 250 ml colloid (with consultation with the senior anaesthetic team) given over 20 mins if concerns of hypovolaemia, as IV antihypertensives can induce CTG abnormalities, this is more likely with IV hydralazine. However, there is no evidence of benefit of routinely giving colloids prior to IV antihypertensives, this may increase the risk of pulmonary oedema. Initial bolus of hydralazine – 2.5 mg over 5 min

Repeat boluses of hydralazine – 2.5 mg every 20 minutes, to a maximum cumulative dose of 15 mg OR heart rate more than 120 bpm. Hydralazine Infusion - 40 mg in 40 ml Normal Saline: start at 10 mgs/hr and double every 30 min until satisfactory response to maximum 40 mg/hr, tachycardia (greater than 120 bpm) or side effects (headache, flushing, dizziness). Weaning from intravenous infusion to oral antihypertensives should generally involve either oral nifedipine SR (Adalat Retard ® - prescribe by TRADE NAME NOT GENERIC DRUG NAME) or labetalol. The speed of weaning and dosages


will depend on the clinical scenario and intravenous regimen used, and should be supervised by the Hypertensive Pregnancy Team (LRI) or the relevant Consultant (LGH).


1st Line Antihypertensive Therapy Guideline – LABETALOL Mean Arterial Pressure (MAP) >140 mmHg is associated with arterial injury, a loss of cerebral autoregulation and a progressively increasing risk of cerebral haemorrhage.

MAP > 120 mmHg OR systolic BP > 160 mmHg constitutes an obstetric emergency MAP = DBP + 1/3 (SBP – DBP)

MAP 120 – 140 mmHg (SBP ~ > 160 mmHg

DBP ~ > 100 mmHg)

Oral Nifedipine SR 20 mg

If the woman is already on the maximum dose of Nifedipine, Labetalol should be given

Check BP every 5 minutes for 15 minutes: if normal commence maintenance therapy as per guideline

If MAP >120 mmHg OR Systolic BP > 160 mmHg 30 min post oral treatment commence IV guideline

MAP >140 mmHg OR

Systolic BP > 160 mmHg

MAP 120-140 mmHg

30 min after oral drug therapy

Recheck BP every 5 min

If sustained >15 min



*LABETALOL 20mg IV over 5 min *

Check BP every 5

minutes

MAP> 125 mmHg

Re-check MAP after 20

minutes

MAP <125 mmHg

Labetalol bolus *over 5 min

40 mg, 40 mg, 80 mg at 10 min

intervals up to maximum

cumulative dose of 180 mg

(8% resistance)

MAINTENANCE

THERAPY * (see Recommendation

three)

Hydralazine to be given if Labetalol contra-indicated OR maximum dose of Labetalol not controlling hypertension (i.e. Mean arterial pressure remaining greater than 125 mm Hg). See Recommendation Two, Page 6.

* Consider, concurrently with antihypertensive, 250 ml crystalloid (with consultation with the senior anaesthetic team) given over 20 min if concerns of hypovolaemia, as IV antihypertensives can induce CTG abnormalities, this is more likely with IV hydralazine.

However, there is no evidence of benefit of routinely giving fluids prior to IV antihypertensives, this may increase the risk of pulmonary oedema. (17)


Alternative Antihypertensive Therapy Guidelines – HYDRALAZINE

Mean Arterial Pressure (MAP) >140 mm Hg or systolic BP > 160mmHg is associated with arterial injury, a loss of cerebral autoregulation and a progressively increasing risk of cerebral haemorrhage.

MAP > 120 mm Hg OR systolic BP > 160 mm Hg constitutes an obstetric emergency MAP = DBP + 1/3 (SBP – DBP)

MAP 120 – 140 mm Hg

(SBP ~ > 160 mm Hg DBP ~ > 100 mm Hg)

Oral Nifedipine SR 20 mg

If the woman is already on the maximum dose of Nifedipine, Labetalol should be given

Check BP every 5 minutes for 15 minutes: if normal commence maintenance therapy as per guideline

If MAP >120 mm Hg OR Systolic BP > 160 mm Hg 30

min post oral treatment commence IV guideline

MAP >140 mm Hg OR

Systolic BP > 160 mm Hg

MAP 120-140 mm Hg

30 min after oral drug therapy





*HYDRALAZINE 2.5 mg over 5 minutes

Check BP every minute for 10 minutes

Check BP every 5 minutes

MAP> 125 mm

Hg

Re-check MAP after 20 minutes

MAP <125 mm Hg

Consider

further bolus of 2.5mg

Hydralazine

Continue with Hydralazine 5-10 mg / hr

titrated according to BP (see Recommendation three)

Aim for BP of 130 / 90

Avoid precipitous fall of BP

* Consider 500ml crystalloid fluid before or at same time as antihypertensive, (with

consultation with the senior anaesthetic team) given over 20 min if concerns of hypovolaemia, as IV antihypertensives can induce CTG abnormalities, this is more likely with IV hydralazine.

However, there is no evidence of benefit of routinely giving colloids prior to IV antihypertensives, this may increase the risk of pulmonary oedema. (17)


Recommendation Four:

Magnesium sulphate should be considered for all women with severe pre-eclampsia.

Loading dose

4g (40 ml) 10% Magnesium Sulphate infused IV over 5-10 minutes.

Maintenance Dose

1 g/hr (3 ml/hr of prepared strength solution, 1g in 3 ml, of Magnesium sulphate) via syringe pump.

Contraindications and cautions

Contraindication: Acute renal failure. Need to add once information from pharmacist Caution: Cardiac disease.

Duration of infusion Continue infusion until 24 hours post delivery, or 24 hours after starting infusion as appropriate. Duration of treatment should rarely normally exceed 24 hours. (NB THE MAJORITY OF ECLAMPTIC FITS OCCUR WITHIN THE FIRST 24 HOURS OF DELIVERY)

Monitoring

Clinical:

- Patellar reflex (after completion of loading dose): - Use arm reflexes in women with an epidural - Hourly urinary output

ECG - Mandatory during and for one hour after loading dose

Pulse oximetry - whilst infusion of magnesium sulphate in progress

Consider nil by mouth

*Presence of reflexes, PO2 and urinary output MUST be recorded hourly on the high dependency chart *


Recommendation Five:

Magnesium sulphate should be used for the treatment and subsequent prophylaxis of eclamptic seizures.

MANAGEMENT OF AN ECLAMPTIC FIT In the event of a SEIZURE

Turn to left lateral and give facial oxygen (remember: Airway / Breathing / Circulation)

Ring emergency buzzer and get help (anaesthetist, senior obstetrician, core midwife)

Ensure safety of patient e.g. cot sides

IV access, bloods (U&Es, LFTs, Blood glucose, calcium, magnesium, full blood count, clotting, Group and Save)

Call consultant obstetrician

Inform consultant anaesthetist

Exclude other causes for seizure e.g. epileptic seizure in woman with a history of epilepsy

Commence magnesium sulphate (see regime below)

Commence continuous CTG or auscultate fetal heart (if less than 28 weeks) once patient stabilised

Consider mode and timing of delivery after discussion with consultant anaesthetist and consultant obstetrician once patient is stabilized.

Document actions taken

Complete incident form once patient stable

Keep woman nil by mouth

Loading Dose

4g (40 ml) 10% Magnesium sulphate infused IV over 15-20 minutes

Maintenance Dose

1g/hr (3ml/hr of prepared strength solution, 1g in 3ml, of Magnesium sulphate) via syringe pump

If convulsions recur

Additional 2g Magnesium sulphate intravenously over 5 min (If possible take blood for Magnesium level prior to additional bolus

†)

If further seizures occur despite above consider:

- Consider ITU transfer & Thiopentone infusion † If Magnesium level < 2.0 mmol/L restart maintenance dose at 2 g/hr.

Contra – indications / caution

Contraindication: Acute renal failure. Use Diazemuls; 5-10 mg intravenously then 2.5 mg/hr under anaesthetic supervision.

Caution: Cardiac disease.

Duration of infusion

Continue infusion until 24 hours post delivery, or 24 hours after starting infusion as appropriate (NB THE MAJORITY OF ECLAMPTIC FITS OCCUR WITHIN THE FIRST 24 HOURS OF DELIVERY)

Monitoring Clinical:

- Patellar reflex (after completion of loading dose): - Use arm reflexes in women with an epidural - Hourly urinary output

ECG - During and for one hour after loading dose

Pulse oximetry - whilst infusion of magnesium sulphate in progress

*Presence of reflexes, PO2 and urinary output MUST be recorded hourly on the high dependency chart *


Recommendation Six:

In the presence of signs of toxicity, magnesium levels should be ascertained.

Experience from the Collaborative Eclampsia and Magpie Trials indicates that magnesium sulphate (according to the above regime) can be used safely without the need to monitor any levels. 3,6

Magnesium is excreted by the kidneys and toxicity is more likely if there is oliguria (urine output less than 100 ml over 4 hrs) or urea greater than 10 mmol/L - halve the dose and check Magnesium levels.

Signs of toxicity are extremely uncommon and correlate with magnesium levels:

Magnesium level (mmol/L)

Therapeutic range

2-4

Loss of reflexes, weakness, nausea, feeling of warmth, flushing, somnolence, double vision, slurred speech

5

Muscle paralysis, respiratory arrest

6-7.5

Cardiac arrest

>12

Management of magnesium toxicity:

Loss of patellar / biceps reflex

1. Stop maintenance infusion 2. Check Magnesium level 3. Withhold Magnesium until patellar reflexes return or

Magnesium level known +

PaO2 persistently <94%

1. Commence oxygen, check patellar reflex, inform

Anaesthetist 2. If reflex present – exclude other causes (e.g. respiratory

depression due to opiates or pulmonary oedema) 3. If reflex absent – see above

Cardiorespiratory arrest

1. Stop maintenance infusion 2. Cardiopulmonary resuscitation 3. Administer 10 ml 10% Calcium Gluconate intravenously 4. Intubate immediately and manage with assisted

ventilation until resumption of spontaneous respirations 5. if possible check Magnesium level

+ Once tendon reflexes return, if Magnesium level less than 4 mmol/L restart maintenance dose at 0.5 g/hr and recheck levels in 3 hrs.


Fluid Guidelines

1 Litre Hartmann’s solution over 12 hours (85 ml/hr)

OLIGURIA <30 ml/hr or ANURIA for more than 1 hour (check catheter draining freely)

Review by senior registrar

Exclude Hypovolaemia due to haemorrhage, haemolysis or D.I.C*

* Women with marked Hypovolaemia due to haemorrhage (>500 ml), haemolysis or DIC need blood +/- blood products

Check U&Es, platelets & LFTs urgently

Senior registrar or consultant review

Output

>100 ml/4hr

Anuria / oliguria persists

(Output <50 ml/4hr)

CONSIDER:

1. Observing for 4 hours 2. Frusemide 10 mg IV

CONSIDER:

Frusemide 10 mg IV

Senior registrar or consultant

review

CVP & early nephrology

consultation

*In the presence of antenatal oliguria or anuria prepare for delivery. If there is also evidence of HELLP, consider ITU transfer (preferably post delivery)


Fluid Guidelines

CVP (antecubital long line; check position with CXR)

CVP measurements can be difficult to interpret and will require senior Obstetric / Anaesthetic management

<4 mmHg

4-8 mmHg

>8 mmHg

Manage expectantly

Signs of pulmonary oedema Basal creps / SaO2 <94%

URINE OUTPUT

URINE OUTPUT

<100 ml/4hr over 8 hrs

<100 ml/4hr over

8 hrs

CVP by >2 or to >8

NO YES

>100ml/4hr

500 ml synthetic colloid

over 20 min

200 ml synthetic

colloid over 20 min

1L Hartmann’s 12 hrs (85

ml/hr)

URINE OUTPUT

Oliguria persists

CXR Frusemide 20 mg

>100 ml/4hr Repeat Creatinine & Potassium

1L Hartmann’s over 12hrs (85

ml/hr)

CONSIDER: 1. Frusemide

10-20mg IV 2. Nephrologist

consultation

Diuresis

Frusemide 40 mg

Women with marked Hypovolaemia due to

haemorrhage (>500 ml), haemolysis or DIC are

obvious exceptions. They need blood +/- blood

products

Rapidly increasing Creatinine /

Potassium >5.5 mmol/L

No Diuresis Persistent PO2

Fluid restriction (urine output in

the previous hour + 30 ml)

1L Hartmann’s 12 hrs (85

ml/hr)

Consider PA catheter


Recommendation Seven:

Mode and timing of delivery should be discussed with the consultant on call in all cases of eclampsia and in antenatal or intrapartum patients with severe pre-eclampsia where delivery is not imminent.

The decision to deliver should be made once the woman is stabilised.

If the fetus is less than 34 weeks gestation and delivery can be deferred, corticosteroids should be given, although after 24 hours the benefits of conservative management should be reassessed.

Conservative management of early gestation should be balanced with maternal wellbeing.

Mode of delivery is dependant on presentation of the fetus, fetal wellbeing and likelihood of success and maternal condition.

Neonatal team should be informed, particularly in the presence of prematurity or concerns about fetal condition

Recommendation Eight

Consider continuous fetal heart rate electronic monitoring above 28 weeks gestation. At gestation less than 28 weeks the fetal heart rate should be auscultated on admission, subsequent monitoring should be discussed with the senior obstetric team.

Less than 28 weeks, the method and frequency of fetal monitoring should be discussed with the Consultant Obstetrician.

At 28 weeks and above a continuous CTG should be commenced unless

otherwise stated in the intrapartum care plan.


Recommendation Nine:

Transfer to the Intensive Therapy Unit should be considered in the following situations:

- Recurrent seizures - Mean arterial pressure greater than 125 mmHg despite intravenous

Labetalol and / or Hydralazine - Persistent oliguria with normal / high Central Venous Pressure - Pulmonary oedema with oliguria - Compromised myocardial function -

See “Enhanced Maternity Care“ guideline for details of transfer to ITU.

Recommendation Ten:

If the platelet count is less than 50 x 109/L a platelet transfusion should be considered for operative delivery, in consultation with a Haematologist.

A platelet count less than 100 x 109/l (or rapidly falling count) warrants a baseline clotting screen.13 Consult Haematologist early where there is clinical or haematological evidence of Coagulopathy.

If a platelet infusion is indicated as above, one adult dose of platelets should be administered prior to incision, plus a further adult dose at uterine closure.

A low fibrinogen is an important indicator of Disseminated Intravascular Coagulation.14

Cryoprecipitate should be given if fibrinogen is less than 1.0 g/l. Fresh frozen plasma should be used to correct a prolonged PT or APTT.

Recommendation Eleven:

Postnatal monitoring should be continued once patient warded and discharge care plan put in place.

Post delivery care:

Inform the hypertension team at the LRI and the hypertension midwives at the LGH. The team will assess the appropriateness of the home BP monitoring (See postnatal monitoring for hypertension guideline)


Maintain adequate analgesia & use anti-embolic stockings and Low Molecular Weight Heparin thromboprophylaxis.

Diclofenac / Non Steroidal Anti-Inflammatory Drugs to be avoided until the renal function, urine output and clotting profile has normalized.

All women should remain on Delivery Suite for a minimum of 24 hours after delivery.

Please ensure that when patient is transferred to the ward the staff are made aware of the need to record strict fluid balance for at least 48 hours and monitor blood pressure 4-hourly.

Clear follow up arrangements should be in place at discharge, including communication of final diagnosis to GP, need for further blood pressure monitoring and/or drug treatment, as well as the need for follow up where clinically appropriate.

Follow Up:

After pre- eclampsia, blood pressure can take up to 3 months to return to normal.

Stop methyldopa. Consider appropriate antihypertensive medication if breast feeding. Usual regimes include nifedipine and labetalol (if not asthmatic). Discuss with the relevant obstetric team or hypertension team if there are concerns.

If discharged home on antihypertensive medication refer to post natal blood pressure monitoring scheme.

- If the patient is suitable, and a home monitor is available, the women

can be weaned off therapy as an out patient. - BP should not exceed 155/100 in this period. - If the patient had significant proteinuria, then a repeat protein

creatinine ratio will need repeating at 6 weeks, if still raised consider renal referral.

For women who do not fill the criteria for home monitoring, the community midwife should be asked to monitor the blood pressure daily in the community for 5 days and further follow up discussed with the relevant obstetric or hypertension teams.

Patients with severe pre eclampsia will be followed up by the Hypertension Team

3. Education and Training


4. Monitoring Compliance

What will be measured to monitor compliance

How will compliance be monitored

Monitoring Lead

Frequency Reporting arrangements

6. Supporting References:

1. Duley L, Henderson-Smart DJ. Drugs for rapid treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Review s Cochrane Library. 2000; Issue 2.

2. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford

University Press, 1989 pp519-526. 3. The Magpie Trial Collaborative Group. Do women with pre-ecpalmpsia, and their babies, benefit

from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;

359:1877-1890. 4. Scientific Advisory Committee of the Royal College of Obstetricians & Gynaecologists.

Management of Eclampsia. RCOG Guideline No. 10, London: RCOG, November 1996. 5. Duley L, Henderson-Smart D. Magnesium sulphate versus diazepam for eclampsia. Cochrane

Database of Systematic Reviews Cochrane Library. Sept 1996;Issue 3. 6. Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence

from the collaborative eclampsia trial. Lancet 1995; 345:1455-1463.

7. Wasserstrum N. Issues in fluid management during labour: maternal plasma volume status and volume loading. Clin Obstet Gynecol 1992; 35:514.

8. Cotton DB, Gonik B, Dorman K, Harrist J. Cardiovascular alterations in severe pregnancy-induced

hypertension: relationship of central venous pressure to pulmonary capillary wedge pressure. Am J Obstet Gynecol 1985; 151:762-764.

9. Walker JJ. Advances in the management of severe pre-eclampsia and antihypertensive therapy. In Recent Advances in Obstetrics and Gynaecology. Edinburgh: Churchill Livingstone, 1998 pp120-122.

10. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995 pp96.

11. Wallenburg HCS. Hemodynamics in hypertensive pregnancy. Handbook of Hypertension Vol 10:

Hypertension in Pregnancy. New York: Elsevier Science Publishers 1988 pp66-101. 12. Belfort M, Uys P, Dommisse J et al. Haemodynamic changes in proteinuric hypertension: The

effects of rapid volume expansion and vasodilator therapy. Br J Obstet Gynaecol 1989; 96: 643.

13. Roberts WE, Perry KG, Woods JB, Files JC, Blake PG, Martin JN. The intrapartum platelet count in patients with HELLP syndrome - is it predictive of later haemorrhagic complications? Am J Obstet Gynecol 1994;171:799-804.

14. Hayman RG, Baker PN. The hypertensive disorders of pregnancy. Definitions, classifications and

haematological investigations. PACE review 97/05. London: RCOG 1997.

15. Halligan A, Shennan A, Thurston H, deSwiet M, Taylor D. Ambulatory blood pressure measurement in pregnancy - the current state-of-the-art. Hypertens Pregnancy;14:1-16.

16. Confidential Enquiry into Maternal and Child Health. Saving Mothers’ Lives: reviewing maternal

deaths to make motherhood safer – 2003-2005. December 2007.


17. Duley L, Williams J, Henderson-Smart, DJ. Plasma volume expansion for the treatment of pre eclampsia. Cochrane Library Issue 2,2007

7. Key Words: Pre-eclampsia, hypertension, Eclampsia

CONTACT AND REVIEW DETAILS

Guideline Lead (C Weisender Consultant Obstetrician)

Executive Lead Andrew Furlong

Details of Changes made during review: Rantidine removed and alternative Omeprazole to be prescribed


Monitoring

Process for monitoring:

Retrospective review of patient health records

How often will monitoring take place:

Annually for severe pre-eclampsia Continuous for Eclampsia-results will be reported quarterly to Maternity Service Governance Group, and an annual report of all four quarters will be generated

Population: 1% sets of health records of women who have delivered with a diagnosis of severe pre-eclampsia All health records(100%) of women who have delivered with a diagnosis of eclampsia

Person responsible for monitoring:

Delivery Suite Leads Senior Midwives for Intrapartum and Inpatient Services

Auditable standards: The first intravenous drug of choice to control hypertension where required was Labetalol unless contra indicated

Magnesium sulphate was administered for seizure prevention in severe pre-eclampsia

Magnesium Sulphate was used for treatment and subsequent prophylaxis in cases of eclamptic seizures.

Blood pressure was recorded on a HDU chart

Fluid balance including urine output was recorded on a HDU chart

Fluid was restricted to 85 ml per hour

Continuous electronic fetal monitoring for gestations of 28 weeks or more was performed

Plan for fetal monitoring at gestations below 28 weeks was discussed with a senior clinician and documented in the health record

Mode and timing of delivery, where appropriate, was discussed with the consultant on call and documented

Incident form was completed for all cases of Eclampsia

Results reported to:

Maternity Service Governance Group All cases of eclampsia are also reported to perinatal risk group

Person responsible for production of action plan:

Delivery Suite Leads Senior Midwives for Intrapartum and Inpatient Services

Action plan signed off by:

Maternity Service Governance Group

Action plan to be monitored by:

Maternity Services Governance Group

How will learning take place: in one or more of the following fora

Newsletter Delivery suite forums Band 7 meetings Team meetings Unit meetings Emails

Face to face discussion where appropriate

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