Pre Eclampsia Manual

Prevention and
management of pre-
eclampsia and
eclampsia
A Reference Manual for
Health Care Providers
Copyright © 2010, 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: A Reference Manual for Health Care
Providers. Baltimore: Jhpiego; 2010.
Prevention and management of pre-eclampsia
and eclampsia
A Reference Manual for Health Care Providers
2010
Maternal and Child Health Integrated Project

(MCHIP)
This manual 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 terms of Subcontract No. __________, under Contract No.
______________. 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 eclampsia i

Table of contents
Introduction ............................................................................................................ v
Understanding pre-eclampsia and eclampsia ................................................................ 1
Key definitions ................................................................................................... 1
Pathophysiology................................................................................................. 1
Epidemiology of pre-eclampsia and eclampsia ........................................................ 2
Morbidity and mortality associated with pre-eclampsia and eclampsia ........................ 3
Identifying pre-eclampsia .......................................................................................... 7
Key definitions ................................................................................................... 7
Introduction ...................................................................................................... 7
Screening ......................................................................................................... 7
Detecting hypertensive disorders in pregnancy ....................................................... 8
Differential diagnosis of hypertension in pregnancy/postpartum .............................. 13
Differential diagnosis of fits in pregnancy/postpartum ........................................... 14
Prevention .............................................................................................................17
Key definitions ................................................................................................. 17
Primary prevention of pre-eclampsia ................................................................... 17
Secondary prevention ....................................................................................... 18
Tertiary prevention........................................................................................... 19
Overview of interventions to prevent pre-eclampsia and eclampsia.......................... 20
Management ..........................................................................................................23
Gestational hypertension ................................................................................... 23
Mild pre-eclampsia - Gestation less than 37 weeks................................................ 23
Mild pre-eclampsia - Gestation more than 37 complete weeks ................................ 24
Severe pre-eclampsia and eclampsia .................................................................. 24
Postpartum care .............................................................................................. 28
Referral for tertiary level care ............................................................................ 28
Complications of gestational hypertension ........................................................... 28
Managing obstetric emergencies ...............................................................................29
General management for an obstetric emergency ................................................. 29
General management for shock .......................................................................... 30
Birth preparedness and complication readiness ...........................................................33
Birth-preparedness plan .................................................................................... 33
Complication-readiness plan .............................................................................. 34
References .............................................................................................................37
ii Prevention and management of pre-eclampsia and eclampsia

Acknowledgements
The writing team of ______________________________________________ is grateful to
the following people, who provided invaluable assistance with this effort:
Contributing editors
Reviewers
Proofreader
Illustrator .
About MCHIP
For more information or additional copies of this report, please contact:
Prevention and management of pre-eclampsia and eclampsia iii

Acronyms
USAID United States Agency for International Development
WHO World Health Organization
iv Prevention and management of pre-eclampsia and eclampsia

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 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.1
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 killers are severe
bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery),
hypertensive disorders in pregnancy (eclampsia) and obstructed labor.2 Pre-eclampsia may
also occur in the immediate post-partum period. This is referred to as "postpartum pre-
eclampsia." The most dangerous time for the mother is the 24–48 hours postpartum and
careful attention should be paid to pre-eclampsia signs and symptoms.3
Ten percent of all pregnancies are complicated by hypertension (HTN). Eclampsia and
preeclampsia 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.4 The fetal
mortality rate varies from 13-30% due to premature delivery and its complications.
Placental infarcts, abruptio placentae, and intrauterine growth retardation also contribute to
fetal demise.5 Maternal death risk is approximately 1.8%, in high 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 patients who have multiple
seizures outside the hospital and those without prenatal care.3
Fortunately, simple, low-cost interventions are available to prevent most cases of eclampsia
and manage them should 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
Prevention and management of pre-eclampsia and eclampsia v

and eclampsia, they must be competent to provide effective initial management and ensure
timely referral for cases that cannot be managed at their level.
To facilitate access to important maternal technologies, countries must 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 training all health workers in prevention,
identification and management of pre-eclampsia and eclampsia at all levels along the
continuum of care
Logistics systems that ensure availability of necessary resources (equipment,
supplies, and consumables for infection prevention and injection safety) are available
Supervision and monitoring systems to assure quality and ensure transfer of learning
to the work site.
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 nurses, midwives, and doctors
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, and clinical and health workers to carry out the following:
vi Prevention and management of pre-eclampsia and eclampsia

Reference manual
Provide safe, respectful, 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 themselves.
Prevention and management of pre-eclampsia and eclampsia vii

viii Prevention and management of pre-eclampsia and eclampsia
Understanding pre-eclampsia and eclampsia
Key definitions
Avoidable factors: are factors causing or contributing to maternal death where there is
departure from generally accepted standards of care.
Risk factors: are factors which make a condition more likely to happen or more dangerous
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
multiple theories have been proposed to explain their cause, resulting in confusion and
myths surrounding both etiology and management. The main etiologic theories
include abnormal trophoblastic invasion, coagulation abnormalities, vascular endothelial
damage, cardiovascular maladaptation, immunologic phenomena, genetic predisposition,
and dietary deficiencies or excess.4
Pathophysiologic changes
In normal pregnancies, blood volume increases 30 to 50%, peripheral vascular resistance
decreases, pregnancy-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:
x Blood pressure begins to rise after 20 weeks of pregnancy
x 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
x 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
x Loss of normal vasodilation of uterine arterioles results in decreased placental perfusion
x 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
x 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:
o Fibrin forms cross-linked networks in the small blood vessels.
o This leads to a microangiopathic hemolytic anemia: the mesh causes destruction of
red blood cells as if they were being forced through a strainer.
o 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.
Prevention and management of pre-eclampsia and eclampsia 1

o HELLP syndrome leads to a variant form of disseminated intravascular coagulation
(DIC), leading to paradoxical bleeding.
Disease progression
Pre-eclampsia and eclampsia are part of the same disorder with eclampsia being the severe
form of the disease. Gestational hypertension may progress from a mild hypertensive
disorder to a life-threatening condition, as follows:
x hypertension without proteinuria or edema
x mild pre-eclampsia
x severe pre-eclampsia
x 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 seizures. Eclampsia can occur during the
antepartum, intrapartum, and postpartum periods; and ninety percent of eclampsia cases
occur after 28 weeks' gestation.5
Epidemiology of pre-eclampsia and eclampsia

Numerous maternal factors can predispose to the disorder; these may be genetic,
behavioral, or environmental. Pre-eclampsia and therefore the risk of eclampsia is more
common in:5, 6,7
x Women with a family history of preeclampsia, prior preeclampsia and eclampsia
x Women with a history of poor outcome of previous pregnancy, including intrauterine
growth retardation, abruptio placentae, or fetal death
x Preexisting medical condition - Obesity, chronic hypertension, renal disease,
thrombophilias-antiphospholipid antibody syndrome, protein C deficiency and protein S
deficiency, antithrombin deficiency, vascular and connective tissue disorders, gestational
diabetes, and systemic lupus erythematosus
x Multifetal gestations, hydatid mole, fetal hydrops, primigravida
x Teen pregnancy
x Primigravida
x Women who are older than 35 years
x Lower socioeconomic status
x primigravida (especially young teenagers and women over 35 years)
x primipaternity (first pregnancy with the male partner)
x obese women
x women with essential or renal hypertension
x multiple pregnancy
x black women
x women with
- diabetes
2 Prevention and management of pre-eclampsia and eclampsia

- hydatidiform mole
- polyhydramnios
- hydrops fetalis
- increased insulin resistance
- increased testosterone
- increased blood homocysteine concentration.
Most traditional risk factors are associated with attributes of the woman or the
pregnancy/fetus. One hypothesis on the causes of pre-eclampsia is immune maladaptation.
Support for this hypothesis comes from epidemiological studies that show that:
x the risk for developing pre-eclampsia decreases with the length of exposure to the sperm
that will ultimately fertilize the woman’s egg8
x although pre-eclampsia is generally thought of as a disease of first pregnancies, the
protective effect of multiparity is lost with change of partner9
x men who fathered a pre-eclamptic pregnancy were nearly twice as likely to father a pre-
eclamptic pregnancy in a different woman, regardless of whether she had already had a
pre-eclamptic pregnancy or not9
“Risk factors” should not be used to predict complications. The system of risk
categorization, or the “risk approach”, previously used for selecting women for specialized
management is not useful, because evidence shows that many women categorized as “high
risk” do not actually experience a complication, while many women categorized as “low risk”
do. All pregnant women should therefore be considered “at risk” of developing a
complication.
Morbidity and mortality associated with pre-eclampsia and

eclampsia
Factors influencing maternal and perinatal outcomes
Pre-eclampsia is a major obstetric problem leading to substantial maternal and perinatal
morbidity and mortality worldwide, especially in low resource settings. Maternal and
perinatal outcomes in pre-eclampsia depend on maternal, community, and health care
factors.
Maternal factors5 influencing maternal and perinatal outcomes:
x In general, maternal and perinatal outcomes are usually favorable in women with mild
pre-eclampsia developing beyond 36 weeks’ gestation who have no other pre-existing
medical disorders.
x By contrast, maternal and perinatal morbidities and mortalities are increased in women
who develop the disorder before 33 weeks’ gestation, in those with pre-existing medical
disorders, and in those receiving care in low resource settings.
Community factors7 influencing maternal and perinatal outcomes:
x Lack of awareness about symptoms of severe pre-eclampsia and eclampsia and the
importance of early and regular antenatal care
x Transportation problems
x Low socioeconomic status
x Financial hardship and inability to pay for transport and medical care

x Community distrust of health care personnel
Health service factors7 influencing maternal and perinatal outcomes:
x Failure to monitor blood pressure and urine during antenatal care
x Failure to counsel women and families about dangerous symptoms of severe pre-
eclampsia and the importance of regular antenatal care
x Delay in referral of women with symptoms and signs of severe pre-eclampsia or
eclampsia
x Lack of a clear-cut management strategy/clinical protocols for dealing with pre-eclampsia
and eclampsia
x inadequately trained staff to treat women with severe eclampsia or eclampsia
x Lack of proper equipment and drugs to treat eclampsia
Maternal and fetal complications in severe preeclampsia
Effects on the mother
These include:
x Respiratory problems (asphyxia, aspiration of vomit, pulmonary edema, broncho-
pneumonia)
x Cardiac problems (heart failure)
x Effects on the brain (hemorrhage, thrombosis, edema)
x Renal complications (acute kidney failure)
x Hepatic disease (liver failure or hemorrhage)
x HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)
x Coagulopathy (clotting/coagulation failure)
x Visual disturbances (temporary blindness due to edema of the retina)
x Injuries during convulsions (fractures)
x Abruptio placentae
x Stroke
x Death
x Long-term cardiovascular morbidity
The main causes of maternal death in eclampsia are intracerebral hemorrhage, pulmonary
complications, kidney failure, liver failure and failure of more than one organ (e.g. heart +
liver + kidney).
Effects on the fetus
These include:
x Intrauterine growth retardation (IUGR)
x Preterm delivery
x Hypoxia
x Neurologic injury
x Perinatal death (1–2%)

x Long-term cardiovascular morbidity associated with low birthweight (fetal origin of adult
disease)
x Hypoxia may cause brain damage if severe or prolonged, and can result in physical or
mental disability.

Identifying pre-eclampsia
Key definitions
Introduction
Mild pre-eclampsia may progress to severe pre-eclampsia and eclampsia very suddenly with
little or no warning. In addition, women with pre-eclampsia do not feel ill until the condition
is severe and the disease is life threatening. Early detection by regular antenatal monitoring
and careful follow-up of those with mild pre-eclampsia is therefore essential for the early
diagnosis and treatment of severe eclampsia.
Screening
Hypertensive disorders in pregnancy are a major contributor to maternal mortality world
wide. With very careful antenatal care, providers can detect blood pressure elevation and
the presence of proteinuria, ensure initiation of appropriate management at the appropriate
level of care, and prevent many of these deaths. Improved detection and care should lead
to a better outcome. If a woman develops hypertension, and/or proteinuria, providers will
need to closely monitor her and encourage her to give birth in a health facility with skilled
attendants.
Detecting proteinuria
The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to
pre-eclampsia. Ruling out proteinuria is key for making a diagnosis of pre-eclampsia.
Detection of proteinuria above the threshold in a pregnant woman with hypertension
differentiates between relatively simple gestational hypertension and pre-eclampsia and
dictates a considerable step-up in surveillance, often including admission. The social and
financial repercussions of this for the woman and the economic consequences for the
healthcare system are considerable. It is therefore important that tests for proteinuria are
accurate.
Measurement of proteinuria differs from country to country and may vary by type of
resources available at the facility. Methods to evaluate proteinuria include:
x Quantitation of a timed collection: This has been the gold standard for many decades and
is expressed as the amount of protein excreted in the urine per unit time. Twenty four-
hour specimens have been traditionally used, but more recently 12-hour collections (and
even 2-hour collections) have been validated.10
x Urinary protein:creatinine ratio: This is used in some institutions instead of a timed
protein collection. A review conducted by Côté et al showed that the spot
protein:creatinine ratio is a reasonable “rule-out” test for proteinuria of 0.3 g/day or
more, among otherwise healthy women with gestational hypertension with or without
proteinuria on dipstick. However, they did not advocate use of the spot protein:creatinine
ratio or spot albumin:creatinine ratio for monitoring or quantifying proteinuria in
pregnancy.11
x Urine dipsticks: Urinalysis by visual reagent strip tests is widely performed in antenatal
clinics and in the community by various health professionals. A review by Waugh et al
showed that significant proteinuria, with point-of-care urine dipstick analysis, cannot be
accurately detected or excluded at the 1+ threshold and is not recommended for

diagnosing preeclampsia. Further research is necessary to determine the prediction of
proteinuria using higher dipstick thresholds.12
While the measure of proteinuria is a poor predictor of either maternal or fetal complications
in women with pre-eclampsia,13 it remains one of the criteria for the diagnosis of pre-
eclampsia. Further work is needed to compare the different methods to evaluate proteinuria
in the management of pregnant women with hypertension, particularly with respect to
accuracy of diagnosis and the effect on inappropriate admissions and discharges.
Detecting hypertension
Gestational blood pressure (BP) elevation is defined as a blood pressure >90 mm Hg
diastolic in a woman who was normotensive before 20 weeks’ gestation. In the absence of
proteinuria the disease is highly suspected when increased blood pressure appears
accompanied by the following symptoms: headache, blurred vision, and abdominal pain, or
by abnormal laboratory test results, specifically low platelet counts and abnormal liver
enzyme values.
The definition of hypertension has changed over the years:
x In the past it has been recommended that an increment of 30 mm Hg systolic or 15 mm
Hg diastolic blood pressure be used as a diagnostic criterion, even when absolute values
remain <140/90 mm Hg
x More recently, the diagnostic criteria for gestational hypertension include: Two readings of
diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks
gestation, without proteinuria
x Some use mean arterial pressure of 90mmHg or more in the second trimester. Mean
arterial pressure is defined as: diastolic blood pressure+one third×(systolic blood
pressureídiastolic blood pressure; or automated mean arterial pressure readings. Mean
arterial pressure appears to be a better predictor for pre-eclampsia than systolic BP,
diastolic BP, or increased BP.14
Blood pressure measurements at the first antenatal visit for healthy

normotensive women in the first and second trimester do not help predict
pre-eclampsia.12
BP readings are prone to inaccuracy due not only to observer and device error, but also to
variability of blood pressure and to rise in BP caused by anxiety/fear due to the effects of
attendance at the clinic (white-coat hypertension). 15
Detecting hypertensive disorders in pregnancy

At every antenatal and postnatal visit:
1. Take a targeted symptom history. ASK the woman if she has had any of these
symptoms: epigastric pain (heart burn), headaches, dizziness, or visual problems
(double vision, partial vision, rings around lights). Note that these are the danger signs
the pregnant / postpartum women should watch for.
2. Take the blood pressure at every visit.
x Blood pressure should always be checked in the sitting position (BP will be highest in
the sitting position, somewhat lower when she lies supine, and lowest when she lies
on her side), with her feet supported or on the ground, and her arm at the level of
the heart

x When BP is checked with the woman in left lateral recumbent, the superior arm has
10-12 mmHg lower BP than the inferior arm
- Measurements should be made with a mercury sphygmomanometer; in centers
where the use of mercury has been banned for clinical purposes, the mercury
sphygmomanometer will have to be replaced by an electronic device that has
been validated for pregnancy.
- The sphygmomanometer should be regularly calibrated
- Remove all tight clothes from around the arm. Tight clothes may partially block
the artery and give a false low reading.
- Wrap the cuff firmly around the upper arm. The cuff must be at least 2–3 cm (1
inch) above the elbow and should encircle at least three–fourths of the
circumference of the arm; otherwise, a false high reading will be obtained.
- A wider cuff should be used when the diameter of the upper arm is more than 30
cm.
- Make sure that the woman is as relaxed and comfortable as possible, in a sitting
position with arm supported or lying tilted to the left side. Lying on the back is
not a good position because the weight of the gravid uterus exerts pressure on
the inferior vena cava, thereby causing a drop in blood pressure.
- Do not kink or twist the tube on the cuff. Make sure that the stethoscope fits into
your ears firmly and snugly. If a mercury blood pressure machine is used, it must
be in the vertical position, and your eyes must be approximately at the same
level as the top of the mercury column or the reading will not be accurate.
- Systolic blood pressure is taken at the point at which the arterial sound appears.
- Diastolic blood pressure is taken at the point at which the arterial sound
disappears.
REMEMBER:
x The normal BP is between 80/60 and 140/90

x When the pre-pregnancy BP is not known, the BP taken before 20
weeks is considered the woman's normal BP
x Because of changes in cardiac output and blood volume, hormonal
changes which mediate a decrease in peripheral vascular
resistance, smooth muscle-relaxing effect of progesterone, and
heat production by the foetus, the BP will have some normal
variations during pregnancy:
- Systolic and diastolic BP begin to fall in the 1st trimester,
decreasing until mid-pregnancy and gradually return to non-
pregnancy baseline by term
- There is a slight increase in pulse pressure: a slight fall in
systolic and considerable decrease in diastolic later in
gestation
- There is no change in venous pressures during pregnancy
because of increased vascular capacity and compliance
3. If the diastolic BP is >90, have the woman lie on her left side for 20 minutes, then
recheck it again with her sitting up
x If the blood pressure is normal, educate the woman about danger signs and have her
return in two weeks for a BP check

x If the blood pressure is still elevated, check a midstream urine sample for protein.
4. If there is greater than 1+ protein in the urine:
x Verify that the sample was a mid-stream/clean-catch sample
Proteinuria is defined as the presence of 300 mg or more of protein per liter in a
clean catch, midstream specimen of urine. Usually proteinuria follows a rise in blood
pressure, but occasionally it is the first sign of the disease.
Vaginal secretions and discharges are common in pregnancy and, if mixed with
urine, give a positive test for protein. To avoid this, it is important that:
- The vulva is cleaned with water
- The labia minor is spread
- While urine is being passed, the middle part of the stream is caught in a clean
container.
Dipstick method:
- The end of the stick is dipped into the urine and excess shaken off by tapping the
stick on the side of the container
- The result is then read by comparison with the color chart on the label at the
time indicated on the dipstick container.
Boiling method:
- Boil the top half of the urine in a test tube
- Compare the top half of the urine with the unboiled bottom half (the boiled part
may become cloudy)
- Add 1–2 drops of 2–3% acetic acid. Do this even if the urine has not become
cloudy
- If, after adding the acetic acid, the boiled part of the urine remains cloudy,
protein is present in the urine
- If the boiled urine was not cloudy to begin with, but becomes cloudy when acetic
acid is added, this is another indication that protein is present
- If cloudy urine becomes clear when acetic acid is added, protein is not present.
x Rule-out pre-eclampsia: Check the biceps and/or patellar reflexes. If the reflexes
are brisk (+3 or +4), refer her to a hospital/doctor.
Testing reflexes
Testing reflexes is part of an examination of the nervous system. It is very helpful
for midwives to know how to test a few basic reflexes on adults. Hyper-reflexia can
indicate many diseases of the nervous system or edema of the brain (cerebrum) in a
pregnant woman. A woman with cerebral edema is at very likely to develop
eclampsia (convulsions).
Using a Reflex Hammer
A reflex hammer is used to check the deep tendon reflexes. Once you are
experienced, you may be able to use your fingers, the side of your hand, your
knuckles, or the head of a stethoscope instead. For beginners (learners), it may be
helpful to use a reflex (percussion) hammer.
1. Hold the hammer loosely between your thumb and index finger.
2. Bring the hammer down onto the tendon in a rapid, smooth movement.
3. Tap quickly and firmly.

4. Lift the hammer back up quickly.
5. Watch for how fast the response is. It is the speed of the response, not how
far the limb moves, that tells you if her reflexes are normal.
Reflexes are usually given a grade of 0 to +4. The scale of grading is:
0 no response
+1 low but within normal response
+2 average or normal response
+3 brisker than average
+4 very brisk, hyperactive, abnormal, may have rhythmic tremors (clonus)
Checking Reflexes
When checking reflexes, always check both sides (both arms or both legs). Check
that the response is similar on both sides. The biceps and patellar reflexes are the
common ones to use when looking for pre-eclampsia in pregnant women.
Biceps Reflex
1. Bend the woman's arm about halfway.

2. With your fingers, feel for her tendon on the inside of her elbow (antecubital
fossa). If it is difficult to locate, move her arm up and down while feeling. You will
notice a cord-like tendon.
3. If the woman is lying down, the bed will support her arm. If she is sitting up, you
will need to support her arm on yours. Place your thumb on the tendon.
Figure XX. Testing Biceps Reflex

4. Strike your thumbnail, which is positioned over the tendon. This causes the
biceps muscle to contract. You may or may not see the slight contraction at the
woman's elbow.
5. You will be able to feel the response from the tendon through your thumb. You
can grade the response by how fast you are able to feel the reflex response. You
will need to check many reflexes before you develop an awareness of what is
normal. Check your family, friends, and all of your clients to gain experience.
Patellar Reflex

1. Have the woman sit on the examining table or couch. Her legs should hang
freely.
2. Feel for her tendon right below the kneecap (patella). If it is difficult to locate,
move her lower leg a little while feeling at the same time.
Figure XX. Testing Patellar Reflex

3. Strike the tendon with a quick, firm tap and lift up immediately. You may also
use the side of your hand or your knuckle to tap the tendon.
4. Tapping the tendon will cause the quadriceps muscle to contract, causing the
lower leg to move.
5. The patellar reflex can also be tested with the woman lying in bed. Place one
hand under the leg, supporting it, and tap.
6. If the woman is tense and contracting her muscles, you will not get an accurate
test of her reflexes. You may need to talk to her and keep her attention away
from what you are doing.
Remember: A woman with severe pre-eclampsia who has hyper-reflexia (+3 or
+4) is very ill. She must be properly stabilised and transferred to a doctor/Level C
facility as quickly as possible. Care of women with pre-eclampsia can save the lives
of both the woman and foetus.
x Rule-out anemia: Check haemoglobin (if there is a laboratory) or check for signs of
anemia; if the woman has moderate anemia, treat appropriately, if the woman has
severe anemia, refer her to a hospital/doctor.
x Check for urinary tract infection or sexually transmitted infections (especially if the
woman has abundant vaginal secretions). If the woman has an STI or a UTI, treat
according to cause and following protocols.
REMEMBER:
x Because of changes in metabolism during pregnancy, the pregnant
woman will spill some protein in her urine and this is normal, as
long as it does not exceed 1+.
x Although proteinuria is most commonly associated with pre-

eclampsia or eclampsia, a woman's urine can test positive for
protein if she is severely anemic, has kidney disease, or has a UTI,
or if the urine has been contaminated by blood (or if she has
schistosomiasis), vaginal discharge, or amniotic fluid.
Differential diagnosis of hypertension in

pregnancy/postpartum
There are many types of hypertensive disorders in pregnancy. It is important to understand
them well, because their management differs. Table XX provides an overview of diagnostic
criteria for the different hypertensive disorders in pregnancy.
Table XX. Differential diagnosis of hypertensive disorders in pregnancy
Diastolic BP 90 mm Hg or more prior to
Chronic hypertension
first 20 weeks of gestation
In women with hypertension and
proteinuria before 20 weeks’ gestation
Preeclampsia superimposed on chronic any of the following are seen:
hypertension (women with hypertension and x New-onset proteinuria
no proteinuria x sudden increase in proteinuria,
early in pregnancy (<20 weeks’ gestation)) x sudden increase in blood pressure in a
woman whose hypertension has
previously been well controlled
Gestational hypertension:
(1) transient hypertension of pregnancy if
preeclampsia is not present at the time of Two readings of diastolic BP 90 mm Hg
delivery and blood pressure returns to normal or more but below 110 mm Hg 4 hours
by 12 weeks post partum (a retrospective apart after 20 weeks gestation, no
diagnosis) or proteinuria
(2) chronic hypertension if the elevation
persists.
Two readings of diastolic BP 90 mm Hg
Mild pre-eclampsia or more but below 110 mm Hg 4 hours
apart, proteinuria up to 2+
Diastolic BP 110 mm Hg or more,
Severe pre-eclampsia
proteinuria 3+ or more
A pregnant woman or a woman who has
recently given birth is found unconscious
Eclampsia or having convulsions (seizures),
diastolic BP 110 mm Hg or more,
proteinuria 2+ or more

Differential diagnosis of fits in pregnancy/postpartum
There are many causes for convulsions in pregnancy. It is important to understand them
well, because their management differs. Table XX provides an overview of diagnostic criteria
for the different disorders in pregnancy that may lead to convulsions.
Table XX. Differential diagnosis of fits in pregnancy
Presenting symptom and
Symptoms and signs sometimes Probable
other symptoms and
present diagnosis
signs typically present
x Coma (unconscious)
x Other signs and symptoms of severe
pre-eclampsia
- Headache (increasing frequency,
x Convulsions
unrelieved by regular analgesics)
x Diastolic BP 90 mm Hg or
- Blurred vision
more after 20 weeks Eclampsia
- Oliguria (passing less than 400 mL
gestation
in 24 hours)
x Proteinuria 2+ or more
- Upper abdominal pain (epigastric
pain or pain in upper right
quadrant)
- Pulmonary edema
x Spasms of face, neck, trunk
x Trismus (difficulty opening
x Arched back Tetanus
mouth and chewing)
x Spontaneous violent spasms
x Convulsions
x Past history of convulsions Epilepsy
x Normal blood pressure
x Fever
x Chills/rigor
Severe /
x Headache x Convulsions
complicated
x Muscle/joint pain x Jaundice
malaria
x Coma
x Anemia
x Headache x Convulsions
x Stiff neck x Confusion Meningitis or
x Photophobia x Drowsiness Encephalitis
x Fever x Coma
To make a differential diagnosis, carefully examine the woman and order tests /
examinations to confirm a diagnosis. If a pregnant woman presents with fits / convulsions,
it is best to begin treatment for eclampsia while you are waiting to rule out other causes.
A small proportion of women with eclampsia have normal

blood pressure. Treat all pregnant/postpartum women with
convulsions as if they have eclampsia until another diagnosis
is confirmed.
The following table gives of an overview of tests to consider performing to rule out or
confirm a diagnosis in a pregnant woman presenting with convulsions.

Eclampsia Epilepsy Cerebral malaria Meningitis
x Usually raised in cases
Blood pressure
of eclampsia
x Will contain protein x Urine may show
temporary proteinuria
Urine for protein after a fit, but
otherwise testing
shows no abnormality.
x In cerebral malaria,
Blood film to
more than 5 per cent
exclude malaria
of circulating red cells
will be parasitized
x Will be elevated in
Liver enzymes
x Eclampsia indicating
and function tests
liver damage
x Often low in pre-
Platelet count
eclampsia/eclampsia
Coagulation x Coagulation defects may
studies (bedside be present in eclampsia
clotting test)
Renal function x Urea may be elevated in x Blood urea is normal.
tests (plasma eclampsia indicating
electrolytes, kidney damage.
blood urea, x Creatinine clearance and
creatinine serum proteins may be
and uric acid) decreased
EEG (electro- x May show typical
encephalogram) abnormalities
x The cerebro-spinal fluid (CSF)
is under increased pressure
x The fluid looks cloudy in coccal
forms of meningitis but is clear
Examination of in viral meningitis
cerebrospinal x The causal organism is usually
fluid found under bacteriological
examination and the cell count
is increased
x Protein is increased, sugar and
chlorides decreased.

Prevention
Key definitions
Primary prevention of pre-eclampsia

By definition, primary prevention can help to avoid the development of a disease. Primary
prevention will be difficult to achieve for pre-eclampsia because the cause is not really
understood and most factors associated with it are difficult to avoid or manipulate.
Nevertheless, there are certain interventions that can serve to prevent pre-eclampsia.
Family planning
Pre-eclampsia is associated with pregnancy, and adolescent and older (more than 35 years
of age) women are at higher risk of pre-eclampsia, therefore prevention of pregnancy will
prevent pre-eclampsia. Of course, women will want to have children and cannot indefinitely
wait for pregnancy. However, family planning can help to delay the first pregnancy until the
woman is at least 20 or 21 years of age; can limit pregnancies beyond 35 years of age if
women no longer want to continue having children; and can ensure adequate spacing
between pregnancies to allow the woman to recover between pregnancies.
Obesity and insulin resistance
Obesity is a definite risk for developing gestational hypertensive disorders, including pre-
eclampsia. Obesity has a strong link with insulin resistance. The exact mechanisms by which
obesity/insulin resistance are associated with an increased risk for pre-eclampsia are not
completely understood. Prevention of or effective treatment of obesity, or both, could result
in a substantial decrease in its frequency. Having a (too) low birthweight as a consequence
of intrauterine growth restriction (IUGR) has also been identified as an important risk factor
of the so-called insulin resistance syndrome in adult life. Prevention of IUGR could therefore,
at least theoretically, contribute to primary prevention of pre-eclampsia (and IUGR) in the
next generation.16
Smoking
Cigarette smoking is associated with a 30–40% decrease in the risk of pre-eclampsia.17
However, this benefit is cancelled out by the substantial negative effect of smoking on fetal
growth, risk for placental abruption, and general health. Understanding the mechanisms of
the preventive effects of smoking on pre-eclampsia could help to unravel important aspects
of its pathophysiology.
Sperm exposure, the paternal factor, and age
Findings from studies on sperm exposure, paternity, and maternal age suggest that it is
better to:
x Stay with the same partner if a first pregnancy was not complicated by pre-eclampsia
x Have pregnancies only with low-risk men, and
x Have children at an age when the endothelium is still able to cope with the inflammatory
stress associated with the pregnant state.16
Health-care providers should realize that the antenatal care of a multiparous patient with a
new partner should be the same as in a woman presenting with her first pregnancy, at
least as far as the risk for pre-eclampsia is concerned.

Secondary prevention
Secondary prevention activities are aimed at early disease detection, thereby increasing
opportunities for interventions to prevent progression of pre-eclampsia. The ability to
prevent eclampsia is limited by lack of knowledge of its underlying cause. Prevention has
focused on identifying women at higher risk, followed by close clinical and laboratory
monitoring to recognize the disease process in its early stages. These women can then be
selected for more intensive monitoring or delivery. Although these measures do not prevent
pre-eclampsia, they may be helpful in preventing some adverse maternal and fetal sequelae
associated with symptoms and in preventing progression to eclampsia.
Antenatal care
Proper antenatal care is the most important part of secondary and tertiary prevention. The
decrease in maternal mortality and serious resulted mainly from the screening and
intervention (such as timed delivery) that comes with organized antenatal care. In order for
antenatal care to be effective, however, health care providers must be adequately trained to
identify, prevent, and manage pre-eclampsia and should have all of the essential
equipment, commodities, and consumables. In addition, adequate systems must be in place
to stabilize the woman and transfer her to the appropriate level of care.
Women, families, and communities need to understand danger signs and the importance of
seeking early antenatal care. During antenatal care, health care providers can assist women
and their families to develop a birth preparedness and complication readiness plan that will
ensure that women access care in a timely manner.
Use of low-dose aspirin to prevent preeclampsia
Benefits of low-dose aspirin prophylaxis are unproven for most women, including nulliparous
women. Despite earlier prospective studies that suggested that aspirin administration
reduced the incidence of preeclampsia, it is not recommended to routinely give aspirin for
prevention to women without risk factors. This opinion is based on the results of eight large
trials in different populations around the world. Overall these trials, which included >27,000
pregnant women, demonstrated minimal to no reduction in the incidence of preeclampsia
with low-dose aspirin therapy.18
Calcium supplementation
In a Cochrane review,19 calcium supplementation was associated with reduced hypertension
and preeclampsia, particularly for those at high risk of the disease and with a low baseline
dietary calcium intake (for those with an adequate calcium intake the difference was not
significant). No side effects of calcium supplementation were recorded in the trials reviewed.
However, the reduction was not indicated in any overall effect on stillbirths or neonatal
deaths. The data lend support to calcium supplementation for women at high risk of pre-
eclampsia and in communities with low dietary calcium intake. The absence of convincing
evidence of effectiveness from the largest trial (n=4589), which recorded no reduction in
the rate or severity of pre-eclampsia or in the timing of onset, have discouraged the use of
calcium supplementation in developed countries.
Other dietary supplements
Prophylactic magnesium supplementation has not been shown to be beneficial in preventing
preeclampsia.20 Three randomized trials of fish oil supplementation for women at high risk
for preeclampsia revealed no reduction in the incidence of preeclampsia. 16 A recent study
showing the benefits of vitamins C and E to prevent preeclampsia was encouraging but
needs further confirmation. 16

Tertiary prevention
Tertiary prevention focuses on the prevention of complications in women with pre-
eclampsia. Reduction of maternal and fetal/newborn mortality and serious morbidity
depends on timely diagnosis and easy referral. The three major interventions for
management of pre-eclampsia and eclampsia are anti-convulsant therapy, anti-hypertensive
treatment, and timed delivery of the baby.
Anti-convulsant medications
Magnesium sulfate reduces the risk of eclampsia21 without any substantive effect on longer-
term morbidity and mortality for the women or children.22, 23 Data from the Magpie study24
provide reassurance about the longer-term safety of magnesium sulfate when used for
women with pre-eclampsia. There appears to be no substantive effect on women's
subsequent fertility, or their use of health care services in the two years after the birth.
Data from the main Magpie Trial follow up study demonstrated that magnesium sulfate has
no clear effect on the child's risk of severe neurodevelopmental delay.23
For prevention of recurrent seizures in women with eclampsia, magnesium is more effective
and has fewer risks than phenytoin and diazepam.25
Anti-hypertensive medications
The goal of treatment of hypertension in pregnancy is to reduce maternal risk without
harming the fetus. Antihypertensive therapy is indicated for maternal benefit, but it may
also permit prolongation of the pregnancy and thereby improve fetal maturity. Acute falls in
maternal systemic blood pressure can result in fetal distress. Administration of a powerful
vasodilator will result in a decreased intervillous blood flow unless the blood pressure
decrease is accompanied by a (more or less specific) vasodilator response in the
uteroplacental circulation. If antihypertensive treatment is chosen, there is no clear choice
of drugs. By subgroup analysis, ǃ blockers could be less effective than calcium channel
blockers. 26 Refer to Table XX for a broad overview of advantages and disadvantages of
anti-hypertensive medications that may be used for management of pre-
eclampsia/eclampsia.16, 18
Medication Advantages Disadvantages
x Stable uteroplacental blood flow x Causes somnolence in many
and fetal hemodynamics individuals
Methyldopa x No long-term adverse effects on
development among children
exposed to methyldopa in utero
x Associated with more maternal and
perinatal adverse effects than other
Hydralazine (IV) drugs
x Should no longer be thought of as the
drug of choice 26
Adrenergic receptor x None of these agents has been
blocking agent associated with any consistent ill
(labetalol effects
hydrochloride)
x None of these agents has been x ǃ blockers prescribed during early
associated with any consistent ill pregnancy, specifically atenolol, may
ǃ -blockers effects be associated with growth restriction
x Long-term follow-up studies are
lacking
x A multicenter prospective cohort x Experience with calcium antagonists
Calcium antagonists study of first-trimester drug is limited
(nifedipine) exposures reported no increase in
major teratogenicity from these

Medication Advantages Disadvantages
agents
x Contraindicated in pregnancy in
settings in which uteroplacental
Diuretics perfusion is already reduced
(preeclampsia and intrauterine
growth restriction).
x Contraindicated during pregnancy
Angiotensin-
because of associations with fetal
converting enzyme
growth restriction, neonatal renal
inhibitors
failure, and neonatal death
Induction of labor
Apart from Cesarean operation or induction of labor (and therefore delivery of the placenta),
there is no known cure for pre-eclampsia. A decision to induce labor will need to weigh
benefits and risks for both the woman and fetus. The National High Blood Pressure
Education Program Working Group on High Blood Pressure in Pregnancy recommends the
following when considering delivering the baby to manage gestational hypertension:
“First, any therapy for preeclampsia other than delivery must have as its
successful end point the reduction of perinatal morbidity and mortality.
Second, the cornerstone of obstetric management of pre-eclampsia is
based on whether the fetus is more likely to survive without significant
neonatal complications in utero or in the nursery.”18
The decision to terminate pregnancy will depend upon:
1. Severity of the disease
2. Gestational age
3. Maternal and fetal condition
The WHO27 recommends the following for timing of delivery:
x In severe pre-eclampsia, delivery should occur within 24 hours of the onset of
symptoms.
x In eclampsia, delivery should occur within 12 hours of the onset of convulsions.
When the woman’s hypertensive disease is mild, induction of labor is associated with
improved maternal outcome and should be advised for women beyond 37 weeks’
gestation.28
Overview of interventions to prevent pre-eclampsia and

eclampsia

For an overview of preventive interventions, see Table XX.20

Reference manual
Management
Management protocols are copied from: WHO. MCPC. Geneva: WHO, 2003.
In order to detect early signs of pregnancy-induced hypertension and pre-eclampsia, regular
antenatal visits are necessary, especially in the third trimester of pregnancy. At each
antenatal visit, the woman’s blood pressure must be measured and her urine should be
checked for protein if diastolic blood pressure is more than 90mmHg. Pregnant women
should be encouraged to come for antenatal care early in their pregnancy so that a baseline
value for their blood pressure can be obtained.
If there is a rise in blood pressure, the woman should be closely monitored at frequent
intervals. If proteinuria develops, she should be admitted to a health facility capable of
coping with a woman who may develop eclampsia.
Gestational hypertension
Diagnostic criteria
x Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after
20 weeks gestation
x No proteinuria
Management
The woman is usually managed as an outpatient and followed up weekly at home or at a
local clinic. Management on an outpatient basis at each visit:
x Monitor blood pressure, urine (for proteinuria) and fetal condition (growth, movement,
heart rate) weekly
x Check if the woman has severe headache, visual disturbances or abdominal pain
x Counsel the woman and her family about the danger signals of severe pre-eclampsia,
ensuring that they know the importance of obtaining immediate medical help if any of the
signs develop.
x If the blood pressure decreases to normal levels and there are no other complications, the
condition has stabilized and the woman should be allowed to proceed with normal labour
and childbirth.
If the blood pressure rises, however, and/or proteinuria develops, or there is significant fetal
growth restriction (signs of poor fetal growth) or fetal compromise (abnormal fetal
Mild pre-eclampsia - Gestation less than 37 weeks

Diagnostic criteria
20 weeks gestation
x Proteinuria up to 2+
Management
If signs remain unchanged or normalize, follow up twice a week as an outpatient:
x Monitor blood pressure, urine (for proteinuria), reflexes and fetal condition.

x Counsel the woman and her family about danger signals of severe pre-eclampsia or
eclampsia.
x Encourage additional periods of rest.
x Encourage the woman to eat a normal diet (salt restriction should be discouraged).
x Do not give anticonvulsants, anti-hypertensives, sedatives or tranquillizers.
x If follow-up as an outpatient is not possible, admit the woman to the hospital:
- Provide a normal diet (salt restriction should be discouraged);
- Monitor blood pressure (twice daily) and urine for proteinuria (daily);
- Do not give anticonvulsants, anti-hypertensives, sedatives or tranquillizers unless
blood pressure or urinary protein level increases;
- Do not give diuretics. Diuretics are harmful and only indicated for use in pre-
eclampsia with pulmonary edema or congestive heart failure;
- If the diastolic pressure decreases to normal levels or her condition remains
stable, send the woman home:
- Advise her to rest and to watch out for significant swelling or symptoms of severe
pre-eclampsia;
- See her twice weekly to monitor blood pressure, urine (for proteinuria) and fetal
condition and to assess for symptoms and signs of severe pre-eclampsia;
- If diastolic pressure rises again, readmit her;
- If the signs remain unchanged, keep the woman in the hospital. Continue the
same management and monitor fetal growth by symphysis-fundal height;
- If there are signs of growth restriction, consider early delivery. If not, continue
hospitalization until term.
x If urinary protein level increases, manage as severe pre-eclampsia (see below).
Note: Symptoms and signs of pre-eclampsia do not completely disappear until after
pregnancy ends.
Mild pre-eclampsia - Gestation more than 37 complete

weeks
Diagnostic criteria
20 weeks gestation
x Proteinuria up to 2+
Management
If there are signs of fetal compromise, assess the cervix and expedite delivery:
x If the cervix is favorable (soft, thin, partly dilated), rupture the membranes with an
amniotic hook or a Kocher clamp and induce labor using oxytocin or prostaglandins.
x If the cervix is unfavorable (firm, thick, closed), ripen the cervix using prostaglandins
or a Foley catheter or deliver by cesarean operation.
Severe pre-eclampsia and eclampsia

Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery
must occur within 12 hours of onset of convulsions in eclampsia. ALL cases of severe pre-

Reference manual
eclampsia should be managed actively. Symptoms and signs of “impending eclampsia”

(blurred vision, hyperreflexia) are unreliable and expectant management is not
recommended.
Diagnostic criteria – severe pre-eclampsia
x Diastolic BP 110 mm Hg or more
Diagnostic criteria –eclampsia
x A pregnant woman or a woman who has recently given birth is found unconscious or having
convulsions (seizures), diastolic BP 110 mm Hg or more
Management during a convulsion
x Give anticonvulsive drugs (see below).
x Gather equipment (airway, suction, mask and bag, oxygen) and give oxygen at 4–6 L
per minute.
x Protect the woman from injury but do not actively restrain her.
x Place the woman on her left side to reduce risk of aspiration of secretions, vomit and
blood.
x After the convulsion, aspirate the mouth and throat as necessary.
General management
x If diastolic blood pressure remains above 110 mm Hg, give antihypertensive
drugs (see below). Reduce the diastolic blood pressure to less than 100 mm Hg but not
below 90 mm Hg.
x Start an IV infusion and infuse IV fluids.
x Maintain a strict fluid balance chart and monitor the amount of fluids administered and
urine output to ensure that there is no fluid overload.
x Catheterize the bladder to monitor urine output and proteinuria.
x If urine output is less than 30 mL per hour:
- Withhold magnesium sulfate and infuse IV fluids (normal saline or Ringer’s lactate)
at 1 L in 8 hours;
- Monitor for the development of pulmonary edema.
x Never leave the woman alone. A convulsion followed by aspiration of vomit may
cause death of the woman and fetus.
x Observe vital signs, reflexes and fetal heart rate hourly.
x Auscultate the lung bases hourly for rales indicating pulmonary edema. If rales are
heard, withhold fluids and give furosemide 40 mg IV once.
x Assess clotting status with a bedside clotting test. Failure of a clot to form after 7
minutes or a soft clot that breaks down easily suggests coagulopathy.
Anticonvulsive drugs
A key factor in anticonvulsive therapy is adequate administration of anticonvulsive drugs.
Convulsions in hospitalized women are most frequently caused by under-treatment.
Magnesium sulfate is the drug of choice for preventing and treating convulsions in
severe pre-eclampsia and eclampsia. Administration is outlined in Box 1.

BOX 1 Magnesium sulfate schedules for severe pre-eclampsia and eclampsia
Loading dose
x Magnesium sulfate 20% solution, 4 g IV over 5 minutes.
x Follow promptly with 10 g of 50% magnesium sulfate solution, 5 g in each buttock as
deep IM injection with 1 mL of 2% lignocaine in the same syringe.
Ensure that aseptic technique is practiced when giving magnesium sulfate deep IM
injection. Warn the woman that a feeling of warmth will be felt when magnesium
sulfate is given.
x If convulsions recur after 15 minutes, give 2 g magnesium sulfate (50% solution) IV
over 5 minutes.
Maintenance dose
x 5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2% IM every 4 hours into
alternate buttocks.
x Continue treatment with magnesium sulfate for 24 hours after delivery or the last
convulsion, whichever occurs last.
Before repeat administration, ensure that:
x Respiratory rate is at least 16 per minute.
x Patellar reflexes are present.
x Urinary output is at least 30 mL per hour over 4 hours.
WITHHOLD OR DELAY DRUG IF:
x Respiratory rate falls below 16 per minute.
x Patellar reflexes are absent.
x Urinary output falls below 30 mL per hour over preceding 4 hours.
Keep antidote ready
x In case of respiratory arrest:
- Assist ventilation (mask and bag, anesthesia apparatus, intubation). Give calcium
gluconate 1 g (10 mL of 10% solution) IV slowly until respiration begins to
antagonize the effects of magnesium sulfate.
If magnesium sulfate is not available, diazepam may be used although there is a
greater risk for neonatal respiratory depression because diazepam passes the placenta
freely. A single dose of diazepam to abort a convulsion seldom causes neonatal respiratory
depression. Long-term continuous IV administration increases the risk of respiratory
depression in babies who may already be suffering from the effects of utero-placental
ischemia and preterm birth. The effect may last several days. Administration of diazepam is
outlined in Box 2.
BOX 2 Diazepam schedules for severe pre-eclampsia and eclampsia
Note: Use diazepam only if magnesium sulfate is not available.
Intravenous administration
Loading dose
x Diazepam 10 mg IV slowly over 2 minutes.
x If convulsions recur, repeat loading dose.
Maintenance dose
x Diazepam 40 mg in 500 mL IV fluids (normal saline or Ringer’s lactate) titrated to
keep the woman sedated but rousable.
x Maternal respiratory depression may occur when dose exceeds 30 mg in 1 hour:
- Assist ventilation (mask and bag, anesthesia apparatus, intubation), if
necessary.
- Do not give more than 100 mg in 24 hours.
Rectal administration
x Give diazepam rectally when IV access is not possible. The loading dose is 20 mg
in a 10 mL syringe. Remove the needle, lubricate the barrel and insert the syringe

Reference manual
into the rectum to half its length. Discharge the contents and leave the syringe in
place, holding the buttocks together for 10 minutes to prevent expulsion of the
drug. Alternatively, the drug may be instilled in the rectum through a catheter.
x If convulsions are not controlled within 10 minutes, administer an additional
10 mg per hour or more, depending on the size of the woman and her clinical
response.
Antihypertensive drugs
If the diastolic pressure is 110 mm Hg or more, give antihypertensive drugs. The goal
is to keep the diastolic pressure between 90 mm Hg and 100 mm Hg to prevent cerebral
hemorrhage. Labetolol and nifedipine are the drugs of choice.
x Give labetolol 10 mg IV
- If response is inadequate (diastolic blood pressure remains above 110 mm Hg)
after 10 minutes, give labetolol 20 mg IV;
- Increase the dose to 40 mg and then 80 mg if satisfactory response is not obtained
after 10 minutes of each dose;
OR
x Give nifedipine 5 mg under the tongue:
- If response is inadequate (diastolic pressure remains above 110 mm Hg) after 10
minutes, give an additional 5 mg under the tongue.
Note: There is concern regarding a possibility for an interaction with magnesium sulfate
that can lead to hypotension.
Delivery
Delivery should take place as soon as the woman’s condition has stabilized. Delaying
delivery to increase fetal maturity will risk the lives of both the woman and the fetus.
Delivery should occur regardless of the gestational age.
In severe pre-eclampsia, delivery should occur within 24 hours of
the onset of symptoms. In eclampsia, delivery should occur
within 12 hours of the onset of convulsions.
x Assess the cervix.
x If the cervix is favorable (soft, thin, partly dilated), rupture the membranes with an
amniotic hook or a Kocher clamp and induce labor using oxytocin or prostaglandins.
x If vaginal delivery is not anticipated within 12 hours (for eclampsia) or 24 hours (for
severe pre-eclampsia), deliver by cesarean operation.
x If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per
minute), deliver by cesarean operation.
x If the cervix is unfavorable (firm, thick, closed) and the fetus is alive, deliver by
cesarean operation.
x If safe anesthesia is not available for cesarean operation or if the fetus is dead
or too premature for survival:
- Aim for vaginal delivery;
- If the cervix is unfavorable (firm, thick, closed), ripen the cervix using
misoprostol, prostaglandins or a Foley catheter.
Note: If cesarean operation is performed, ensure that:
x Coagulopathy has been ruled out;

x Safe general anesthesia is available. Spinal anesthesia is associated with the risk of
hypotension. This risk can be reduced if adequate IV fluids (500–1 000 mL) are infused
prior to administration of the anesthetic.
Do not use local anesthesia or ketamine in women with pre-eclampsia or
eclampsia.
Postpartum care
x Anticonvulsive therapy should be maintained for 24 hours after delivery or the last
convulsion, whichever occurs last.
x Continue antihypertensive therapy as long as the diastolic pressure is 110 mm Hg or
more.
x Continue to monitor urine output.
x Ensure counseling about family planning in the postpartum period.
Referral for tertiary level care

Consider referral of women who have:
x oliguria that persists for 48 hours after delivery;
x coagulation failure [e.g. coagulopathy or hemolysis, elevated liver enzymes and low
platelets (HELLP) syndrome];
x persistent coma lasting more than 24 hours after convulsion.
Complications of gestational hypertension

Complications may cause adverse perinatal and maternal outcomes. Because complications
are often difficult to treat, efforts should be made to prevent them by early diagnosis and
proper management. Health care providers should be aware that management could also
lead to complications. Manage complications as follows:
x If fetal growth restriction is severe, expedite delivery.
x If there is increasing drowsiness or coma, suspect cerebral hemorrhage:
- Reduce blood pressure slowly to reduce the risk of cerebral hemorrhage;
- Provide supportive therapy.
x If heart, kidney or liver failure is suspected, provide supportive therapy and observe.
x If a clotting test shows failure of a clot to form after 7 minutes or a soft clot that breaks
down easily, suspect coagulopathy.
x If the woman has IV lines and catheters, she is prone to infection. Use proper infection
prevention techniques and closely monitor for signs of infection.
x If the woman is receiving IV fluids, she is at risk of circulatory overload. Maintain a strict
fluid balance chart and monitor the amount of fluids administered and urine output.

Reference manual
Managing obstetric emergencies

Management protocols are copied from: WHO. MCPC. Geneva: WHO, 2003.
General management for an obstetric emergency

Emergencies can happen suddenly, as with a convulsion, or they can develop as a result of
a complication that is not properly managed or monitored.
Preventing emergencies
Most emergencies can be prevented by:
x careful planning;
x following clinical guidelines;
x Close monitoring of the woman.
Responding to an emergency
Responding to an emergency promptly and effectively requires that members of the clinical
team know their roles and how the team should function to respond most effectively to
emergencies. Team members should also know:
x clinical situations and their diagnoses and treatments;
x drugs and their use, administration and side effects;
x Emergency equipment and how it functions.
Note: The ability of a facility to deal with emergencies should

be assessed and reinforced by frequent practice emergency
drills.
Initial management
In managing an emergency:
x Stay calm. Think logically and focus on the needs of the woman.
x Do not leave the woman unattended.
x Take charge. Avoid confusion by having one person in charge.
x SHOUT FOR HELP. Have one person go for help and have another person gather
emergency equipment and supplies (e.g. oxygen cylinder, emergency kit).
x If the woman is unconscious, assess the airway, breathing and circulation.
x If shock is suspected, immediately begin treatment. Even if signs of shock are not
present, keep shock in mind as you evaluate the woman further because her status
may worsen rapidly. If shock develops, it is important to begin treatment
immediately.
x Position the woman lying down on her left side with her feet elevated. Loosen tight
clothing.

x Talk to the woman and help her to stay calm. Ask what happened and what
symptoms she is experiencing.
x Perform a quick examination including vital signs (blood pressure, pulse, respiration,
temperature) and skin color.
x Estimate the amount of blood lost and assess symptoms and signs.
General management for shock

Signs and symptoms usually seen in shock:
Fast, weak pulse (110 per minute or more).
Low blood pressure (systolic less than 90 mm Hg).
Other signs and symptoms of shock include:
Pallor (especially of inner eyelid, palms, or around the mouth).
Sweaty or cold, clammy skin.
Rapid breathing (rate of 30 breaths per minute or more).
Anxiousness, confusion, or unconsciousness.
Low urine output (less than 30 mL per hour).
Immediate management of shock

Shout for help. Urgently mobilize all available personnel.
Evaluate vital signs (pulse, blood pressure, respiration, temperature).
Turn the woman onto her side to reduce the risk of aspiration from vomiting and to
ensure an open airway.
Keep the woman warm; however, avoid overheating which increases peripheral
circulation and reduces blood supply to the vital organs.
Elevate the legs to increase return of blood to the heart (if possible, raise the foot
end of the bed).
Specific management
Start an IV infusion (or two if possible) using a large-bore cannula or needle (16
gauge or largest available).
Collect blood to test hemoglobin; do an immediate cross-match and bedside clotting
(see below) before infusion of fluids:
Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the
rate of 1 L in 15 to 20 minutes.
Note: Avoid using plasma substitutes (e.g., dextran) because

there is no evidence that plasma substitutes are superior to
normal saline in resuscitating a shocked woman. In addition,
dextran can be harmful in large doses.
Give at least 2 L of these fluids in the first hour. (This amount is in

addition to fluids given for lost blood.)

Reference manual
Note: Do not give fluids by mouth to a woman in shock. A

quicker rate of infusion is needed in the management of shock
from bleeding. Aim to replace 2 to 3 times the estimated fluid
loss.
When finding a peripheral vein is not possible, do a venous cut-down.

Continue to monitor vital signs and blood loss (every 15 minutes).
Catheterize the bladder and monitor fluid intake and urine output.
If available, give oxygen at 6 to 8 L per minute by mask or nasal cannula.
Bedside clotting test

Assess blood clotting status using this bedside clotting test:
1. Take 2 mL of venous blood into a small, dry, clean, plain glass test-tube
(approximately 10 mm x 75 mm).
2. Hold the tube in your closed fist to keep it warm (+37°C).
3. After four minutes, tip the tube slowly to see if a clot is forming. Then tip
it again every minute until the blood clots and the tube can be turned
upside down.
4. If a clot does not form after seven minutes or a soft clot forms that breaks
down easily, the woman may have a blood clotting disorder.
Decide and manage the cause of shock

After the woman is stabilized, determine the cause of shock and manage the condition
accordingly.

Reference manual
Birth preparedness and complication readiness

When delays occur in recognizing problems and referring women to appropriate health care
facilities, the result can lead to maternal and newborn deaths. One solution to combat these
problems is to work with the pregnant woman and her family to develop two plans: a birth-
preparedness plan and a complication-readiness plan.64
Birth-preparedness plan
Having a birth plan can reduce delayed decision-making and increase the probability of
timely care. A birth-preparedness plan is an action plan made by the woman, her family
members, and the health care provider. Often this plan is not a written document, but
instead is an ongoing discussion between all concerned parties to ensure that the woman
receives the best care in a timely manner. Each family should have the opportunity to make
a plan for the birth. Health care providers can help the woman and her family to develop
birth-preparedness plans and discuss birth-related issues. Work with the woman to:
Make plans for the birth:
Discuss the idea of a birth plan and what to include during the first visit.
Inquire about the birth-preparedness plan during the third or fourth antenatal visits.
Ask if arrangements are made for a skilled birth attendant and the birth setting
during the antenatal visit in the eighth month.
If planning a home delivery with a skilled birth attendant, discuss access to a safe
delivery kit consisting of 1) a piece of soap for cleaning the birth attendant’s hands
and the woman’s perineum, 2) a plastic sheet about one square meter for use as a
clean delivery surface, 3) clean string for tying the umbilical cord (usually two
pieces), and 4) a clean razor blade for cutting the cord.
Make birth-related decisions:
Where to give birth.
Who will be the skilled birth attendant.
How to contact the provider.
How to get to the place of birth.
Who will be the birth companion.
Who will take care of the family while the woman is absent.
How much money is needed and how to access these funds.
Prepare for the birth:
Discuss items needed for the birth (perineal pads/cloths, soap, clean bed sheets,
etc.) on the third antenatal visit.
Confirm necessary items are gathered near the due date.
Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor 33
Note: In some cultures, superstition surrounds buying items
for an unborn baby. If this is not the case, families can prepare
for the birth by buying baby supplies such as blankets, diapers,
and clothes.
Save money:
Discuss why and how to save money in preparation for the birth during the first visit.
Discuss how to plan to make sure that any funds needed are available at birth.
Check that the woman and her family have begun saving money or that they have
ways to access necessary funds.
Note: Encourage the family to save money so necessary funds

are available for routine care during pregnancy and birth.
Assess financial needs with the women as well as sources for
accessing these funds so they are available before labor.
Complication-readiness plan
The complication-readiness plan is an action plan that outlines steps that can be discussed
and determined prior to an emergency. Developing this plan helps the family to be prepared
for and respond quickly when the woman or newborn has a complication and needs medical
care. It is important that a complication-readiness plan is prepared with the woman and her
chosen family members. Unless others are involved, the woman may have difficulties
putting the plan into action should complications occur for her or her baby.
Recognize danger signs
Women, family members, and community caregivers must know the signs of life-
threatening complications. Many hours can be lost from the time a complication is
recognized until the time arrangements are made for the woman to reach help. For PPH, the
time from the start of bleeding to death can be as little as two hours. In too many cases,
families of women who died in pregnancy, birth, or postpartum, did not recognize the
problem in time. It is critical to reduce the time needed to recognize problems and make
arrangements to receive care at the most appropriate level of care. Women, family
members, and community caregivers must know the signs of life-threatening complications.
Maternal danger signs include:

Vaginal bleeding (any vaginal bleeding during pregnancy; heavy vaginal bleeding or
a sudden increase in vaginal bleeding during the postpartum period).
Breathing difficulties.
Fever.
Severe abdominal pain.
Severe headache/blurred vision.
Convulsions or loss of consciousness.
Foul-smelling discharge from vagina, tears, and incisions.
Calf pain with or without swelling.
Night blindness.
Verbalization or behavior indicating she may hurt the baby or herself.
Hallucinations.

Reference manual
Newborn danger signs include:

Breathing problems.
Feeding difficulties or not sucking.
Feels cold or has fever.
Redness, swelling, or pus from eyes or around the cord or umbilicus.
Convulsions or fits.
Jaundice (yellow skin).
Save money
Similar to the birth preparedness plan, the family should be encouraged to save money so
necessary funds are available for emergencies. In many situations, women either do not
seek or receive care because they lack funding to pay for services.
Choose a decision-maker in case of emergency

In many families, one person is the primary decision-maker. Too often, other members of
the family do not feel they can make decisions if that person is absent. This can result in
death when an emergency occurs and the primary decision-maker is absent. It is important
to discuss how the family can make emergency decisions without disrupting or offending
cultural and family values. If possible, find out which family member can make a decision in
the absence of the chief decision-maker.
Have an emergency transportation plan

Too many women and newborns die because they suffer serious complications and do not
have access to transportation to the type of health care facility that can provide needed
care. Each family should develop a transportation plan during the woman’s early pregnancy
in case the woman experiences complications and urgently needs a higher level of care. This
plan should be prepared during pregnancy and after giving birth, either before discharge
from the health facility or immediately after returning home. The plan should address the
following:
Where to go if complications arise.
How to get to the next level of care in case of an emergency.
Who in the family will accompany the woman.
Have an emergency blood donation plan

Many health care facilities lack an inadequate, safe blood supply for transfusions. After
birth, women are more likely to need blood transfusions because the complications they
experience from birth lead to blood loss. For these reasons, it is extremely important
that the woman and her family determine blood donors that can be available if needed.
Reference manual
References
1
World Health Organization (WHO) Mother-Baby Package: Implementing Safe Motherhood in
Countries. WHO/FHE/MSM/94.11. Geneva: WHO; 1994.
2
The world health report 2005 – Make every mother and child count. Geneva, World Health
Organization, 2005 (http://www.who.int/whr/2005/en, accessed 14 August 2008).
3
Munjuluri N, Lipman M, Valentine A, Hardiman P, Maclean AB (November 2005). "Postpartum
eclampsia of late onset". BMJ 331 (7524): 1070–1. doi:10.1136/bmj.331.7524.1070. PMID 16269495
4 Craici I, Wagner S, Garovic VD. Preeclampsia and future cardiovascular risk: formal risk factor or
failed stress test?. Ther Adv Cardiovasc Dis. Aug 2008;2(4):249-59. [Medline].
5
Gabbe. Hypertension. In: Obstetrics: Normal and Problem Pregnancies. 5th ed. Churchill Livingstone,
An Imprint of Elsevier; 2007:[Full Text].
6
Roberts J M, Cooper D W. Pathogenesis and genetics of pre-eclampsia. Lancet 2001; 357: 53–56
7
World Health Organization (WHO) Department of Making Pregnancy Safer. Midwifery Education
Modules (2nd Edition): Managing eclampsia. Geneva, Switzerland: WHO; 2008.
8
Marti JJ, Hermann U. Immunogestosis: a new etiologic concept of “essential” EPH gestosis, with
special consideration of the primigravid
patient. Am J Obstet Gynecol 1977; 128: 489–93.

9
Robillard PY, Dekker GA, Hulsey TC. Revisiting the epidemiological standard of preeclampsia:
primigravidity or primipaternity. Eur J Obstet
Gynecol Reprod Biol 1999; 84: 37–41.

10
G Justus Hofmeyr1
11
Anne-Marie Côté,
12
Jason J. S. Waugh,
13
Thangaratinam
14
Jeltsje S Cnossen
15
John R Higgins, Michael de Swiet
16
Dekker
17
Conde-Agudelo A, Belizan JM. Risk factors for pre-eclampsia in a large cohort of Latin American and
Caribbean women. Br J Obstet Gynaecol 2000; 107: 75–83.
18
National High Blood Pressure Education Program Working Group on High Blood Pressure
in Pregnancy
19
Hofmeyr GJ, Atallah ÁN, Duley L
20
Baha Sibai,
21
Magpie Trial Collaborative Group: Do women with pre-eclampsia, and their babies, benefit from
magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002,
359(9321):1877-90.
22
Th Magpie Trial Follow-up Study Collaborative Group: The Magpie Trial: a randomised trial
comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for children at 18 months.
BJOG 2007, 114(3):289-299.
23
The Magpie Trial Follow-up Study Collaborative Group: The Magpie Trial : a randomised trial
comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for women at two years.
BJOG 2007, 114(3):300-309
24
Smyth, 2009
25
Duley L, Carroli G, Belizan J, et al. Which anticonvulsant for women with eclampsia: evidence from
the collaborative eclampsia trial. Lancet 1995; 345: 1455–63.
26
Magee LA, Ornstein MP, von Dadelszen P. Management of hypertension in pregnancy. BMJ 1999;
318: 1332–36.
27
WHO. MCPC.
28
Corine M Koopmans, Denise Bijlenga, Henk Groen, Sylvia M C Vijgen, Jan G Aarnoudse, Dick J
Bekedam, Paul P van den Berg, Karin de Boer, Jan M Burggraaff , Kitty W M Bloemenkamp, Addy P
Drogtrop, Arie Franx, Christianne J M de Groot, Anjoke J M Huisjes, Anneke Kwee, Aren J van Loon,
Annemiek Lub, Dimitri N M Papatsonis, Joris A M van der Post, Frans J M E Roumen, Hubertina C J
Scheepers, Christine Willekes, Ben W J Mol, Maria G van Pampus, for the HYPITAT study group*
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Baltimore, MD: JHPIEGO/MNH; 2001.
38 Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor

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Prevention and

A Reference Manual for Health Care Providers

Maternal and Child Health Integrated Project

Prevention and management of pre-eclampsia and eclampsia i

ii Prevention and management of pre-eclampsia and eclampsia

For more information or additional copies of this report, please contact:

Prevention and management of pre-eclampsia and eclampsia iii

USAID United States Agency for International Development

WHO World Health Organization

iv Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia v

About the learning materials

vi Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia vii

Prevention and management of pre-eclampsia and eclampsia 1

Epidemiology of pre-eclampsia and eclampsia

2 Prevention and management of pre-eclampsia and eclampsia

Morbidity and mortality associated with pre-eclampsia and

Prevention and management of pre-eclampsia and eclampsia 3

4 Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia 5

Prevention and management of pre-eclampsia and eclampsia 7

Blood pressure measurements at the first antenatal visit for healthy

Detecting hypertensive disorders in pregnancy

8 Prevention and management of pre-eclampsia and eclampsia

x The normal BP is between 80/60 and 140/90

Prevention and management of pre-eclampsia and eclampsia 9

10 Prevention and management of pre-eclampsia and eclampsia

1. Bend the woman's arm about halfway.

Figure XX. Testing Biceps Reflex

Prevention and management of pre-eclampsia and eclampsia 11

Figure XX. Testing Patellar Reflex

12 Prevention and management of pre-eclampsia and eclampsia

Differential diagnosis of hypertension in

Prevention and management of pre-eclampsia and eclampsia 13

A small proportion of women with eclampsia have normal

14 Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia 15

Primary prevention of pre-eclampsia

Prevention and management of pre-eclampsia and eclampsia 17

18 Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia 19

Overview of interventions to prevent pre-eclampsia and

20 Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia 21

Mild pre-eclampsia - Gestation less than 37 weeks

Prevention and management of pre-eclampsia and eclampsia 23

Mild pre-eclampsia - Gestation more than 37 complete

Severe pre-eclampsia and eclampsia

24 Prevention and management of pre-eclampsia and eclampsia

eclampsia should be managed actively. Symptoms and signs of “impending eclampsia”

Prevention and management of pre-eclampsia and eclampsia 25

26 Prevention and management of pre-eclampsia and eclampsia

Prevention and management of pre-eclampsia and eclampsia 27

Referral for tertiary level care

Complications of gestational hypertension

28 Prevention and management of pre-eclampsia and eclampsia

Managing obstetric emergencies

General management for an obstetric emergency

Note: The ability of a facility to deal with emergencies should

Prevention and management of pre-eclampsia and eclampsia 29

General management for shock

eclampsia should be managed actively. Symptoms and signs of “impending eclampsia”

Give at least 2 L of these fluids in the first hour. (This amount is in

When finding a peripheral vein is not possible, do a venous cut-down.

patient. Am J Obstet Gynecol 1977; 128: 489–93.

Gynecol Reprod Biol 1999; 84: 37–41.