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
2010
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.
About MCHIP
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
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:
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.
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.
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
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
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-
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.
Key definitions
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
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
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;
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.
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.
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.
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.
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.
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.
Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor 35
36 Prevention and management of pre-eclampsia and eclampsia
Reference manual
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Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor 37
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38 Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor