Download - Mid Essex Hospital Services NHS Trust

MANAGEMENT OF PRE-ECLAMPSIA AND HYPERTENSION
ON THE DAY ASSESSMENT UNIT
CLINICAL GUIDELINES
Register No: 11006
Status:
Public
Developed in response to:
Intrapartum NICE Guidelines
RCOG guideline
Contributes to CQC Outcome
4
Consulted With
Post/Committee/Group
Anita Rao/
Clinical Director for Women’s, Children’s and Sexual Health
Alison Cuthbertson Directorate
Chris Spencer
Consultant for Obstetrics and Gynaecology
Sam Brayshaw
Anaesthetic Consultant
Alison Cuthbertson Head of Midwifery / Nursing
Deb Cobie
Lead Midwife Labour Ward and Acute Inpatient Services Manager
Chris Berner
Maternity Risk Manager
Diane Roberts
Lead Midwife Community Services; Named Midwife Safeguarding
Gemma May
Practice Development Midwife
Professionally Approved By
Dr Rao
Lead Consultant for Obstetrics and Gynaecology
Version Number
Issuing Directorate
Ratified By
Ratified On
Implemented on
Executive Management Group Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in
conjunction with)
Review No
1.0
1.1
1.2
2.0
2.1
Date
August 2014
August 2014
2.1
Obstetrics and Gynaecology
Documents Ratification Group Chairmans Action
30th October 2014
3rd November 2014
November 2014
October 2017
Madhu Joshi, Consultant for Obstetrics and Gynaecology
Midwives, Obstetricians, Paediatricians
Intranet & Website. Notified on Staff Focus
04071 Standard Infection Prevention
04072 Hand Hygiene
06036 Guideline for Maternity Record Keeping including
Documentation in Handheld Records
05110 Management of eclampsia and severe pre-eclampsia
06033 Referral and Care of Women on The Antenatal
Assessment and Treatment Unit
07043 Abdominal palpation and examination in pregnancy
06034 Reduced Fetal Movements
Reviewed by
Sue Alcide
Sarah Moon - clarification to 6.2
Anita Rao - clarification to 10.1
Madhu Joshi
Madhu Joshi - clarification to point 9.3 ; bullet point 4
Active Date
October 2011
December 2012
February 2014
October 2014
14 December 2015
1
INDEX
1.
Purpose
2.
Equality and Diversity
3.
Incidence
4.
Background
5.
Definitions
6.
Antenatal Care and General Aspects
7.
Symptoms and Signs of Pre-Eclampsia
8.
Antiplatelet Agents
9.
Assessment in the Day Assessment Unit
10.
Assessment of Proteinuria in Hypertensive Disorders of Pregnancy
11.
Management of Different Hypertensive Disorders
12.
Fetal Monitoring
13.
Corticosteroids for Fetal Lung Maturation
14.
Role of the DAU Midwife in Relation to Mild Hypertension
15.
Role of the DAU Midwife in Relation to Moderate/Severe Hypertension
16.
Blood Tests Relating to Pre-eclampsia
17.
Laboratory tests for Proteinuria
18.
Umbilical Artery Doppler
19.
DAU Obstetric Review
20.
Allocate to a Named Consultant
21.
Follow-up Monitoring on the Day Assessment Unit and Community Setting
22.
Staff and Training
23.
Supervisor of Midwives
24.
Infection Prevention
25.
Audit and Monitoring
26.
Communication
27.
References
28.
Appendices
Appendix A
Appendix B
-
Hypertension/ Pre Eclampsia Flowcharts
Antenatal Pharmacological Management
2
1.0
Purpose
1.1
To ensure a system of clear referral pathways are established, so that pregnant patients
who require additional care are managed and treated by the appropriate specialist team
when problems are identified.
1.2
To set clear definitions of pregnant patients who will be appropriate for referral/
admission.
1.3
To provide an individualised service, during assessment, treatment or admission.
Antenatal care should be readily and easily accessible to all patients and should be
sensitive to the needs of the individual patient and local community.
2.0
Equality and Diversity
2.1
Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is
fair, accessible and meets the needs of all individuals.
3.0
Incidence
3.1
Hypertension is the most frequent complication of pregnancy, occurring in 10% of
pregnancies, and Pre-eclampsia is one of the main causes of maternal and fetal
morbidity and mortality (CEMACH 2004, 2007, 2011; CESDI 1999, 2001; Waterstone et
al, 2001).
3.2
Hypertensive disorders are the second commonest direct cause of maternal death and
the leading single identifiable risk factor in pregnancy associated with stillbirth, about 7%
of which are directly caused by pre-eclampsia.
4.0
Background
4.1
Hypertension is the most common first sign of pre-eclampsia. In the most recent UK
perinatal mortality report, 1 in 20 (5%) stillbirths in infants without congenital abnormality
occurred in women with pre-eclampsia. Pre-eclampsia is also associated with fetal
growth restriction, low birth weight, preterm delivery, small for gestational age (SGA)
infants and respiratory distress syndrome (The Magpie Collaborative Group, 2002). 8–
10% of all preterm births result from hypertensive disorders. Preterm delivery occurs in
half of women with severe pre-eclampsia.
4.2
New hypertension can occur without significant proteinuria (gestational hypertension) or
with significant proteinuria (pre- eclampsia).
4.3
Hypertensive disorders during pregnancy can occur in women with chronic hypertension,
(pre existing hypertension).
4.4
Treatment and care should take into account women’s individual needs and preferences.
Good communication is essential supported by evidence based information, to allow
women to reach informed decisions about their care.
3
5.0
Definitions
5.1
Degrees of hypertension
•
•
•
Mild Hypertension - 140/90 – 149/99
Moderate Hypertension –150/100-159/109
Severe Hypertension - >160/100
•
New hypertension - hypertension at or after 20 weeks gestation in a patient with a
diastolic blood pressure of less than 90mmHg before 20 weeks
Gestational hypertension or Pregnancy induced hypertension - new hypertension
presenting after 20 weeks without significant proteinuria
Chronic hypertension - a diastolic blood pressure pre-pregnancy or at booking (before
20 weeks) of 90mmHg or more or that is being treated at the time of referral to
maternity services
•
•
5.2
Degrees of proteinuria:
•
•
5.3
New proteinuria - the presence of proteinuria as shown by 1+ (0.3g/l) or more on
proteinuria dipstick testing o or a urine protein excretion of 300mg or more per 24
hours
Significant proteinuria - urine protein excretion ≥ 300mg per 24 hours
Definitions of hypertension:
•
Pre-eclampsia - new hypertension and significant proteinuria at or after 20 weeks of
pregnancy, confirmed if it resolves after delivery
Superimposed pre-eclampsia - the development of features of pre-eclampsia in the
context of existing hypertension, existing proteinuria or both
Severe pre- eclampsia. Pre- eclampsia with severe hypertension and/or with
symptoms, and/or biochemical and/or haematological impairment
Eclampsia Convulsive condition associated with pre-eclampsia
•
•
•
6.0
Antenatal Care and General Aspects
6.1
As part of routine antenatal care all women in their first ongoing pregnancy should be
reviewed (including BP measurement, urine dipstick and pre-eclampsia symptoms/signs
assessment) every 3-4 weeks from 24 weeks gestation.
(Refer to the guideline entitled ‘Maternity Care’; register number 042722)
7.0
Symptoms and Signs of Pre-eclampsia
7.1
Pregnant women should be made aware of the need to seek immediate advice from a
healthcare professional if they experience symptoms of pre-eclampsia.
7.2
Symptoms include:
•
•
•
•
•
•
Headache
Visual disturbances, such as blurring or flashing lights before the eyes
Epigastric pain or right upper quadrant (RUQ) pain
Nausea or vomiting
Sudden swelling of the face, hands or feet
Decreased fetal movements
4
7.3
Signs include:
•
•
•
•
•
•
Raised BP and proteinuria
Oedema (facial in particular)
Clonus (>3 beats is significant)
Liver edge or epigastric tenderness
Papilloedema
Blood tests abnormalities (haemolysis, alterations of liver function tests, decreased
platelets, increased creatinine, increased urate)
8.0
Antiplatelet Agents
8.1
Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily from 12 weeks
until the birth of the baby.
8.2
Women at high risk are those with any of the following:
•
•
•
•
•
•
•
Hypertensive disease during a previous pregnancy
Chronic kidney disease
Autoimmune disease such as systemic lupus erythematosus or antiphospholipid
syndrome
Type 1 or type 2 diabetes
Pre-existing hypertension
Sickle cell disease
PAPP-A < 0.3 MoM
8.3
Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg
of aspirin daily from 12 weeks until the birth of the baby.
8.4
Factors indicating moderate risk are:
•
•
•
•
•
First pregnancy age > 40 years
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m2 or more at first visit
Family history of pre-eclampsia
Multiple pregnancy.
9.0
Assessment in the Day Assessment Unit (DAU)
(Refer to Appendix A)
9.1
Maternal and fetal assessment to be undertaken within 30 minutes of admission to unit;
once the woman has been shown to her bed or assessment area.
9.2
Large cuffs must be used for patients with an arm circumference of 41cm or more. Use
equipment that is accurate in measuring hypertensive individuals; automated devices
that are accurate in pregnancy can under-read by clinically significant amounts in
patients with pre-eclampsia. The most accurate is the standard mercury
sphygmomanometer. The environment should be relaxed, quite and preferably after rest.
9.3
Clinical assessment by the midwife should be consistent and documented as follows in
the patients healthcare records:
5
•
•
•
•
•
•
•
Review of current obstetric history - note the most recent community dipstick test
result and date; gestational age; booking blood pressure; booking dipstick protein
results; booking risk factors
Clinical assessment of maternal symptoms relating to pre-eclampsia – visual
disturbance (‘tunnelling’), headaches, nausea, epigastric pain/ right upper quadrant
pain
Clinical assessment of fetal size and wellbeing relating to pre-eclampsia. This
generally includes measurement of symphysis -fundal height and clinical enquiry
about fetal movements. (Refer to the guideline entitled ‘Abdominal palpation and
examination in pregnancy’ register number 07043; and the guideline entitled ‘Reduced
fetal movements’, register number 06034)
If there are no concerns regarding the fetal movements and the fetal growth is normal
(and no other concerns in relation to the fetus) routinely a CTG is not required.
However, if a CTG is required, it should be undertaken for women who are more than
equal to 28 weeks gestation
Dipstick test for proteinuria - dipstick proteinuria (none, trace, 1+, 2+, >2+ protein)
Obtain PET bloods
Obstetric review
10.0
Assessment of Proteinuria in Hypertensive Disorders of Pregnancy
10.1
Use urine dipstick or a spot urinary protein:creatinine ratio (PCR) for estimating
proteinuria.
•
•
•
10.2
Perform midstream specimen of urine (MSU) to exclude infection (if leucocytes and/or
nitrite +)
If dipstick urinalysis of 1+ proteinuria is obtained use a spot urinary PCR to quantify
the proteinuria.
If proteinuria is confirmed without hypertension the patient should be referred to the
linked consultant for assessment.
Use of PCR as a diagnostic test for PET
•
•
•
•
•
•
Urinary PCR greater than 50 mg/mmol is diagnostic of PET and no further testing is
required
If the protein creatinine ratio is between 30-49 mg/mmol proceed to a 24-hour urine
collection, if this is greater than 300 mg protein in 24 hours it is diagnostic of PET.
If the urine volume on 24 hour collection is less than a litre, this may result in a false
negative for proteinuria
Consultant at any time may decide to proceed to a 24 hour urine collection
There is no need to repeat quantification of proteinuria once pre-eclampsia is proven.
Adequate blood pressure control, normal PET bloods and asymptomatic for PET then
a 24 hour urine collection if required may be carried out as an outpatient (i.e. PCR is
30-49mg/mmol).
11.0
Management of Different Hypertensive Disorders
11.1
Pre-existing Hypertension/Chronic Hypertension
11.1.1 Antenatal Management
•
Women who have had hypertension diagnosed prior to (or in early) pregnancy should
be referred to their lead obstetric consultant by 14 weeks gestation.
6
•
•
•
•
•
(Refer to appendix for pharmacological management for details on treatment)
In women taking ACE inhibitors or ARBs or diuretics stop antihypertensive treatment
pre-pregnancy if possible or when they become pregnant and offer alternatives if
blood pressure remains > 150/100 mmHg.
In pregnant women with uncomplicated essential hypertension aim to keep blood
pressure lower than 150/100 mmHg. Do not offer treatment to lower diastolic
pressure below 80mmHg in these patients.
If the blood pressure is satisfactory without treatment the woman should be
counselled that antihypertensive medication may be required at 26-30 weeks
gestation.
Offer pregnant women with target-organ damage secondary to chronic hypertension
(for example, kidney disease) treatment with the aim of keeping blood pressure lower
than 140/90 mmHg.
Schedule additional antenatal consultations based on the individual needs of the
woman and her baby.
11.1.2 Timing of Birth
•
•
•
Do not plan delivery before 37 weeks in women with pre-existing hypertension whose
blood pressure is lower than 160/110 mmHg, with or without antihypertensive
treatment.
After 37 weeks, timing of birth and maternal and fetal indications for birth should be
agreed between the woman and the link-obstetrician/ obstetric medicine team.
If the blood pressure is well controlled, there is no superimposed PET and the fetal
growth is normal, then pre-existing hypertension per se is not an indication for
induction.
11.2 Management of Pregnancy Induced Hypertension (PIH)
11.2.1 Antenatal Care
•
•
•
Initial assessment of women with PIH should be carried out in DAU or in their link
consultant clinic within 48 hours (unless sever which should be reviewed that day).
In women receiving outpatient care for severe PIH, after it has been effectively
controlled, measure blood pressure and test urine twice weekly and carry out weekly
blood tests.
In women with mild or moderate hypertension presenting before 32 weeks, or at high
risk of pre-eclampsia, measure blood pressure and test urine twice weekly.
11.2.2 Table 1. Management of Pregnancy Induced Hypertension
Degree of
Hypertension
Mild Hypertension
(140/90-149/99
mmHg)
Admit to
Hospital
No
Treatment
No changes
Moderate
Hypertension
(150/100-159/109
mmHg)
No
With first line drug
therapy to keep:
• Diastolic BP
between
80-100mmHg
Sever Hypertension
(160/110mmHg or
higher)
Yes
(until blood pressure is
159/109 mmHg or less)
With first line drug
therapy to keep:
• Diastolic
BP
between
7
•
Measure
Blood
Pressure
Test for
Proteinuria
Blood tests
Systolic BP
less than 150
mmHg
80-100mmHg
• Systolic BP
less than
150mmHg
At least four times a day
Not more than once
a week
At least twice a week
At each visit a
urinalysis dipstick
Only those for
routine antenatal
care
At each visit a
urinalysis dipstick
PET Blood tests
Daily urinalysis dipstick
Do not carry out
further blood tests if
no proteinuria at
subsequent visits
Test at presentation and
then twice weekly
PET blood tests
.
11.2.3 Timing of Birth
•
11.3
Follow the same recommendations as described for pre-existing hypertension
Management of pre-eclampsia
11.3.1 Treatment
• If PET confirmed admit the woman (usually until delivery).
• The rationale for admitting women with a diagnosis of pre-eclampsia is the
increased risk of placental abruption and eclampsia.
• On admission, any symptom relating or possibly relating to pre-eclampsia
(headache, abdominal pain, breathlessness) should prompt consideration of a full
set of observations (temperature, pulse, respiratory rate, blood pressure), PET
bloods, and medical review.
11.3.2 Table 2. Management of pregnancy with pre-eclampsia
Degree of
Hypertension
Mild Hypertension
(140/90-149/99
mmHg)
Admit to
Hospital
Treatment
Yes
No changes
Measure
At least four times a
Moderate
Hypertension
(150/100-159/109
mmHg)
Yes
With first line drug
therapy to keep:
• Diastolic BP
between
80-100 mmHg
• Systolic BP
less than 150
mmHg
At least four times a
Severe Hypertension
(160/110 mmHg or
higher)
Yes
With first line drug
therapy to keep:
• Diastolic BP
between
80-100 mmHg
• Systolic BP less
than 150 mmHg
More than four times a
8
Blood
Pressure
Test for
Proteinuria
Blood Tests
day
day
Daily dipstick urine
(Do not repeat
quantification of
proteinuria)
Daily dipstick urine
(Do not repeat
quantification of
proteinuria)
day depending upon
clinical circumstances
Daily dipstick urine
(Do not repeat
quantification of
proteinuria)
PET Bloods
PET Bloods
PET Bloods
Test at presentation
and then three times
weekly
Test at presentation
and then three times
weekly
Test at presentation
and then three times
weekly/ daily at
consultant’s discretion
11.3.3 Timing of birth
•
Initial stabilization of the maternal condition leads to a safer delivery by whatever
route.
Check to see if the patient fits the criteria for inclusion in the Severe PET Protocol.
Consultant obstetric staff should document in the woman’s notes the maternal
(biochemical, haematological and clinical) and fetal thresholds for elective birth
before 34 weeks in women with pre-eclampsia.
Possible criteria for intervention:
•
•
•
Fetal indications:
• No fetal growth 2-4 weeks
• Reversed EDF
•
•
•
•
•
•
•
Maternal indications
Persistent significant symptoms of PET
Platelets <70 x109 /l
ALT>100 IU/L
Albumin<20 g/L
Creatinine > 120 μmol/L
Inability to control SBP<160mmHg
Recommend birth within 24–48 hours for women who have pre-eclampsia at 38
weeks.
12.0
Fetal Monitoring
12.1
Women at High Risk of Pre-eclampsia
•
•
Carry out uterine artery Doppler between 20 and 24 weeks.
Carry out ultrasound fetal growth and amniotic fluid volume assessment and
umbilical artery Doppler velocimetry starting at 28-30 weeks (or at least 2 weeks
before previous gestational age of onset if earlier than 28 weeks) and repeating
4 weeks later in women with previous:
• Severe pre-eclampsia
• Pre-eclampsia that needed birth before 34 weeks
• Pre-eclampsia with a baby whose birth weight was < 10th centile
• Intrauterine death
9
• Placental abruption
12.2
Pre-existing hypertension
12.2.1 Carry out uterine artery Doppler between 20 and 24 weeks.
12.2.2 Carry out ultrasound fetal growth and amniotic fluid volume assessment and umbilical
artery doppler velocimetry 28-30 weeks and 32-34 weeks. If results are normal, do not
repeat at more than 34 weeks, unless otherwise clinically indicated.
12.2.3 Only carry out CTG if fetal activity is abnormal.
12.3 Mild and moderate PIH
12.3.1 In women with mild or moderate gestational hypertension, carry out ultrasound fetal
growth and amniotic fluid volume assessment and umbilical artery Doppler velocimetry if
diagnosis is confirmed at less than 34 weeks (do not perform these tests if diagnosis is
confirmed beyond 34 weeks). If results are normal, do not repeat at more than 34 weeks,
unless otherwise clinically indicated.
12.3.2 Only carry out CTG if fetal activity is abnormal.
12.4
Severe PIH or pre-eclampsia
12.4.1 If conservative management is planned, carry out ultrasound fetal growth and amniotic
fluid volume assessment and umbilical artery doppler velocimetry at diagnosis.
•
•
Repeat them every 2 weeks.
If the umbilical Doppler is above the normal range repeat weekly if end diastolic flow
present and twice weekly if absent
12.4.2 Carry out CTG at diagnosis.
•
If the results of all fetal monitoring are normal do not routinely repeat CTG more than
weekly, unless any of the following occur:
• The woman reports a change in fetal movement
• Vaginal bleeding
• Abdominal pain
• Deterioration in maternal condition.
12.4.3 Document a care plan that includes all of the following:
•
•
The timing and nature of future fetal monitoring
Fetal indications for birth and if and when corticosteroids should be given when
discussion with neonatal paediatricians and obstetric anaesthetists should take place
and what decisions should be made.
13.0
Corticosteroids for Fetal Lung Maturation
13.1
If birth is considered likely within 7 days in women with pre-eclampsia:
•
13.2
in women between 24 and 34 weeks give two doses of betamethasone 12 mg
intramuscularly 24 hours apart
Consider the same treatment in women between 35 and 36 weeks.
10
14.0
Role of the DAU Midwife in Relation to Mild Hypertension
(Refer to Appendix A)
14.1
The DAU midwife should undertake the following action in relation to mild hypertension
14.2 New proteinuria without hypertension – if there is no clinical suspicion of fetal
compromise, no maternal symptoms but there is 1+ of proteinuria on the dipstick the
following should be performed:
•
•
•
•
•
•
•
14.3
Diastolic BP 90-99 mmHg:
•
•
•
•
•
•
•
14.4
Blood tests relating to pre-eclampsia
(Refer to point 5.2)
Cardiotocograph (CTG) monitoring
Ultrasound growth and liquor if concern with growth
Arrange an appointment to attend DAU as an outpatient
Abnormal blood test and/ or Doppler results arrange an obstetric review
Normal blood tests and Doppler results allocate patient to a named obstetric
consultant
Monitor at least weekly from DAU, do not routinely repeat blood tests
Diastolic BP 90 - 99mmHg and 1+ proteinuria:
•
•
•
•
•
14.4
No significant proteinuria – contact the community lead to arrange the next preeclampsia assessment in the community within one week
In the presence of significant proteinuria, arrange for the patient to be reviewed by
the obstetric registrar/ consultant on call
If there are 2+ or more proteinuria on the dipstick, blood tests relating to preeclampsia (full blood count (FBC), clotting, liver function tests (LFT’s) and LDH
should be obtained and sent for analysis
Arrange PCR
Obtain and send a mid stream specimen of urine for culture and sensitivity (MSU) to
exclude infection
The patient should be reviewed by the obstetric registrar/ consultant on call
Ultrasound: growth/ liquor/ umbilical artery Doppler, abnormal blood tests and /or
Doppler or significant proteinuria
24 hour urine collection as an out-patient (if no maternal symptoms or clinical
suspicion of fetal compromise)
Blood tests relating to pre-eclampsia, the patient should wait for the result
Perform a CTG
Ultrasound for growth and liquor
Attend DAU as an outpatient
Diastolic BP 90-99mmHg and new proteinuria ≥ 2+ on dipstick:
• 24 hour urine collection as out-patient (if no maternal symptoms or clinical suspicion of
fetal compromise)
• The patient should be admitted and reviewed by the obstetric registrar or consultant on
call
• Blood tests relating to pre-eclampsia (Refer to point 5.2)
• Perform a CTG
11
• Ultrasound growth/ liquor/Umbilical artery Doppler should be considered following
Assessment
15.0
Role of the DAU Midwife in Relation to Moderate/Severe Hypertension
(Refer to Appendix A)
15.1
Diastolic BP ≥ 100 mmHg or Systolic BP ≥ 100mmHg:
•
•
•
•
15.2
Diastolic BP ≥ 110 mmHg with new proteinuria of 1+:
• The patient should be admitted to labour ward and reviewed by the obstetric
registrar/ consultant on call
• 24 hour urinary collection
• Blood test relating to pre-eclampsia (consider cannulation)
• Perform a CTG
• Ultrasound growth/ liquor/ umbilical artery Doppler
16.0
16.1
The patient should be admitted to labour ward and reviewed by the obstetric
registrar/ consultant on call
Blood tests should be obtained relating to pre-eclampsia i.e. full blood count, urea
and electrolytes, uric acid and clotting studies (consider cannulation). PCR should
be performed
A cardiotocograph (CTG) should be performed
Umbilical artery Doppler’s should be considered following assessment
Blood Tests Relating to Pre-eclampsia
The blood tests relating to pre-eclampsia are as follows:
•
•
•
Platelet count
Transaminases -AST
Serum urate and serum creatinine
(Serum urate is not required if there is no proteinuria)
• Full blood count
• LDH (lactate dehydrogenase) > 600 U/L (signifies haemolysis and/or infarction)
16.2
Use pregnancy-specific normal ranges for platelets, transaminases and creatinine;
gestational age dependent ranges for serum urate as shown below:
AST
ALT
Non –pregnant
7 - 40
0 - 40
1st trimester
10 - 28
6 - 32
2nd Trimester
11 - 29
6 - 32
3rd Trimester
11 - 30
6 - 32
Platelet count
<150x10 9/L
Creatinine
>90microgmol/L
12
16.3
Liver function tests: gestation specific 95% reference ranges (2.5th centile – 97.5th
centile) in normal population.
16.4
It is imperative that the DAU midwife follows up all results within 24 hours of the blood
sample being obtained by accessing the results/sample diary.
16.5
Laboratory test results should be available within no more than 24 hours of the patient
attending and the same day where practically possible, with a mechanism to review the
tests and talk to the patient concerned within those 24 hours.
16.6
If any of the blood tests results are outside the normal range, the obstetric registrar/
consultant on call should review the results. The DAU midwife should contact the patient
concerned to discuss the results with the revised antenatal care plan.
16.7
If the blood tests are within the normal range, contact the pregnant patient and arrange/
confirm appointment in DAU to repeat assessments in one week
(Refer to 4.1)
17.0
Laboratory Tests for Proteinuria
17.1
The DAU midwife should test the urine to exclude or confirm significant proteinuria in
patients with 1+ dipstick proteinuria. If there is a trace of proteinuria apparent from the
Day Assessment Unit sample and 1+ of proteinuria from the community sample; use the
community result. Greater than or equal to one plus of protein requires further
investigations.
17.2
A 24 hour urine collection of ≥ 300mg in 24 hours both confirms and quantifies
proteinuria. It is not necessary to repeat this once proteinuria has been confirmed.
17.3
In addition, a protein creatinine ratio (PCR) can be analysed by the MEHT laboratory
technicians which is an instant assessment of protein; but the 24 hour urine collection
remains the gold standard for the quantitative proteinuria. For example:
•
•
17.4
PCR < 30mg/mmol excludes significant proteinuria
PCR > 30mg/mmol does not reliably quantify proteinuria, so a 24 hour urine collection
may be required
For patients with new hypertension between 90-99mmHg diastolic and 1+ proteinuria in
this guideline the decision to admit should been deferred until the results of the urinary
proteins are known. This is appropriate only when there are no maternal symptoms or
clinical suspicion of fetal compromise.
18.0
Umbilical Artery Doppler
18.1
The Pre-eclampsia Community Guideline (PRECOG) group recommend umbilical artery
Doppler as the best test for predicting an at-risk fetus relating to pre-eclampsia in a
patient with pre-term new hypertension and no clinical suspicion of fetal compromise.
18.2
Abnormal umbilical artery Doppler thresholds include:
•
•
19.0
Umbilical artery PI > 2SD
Absent or reverse end diastolic flow
DAU Obstetric Review
13
19.1
An obstetric review should be arranged within the Day Unit attended by the obstetric
registrar/ consultant on call for the following patients in line with this guideline:
•
•
•
If a patient has an abnormal blood test result
An abnormal Doppler
Patients with new hypertension (100-109mmHg diastolic or 150-159mmHg systolic)
without proteinuria
19.2
Following review of the patient the obstetric registrar/ consultant on call should amend
the patient’s individual antenatal care plan, documented in the patient’s healthcare
records.
20.0
Allocation to a Named Consultant
20.1
All patients who reach the threshold for a midwifery assessment in DAU,
(Diastolic >90mmHg) are at higher risk of pre-eclampsia and poor outcomes associated
with the diagnosis. The DAU midwife should ensure that all patients who have had
midwifery assessment have been allocated to a named obstetric consultant before they
leave the DAU (with the exception to the patients who after a midwife assessment in
DAU have no hypertension, no proteinuria, no relevant symptoms and a healthy baby).
20.2
The named obstetric consultant will either directly or indirectly determine subsequent
management which should recorded in the patient’s plan of care, documented in the
healthcare records.
21.0
Follow-up Monitoring on the Day Assessment Unit and Community Setting
21.1
The DAU midwife should arrange a subsequent assessment no longer than 7 days
(minimum standard) after the initial assessment and sooner if appropriate. Frequency of
assessments should be determined on an individual basis, depending on blood test/
Doppler results, gestational age, history and following an antenatal care plan determined
by the named consultant in consultation with the pregnant patient.
21.2
For patients with new hypertension of 90-99mmHg without proteinuria with no relevant
symptoms, a normal umbilical artery Doppler and blood tests that are within the normal
range at the first assessment; this assessment should be repeated in one week.
21.3
If there is no change in signs or symptoms, do not routinely repeat the blood tests. A
review by the obstetric registrar/ consultant on call may be appropriate if the
hypertension is persistent. Progression, as shown by changing blood parameters,
emerging symptomatology or change in signs will require reviewed by the obstetric
registrar/ consultant on call review resulting in a possible admission episode.
21.4
Arrange for the patient to be assessed in the community within a maximum of 7 days of
leaving the Day Assessment Unit if she has no hypertension, no new or significant
proteinuria, no symptoms and there is no suspicion of fetal compromise.
21.5
In the subsequent plan of care there should be an interval of no more than 2 weeks
between assessments; these patients are no longer within the NICE guideline
recommendations for routine antenatal care and all are at higher risk of developing preeclampsia.
21.6
Some patients will have had transient signs/ symptoms that will recur. Offer a DAU
14
assessment to detect and act on any signs and symptoms.
21.7
Before a patient leaves her initial DAU assessment she should have the following:
•
•
•
•
•
•
•
Information to understand the signs and symptoms of fulminating pre-eclampsia, the
rate at which it may develop and the potential seriousness of her situation to include
the hypertension and pre-eclampsia patient information leaflet
(Refer to Appendix B)
A mechanism to report and act on any new symptoms that she may notice herself;
encourage her to self monitor
Patient handheld records or a DAU summary from her assessment
A follow-up appointment
Allocation to a named obstetric consultant
Agreed mechanisms by which the patient will be informed of her test results and
discuss any change to her antenatal care plan within 24 hours
An understanding that she can be proactive in following up any results and arranging
a follow up appointment if the contact arrangements do not work
22.0
Staffing and Training
22.1
All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training.
22.2
All midwifery and obstetric staff are to ensure that their knowledge and skills are
up-to-date in order to complete their portfolio for appraisal.
23.0
Supervisor of Midwives
23.1
The supervision of midwives is a statutory responsibility that provides a mechanism for
support and guidance to every midwife practising in the UK. The purpose of supervision
is to protect women and babies, while supporting midwives to be fit for practice'. This role
is carried out on our behalf by local supervising authorities. Advice should be sought from
the supervisors of midwives who are experienced practising midwives who have
undertaken further education in order to supervise midwifery services. A 24 hour on call
rota operates to ensure that a Supervisor of Midwives is available to advise and support
midwives and women in their care choices.
24.0
Infection Prevention
24.1
All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively ‘decontaminate their hands’ before and after each procedure.
24.2
All staff should ensure that they follow Trust guidelines on infection prevention. All
invasive devices must be inserted and cared for using High Impact Intervention
guidelines to reduce the risk of infection and deliver safe care. This care should be
recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork
(Medical Devices).
15
25.0
Audit and Monitoring
25.1
Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy, the Maternity annual audit work
plan and the NHSLA/CNST requirements. The Audit Lead in liaison with the Risk
Management Group will identify a lead for the audit.
25.2
The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will
be developed to address any identified deficiencies. Performance against the action plan
will be monitored by this group at subsequent meetings.
25.3
The audit report will be reported to the monthly Maternity Directorate Governance
Meeting (MDGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.
25.4
Key findings and learning points from the audit will be submitted to the Patient Safety
Group within the integrated learning report.
25.5
Key findings and learning points will be disseminated to relevant staff.
26.0
Communication
26.1
A quarterly ‘maternity newsletter’ is issued and available to all staff including an update
on the latest ‘guidelines’ information such as a list of newly approved guidelines for staff
to acknowledge and familiarise themselves with and practice accordingly.
26.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.
26.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.
26.4 Regular memos are posted on the ‘Risk Management’ notice boards in each clinical area
to notify staff of the latest revised guidelines and how to access guidelines via the
intranet or clinical guideline folders.
27.0
References
Pre-eclampsia Community Guideline PRECOG DAU Guideline. 2008.
(www.apec.org.uk)
CEMACH Saving Mothers Lives (2007) 7th report of confidential Enquiries into Maternal
and Child Health, 2003-2005. CEMACH RCOG London: 2007.
Royal College of Obstetricians and Gynaecologists (2006) Management of severe preeclampsia/eclampsia, Green Top Guideline10 (A), RCOG, London.
Pre-eclampsia Community Guideline (2004) March. PRECOG
CEMACH, Why Mothers Die. (2004) 6th Report of confidential Enquiries into Maternal
and Child Health.2000-2003 CEMACH RCOG London:
16
Appendix A
Hypertension/ Pre Eclampsia Flowchart
Care in Day Assessment Unit
Carry out full assessment in Day Assessment Unit
A healthcare professional trained in the management of hypertensive disorders should carry out
the assessment
Take into account previous history of pre-eclampsia or gestational hypertension, pre-existing
vascular or kidney disease, moderate risk factors for pre-eclampsia and gestational age at
presentation
Mild hypertension
Moderate hypertension
Severe hypertension
(BP 140/90–149/99 mmHg)
(BP 150/100–
159/109mmHg)
(BP ≥
160/110 mmHg)
Clinical assessment for
maternal symptoms
Clinical assessment of
fetal size and wellbeing,
consider ultrasound for
growth and liquor
volume
Follow mild criteria, with
the addition ofArrange an obstetric
review
Consider Umbilical
artery Dopplers
Dipstick test for
proteinuria, if 1+>
consider 24 hour
collection
Consider first line oral
Labetalol
Serial BP- 3x 15 minute
intervals
Consider
corticosteroids if less
than 35 weeks
gestation
Blood tests relating to
Pre eclampsia.
Following mild/
moderate criteria, with
the addition ofAdmit to Labour ward
Consider cannulation
when obtaining blood
samples
No
Yes
Refer to care in
labour
Timing of birth
Before 34 weeks gestation
Manage conservatively, make plan of care, offer steroids,
offer birth if maternal, clinical indications develop.
34-36 weeks gestation
Offer birth if Pre Eclampsia with mild or moderate
hypertension depending on maternal and fetal condition,
risk factors and availability of neonatal intensive care
After 37 weeks gestation recommend birth within 24 -48
hours, if pre-eclampsia with mild or moderate
hypertension
In patients receiving
outpatient care after
severe hypertension has
been effectively
controlled in hospital:
Measure BP and test
for proteinuria
2 times a week
Carry out blood tests
weekly
17
RECOMMENDATION 10: FLOWCHART 1
New proteinuria without hypertension; no
suspicion of fetal compromise or symptoms
1+ proteinuria on dipstick
2+ proteinuria or more on dipstick
Blood tests for pre-eclampsia;
24 hour urine collection
24 hour urine collection
Significant proteinuria
Arrange medical review
No significant proteinuria
Community assessment
within 1 week
Oxford Sonicare CTG
Normal blood test and
CTG; no significant
proteinuria
Allocate to named consultant;
monitor at least weekly
Abnormal blood and/or
CTGor significant
proteinuria
Arrange medical review
Key: PCR: Urinary protein creatinine ratio Blood tests for pre-eclampsia: platelet count; AST or ALT; serum creatinine; serum urate
Guideline: precog DAU/ recommendation 10 flowcharts
18
RECOMMENDATION 10: FLOWCHART 2
New hypertension and new proteinuria; no
suspicion of fetal compromise or symptoms
Diastolic BP ≥
110mmHg and new
proteinuria of 1+
Diastolic Bp 100109mmHg and new
proteinuria of 1+
ADMIT
Arrange medical
review to consider
admission
Diastolic BP ≥
90mmHg and new
proteinuria 2+ or more
ADMIT
No significant
proteinuria, normal
blood test and Doppler
results
Allocate to named consultant
Monitor at least weekly
Diastolic BP 90-99mmHg and 1+
proteinuria (use higher of community or
DAU results)
24 hour urine collection as
outpatient; blood tests for
pre-eclampsia
Significant proteinuria
ADMIT
Oxford Sonicare
CTG
Abnormal blood
and/or CTG
Arrange medical
review
Key: PCR: Urinary protein creatinine ratio Blood tests for pre-eclampsia: platelet count; AST or ALT; serum creatinine; serum urate
Guideline: precog DAU/ recommendation 10 flowcharts
19
RECOMMENDATION 10: FLOWCHART 3
New hypertension without proteinuria; no
clinical suspicion of fetal compromise and
no symptoms
Diastolic BP ≥110mmHg or
Systolic BP ≥ 170mmHg
ADMIT
Diastolic BP 100-109mmHg or
Systolic BP 160-169mmHg
Arrange medical review to
consider admission
Diastolic BP 90-99mmHg
Blood tests for preeclampsia.
Abnormal CTGand/or
blood test results
Arrange medical review
CTG
CTGand blood test results
Allocate to named consultant;
Monitor at least weekly. Do not
routinely repeat blood tests
Key: PCR: Urinary protein creatinine ratio Blood tests for pre-eclampsia: platelet count; AST or ALT; serum creatinine; serum urate
Guideline: precog DAU/ recommendation 10 flowcharts
20
Appendix B
Antenatal Pharmacological Management
Drugs for the treatment of hypertension in pregnancy
AGENTS
DOSE
COMMENTS
Labetalol
200 mg bd – 600 mg qds
Contraindicated in moderate-severe asthma. May be
associated with neonatal bradycardia
First line therapy
Methyldopa
250 mg bd – 1g tds
May cause lethargy and dizziness, rarely depression
and deranged liver function tests
First line therapy
Nifedipine
10 – 40 mg SR bd
Possible interference with labour. Hypotension
reported with concominant use of magnesium
sulphate in preeclampsia.
May cause headache, flushing and peripheral
oedema
First line therapy
Hydralazine
25 – 75mg tds
Second / Third line therapy
Amlodipine
5-10mg od
Third line therapy if nifedipine not tolerated or poor
concordance with bd / tds therapy
Doxazocin
1mg od – 8 mg bd
Third line therapy
21