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Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia A Clinical Guideline For Use in: By: Obstetrics All Staff Caring for Pregnant Women For: Pregnant Women Division responsible for document: Women / Children Key words: severe pre-eclampsia (PET), eclampsia Name of document author: Job title of document author: Name of document author’s Line Manager: Job title of author’s Line Manager: Mrs Daisy Nirmal Consultant, Obstetrics and Gynaecology Supported by: Obstetric Guidelines Committee Assessed and approved by the: Obstetric Guidelines Committee Date of approval: 28/10/2015 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Reference and / or Trust Docs ID No: Version No: Clinical Standards Group and Effectiveness Sub-Board Description of changes: No significant changes Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE?If so why? Alastair McKelvey Consultant Obstetrician 28/10/2018 Mrs Daisy Nirmal AO4 id 887 8 (e.g. NICE, CQC) Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 1 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia Quick reference guideline/s Appendix A: Antihypertensive therapy in severe PET Recheck BP every 5 min If sustained over 15 min Recheck BP every 15 min Recheck BP every 15 min If sustained over 45 min MAP < 125 Recheck MAP mmHg After 5 min (Confirm with manual sphyg) MAP>125 mmHg Repeat labetalol 50 mg every 5 min (max. dose 200mg) until either or MAP ≥125 mmHg Consider referral to HDU/ITU Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 2 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia Appendix B: Fluid balance in women with severe PET who have a CVP Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 3 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia Objectives & Rationale Hypertension is the most common medical disorder of pregnancy and both severe PET and eclampsia are life-threatening conditions, as well as causing significant morbidity. Although the incidence of eclampsia and its complications in the United Kingdom appears to have declined since 1992, severe pre-eclampsia/eclampsia remains the second highest cause of direct maternal deaths. Furthermore, the importance of adequate treatment of systolic hypertension has been one of the “Top ten” recommendations in the last two confidential enquiries into maternal deaths. Locally, severe PET is the commonest reason for patients to receive Level 2 Intensive Care on the Delivery Suite. Broad recommendations The principles of management of severe PET are to stabilise the maternal condition by controlling blood pressure, prevent seizures, then to deliver the baby by the safest route. Measurement of blood pressure Initially, the blood pressure should be measured using a manual sphygmomanometer, and recorded to the nearest 2mmHg. The diastolic pressure should be measured at the disappearance of sounds (Korotkoff phase V) and NOT as muffling (Korotkoff phase IV), as recommended in the past. A large BP cuff should be used when the upper arm circumference exceeds 33 cm. Assessment and diagnosis of severe Pre-eclampsia Although the diagnosis of severe hypertension is based on the absolute BP, the subsequent management is largely based on the mean arterial pressure or MAP (the MAP is usually taken as the diastolic BP plus 1/3 the systolic – diastolic difference). 1. Absolute BP 160mmHg systolic or ≥110mmHg diastolic with proteinuria 2+ (1g./L) or more. 2. Absolute BP >140/90 (or else a rise in systolic BP of 25mmHg and/or a rise in diastolic BP of ≥15 mmHg from first trimester values) with proteinuria ≥2+ (1g./L) or protein creatinine ratio (PCR) >30mg/mmol or more and one of the following:a. headaches, visual disturbance, dyspnoea, chest or epigastric pain. b. clonus > 3 beats c. platelets <100 x 109 /lL or urate >450 umol/lL or ALT >50 u/L d. creatinine greater than 100 umol/L 3. Eclampsia – a seizure occurring in a patient with PET 4. H.E.L.L.P. syndrome Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 4 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia 5. Clinical discretion should be used to include any other women who present with atypical symptoms. Immediate action 1. Transfer patient to the Delivery Suite to stay until at least 24 hours after delivery. The patient needs to be “specialled” and a high dependence monitoring chart should be commenced and meticulously up-dated. 2. Insert IV cannula into forearm vein with Hartmann's infusion at 85 mL/hour. 3. Indwelling urinary catheter for hourly urine measurements. 4. Initial maternal investigations: a. full blood count (including haematocrit) ) Request b. urea and electrolytes and urate. ) “Pre-eclampsia c. liver function tests ) screen“ d. group and save ) on ICE A clotting screen is also required if the platelet count is < 100 x 10 9/L 1. Give prophylactic antacid (ranitidine 150 mg 6-hourly, by mouth) 2. Notify the Delivery Suite coordinator and the duty consultant obstetrician and obstetric anaesthetist. It may also be appropriate to alert NICU of the patient’s admission (see below). Lines of communication Clear lines of communication between the consultant obstetrician, consultant anaesthetist, neonatologist and Delivery Suite co-ordinator are essential to recognise rapid deterioration and plan appropriate management. 1. The woman will have one-to-one care with a qualified midwife who will provide the continuity of care and report to the co-ordinating midwife. 2. Care for women with severe pre-eclampsia or eclampsia on Delivery Suite will be coordinated by the consultant obstetrician, consultant anaesthetist and the senior midwife coordinator on duty/call. 3. The named obstetric consultant will take the overall lead in the management of care. 4. The woman will be reviewed by the multi-professional team at each ward round or more frequently depending on the clinical findings to provide an opportunity for clear lines of communication. 5. Following each review a plan of care will be clearly documented in the maternal notes. 6. Any deterioration in the woman’s condition must be immediately communicated to the consultant obstetrician, consultant anaesthetist and coordinator of midwives for DS in order to ensure appropriate care is given. Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 5 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia 7. The neonatologist and Neonatal Intensive care unit (NICU) will be made aware of the woman’s condition, gestation, fetal wellbeing and any plans to induce labour/deliver the baby 8. Liaison will be made with consultant haematologist where there is concern regarding abnormal blood parameters. 9. The multi-professional team will ensure that the woman and her family are given the information required to make informed choices/give informed consent in relation to her care and that they are included in the decision making regarding the management of labour and delivery. Maternal Monitoring 1. After initial measurement of blood pressure with a manual sphygmomanometer, subsequent measurements may be made more easily with an automated device, such as a Datascope or Dinamap machine. Although these machines will tend to underestimate the BP, this is rarely of clinical significance. 2. Record MAP and pulse every 15 minutes for a minimum of four hours until stabilized, and then half hourly. Treatment should be based on the trends in blood pressure. The anaesthetist may consider it appropriate to site an invasive arterial line if the MAPs are persistently greater than 140. 3. Oxygen saturation should be measured continuously and recorded hourly. If saturation falls below 95% on room air, administer oxygen and consult anaesthetist promptly – consider interstitial pulmonary oedema (fluid overload) or excess respiratory depressants. 4. Indwelling catheter and hourly measurement of urine output and proteinuria. 5. Fluid balance should be monitored very carefully. Detailed Input and Output recordings should be added to the megachart. 6. Temperature should be assessed four hourly. 7. Routine PET blood samples should be taken every 12-24 hours – or more frequently at the discretion of the consultant. 8. (CVP only necessary if oliguric or bleeding - see below. Most patients can be managed safely without CVP monitoring) Blood pressure control and anti-hypertensive treatment (see Appendix A) Reduction of severe hypertension (MAP > 125 and/or systolic BP of 150-160mmHg) is mandatory to reduce the risk of cerebrovascular accident. In eclampsia, antihypertensive treatment may also reduce the risk of further seizures. The aim of the anti-hypertensive treatment is to keep the diastolic blood pressure between 90 – 100 mmHg and the systolic blood pressure between 140 – 150 mmHg. In the acute situation, the treatment alternatives include intravenous, labetolol and intravenous hydralazine and there appears little to choose between these drugs in terms of efficacy. However, recent national guidance recommends labetolol, with Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 6 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia hydralazine as a second line therapy for those who may less responsive to labetolol, such as women of Afro-Caribbean origin, or when it is contraindicated, such as in women with asthma. Labetolol regimen: NB Contraindications to labetolol: asthma and cardiac failure Principles: 1. Aim for MAP 125 and for systolic BP of less than 150-160mmHg. 2. For undelivered women with MAP over 140 the labetolol should be given immediately. 3. If the woman can tolerate oral therapy an initial 200mg oral dose can be given. This can be done immediately before venous access and so can achieve as quick a result as an initial intravenous dose. This should lead to a reduction in blood pressure in about half an hour. A second 200mg oral dose can be given if needed in 30 minutes. 4. If there is no initial response to oral therapy or if it cannot be tolerated control should be by repeated bolus of labetalol followed, if necessary, by a labetalol infusion. 5. Bolus infusion is 50mg (= 10mL of labetalol 5mg/mL) given over at least 1 minute. This should have an effect by 5 minutes and should be repeated if diastolic blood pressure has not been reduced. This can be repeated to a maximum dose of 200mg (four bolus doses). The pulse rate should remain over 60 beats per minute. Labetalol is located in the red eclampsia box on the emergency trolley 6. Following this a maintenance infusion of labetalol should be commenced, if required an infusion of (neat) labetalol 5mg/mL at a rate of 4mL/hour via a syringe pump should be started. The infusion rate should be doubled every half-hour to a maximum of 32mL (160mg)/ hour until the blood pressure has dropped and then stabilized at an acceptable level. This level will vary between women. 7. Oral antihypertensive treatment should be considered when intravenous treatment has been discontinued. Hydralazine regime Principles: 1. Aim for MAP 125 and for systolic BP of less than 150-160mmHg. 2. Hydralazine may induce placental hypoperfusion in undelivered women, so before it is administered to lower blood pressure in the acute phase of treatment, volume expansion using a bolus dose of 500 mL Voluven 6% is essential. For undelivered women with MAP 125-140 administer the Voluven 6% over 20 minutes, then recheck the blood pressure before administering hydralazine, if necessary. For undelivered women with MAP over 140 the Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 7 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia hydralazine should be given immediately after starting the Voluven. No prior volume expansion with Voluven is necessary before hydralazine administration if the patient is delivered. 3. Initial dose of hydralazine 5 mg. IV slowly every 10 min. until BP controlled (maximum dose 20 mg). The BP response to the administered hydralazine needs to be monitored by automated BP measurement, and confirmed by one or two measurements using a manual sphygmomanometer. 4. Maintenance IV infusion of hydralazine 50 mg. in 50 mL. saline via syringe pump starting at 5mlL/hour and titrating with MAP. 5. Reduce the dose if there are significant side effects or the maternal pulse > 120 bpm 6. Caution should be used in patients with renal disease. 7. Oral antihypertensive treatment should be considered when intravenous treatment has been discontinued. Prevention of seizures - prophylactic anti-convulsant treatment One in 200 cases of severe PET progress to eclampsia, prophylactic anti-convulsant therapy is aimed at reducing the risk of this progression. 1. Loading dose of magnesium sulphate 4 g. (20 mL. of 20% solution) given slowly IV (over 10 min) via a syringe driver, only once the BP has been stabilised. 2. Maintenance infusion of magnesium sulphate at a set dose of 1 g./hour (5 mL/hour of 20% solution via syringe driver). This rate continued unless knee jerks abolished urine output less than 100 mL in 4 hours, or respiratory rate under 12 per min. when the infusion should be stopped. 3. Test reflexes and monitor respiratory rate hourly. The knee jerks are usually the easiest reflexes to test, but these will be affected by regional anaesthesia and the biceps reflexes are more appropriately tested under these circumstances. Control of an eclamptic seizure Eclampsia is defined as generalised convulsions in any woman with signs and symptoms of pre-eclampsia, or in any woman who then presents with hypertension in pregnancy. The overall incidence of eclampsia is only 2.7/10,000 maternities in the UK – but the associated maternal mortality rate is 3.1%. Eclampsia rarely occurs without premonitory symptoms (e.g. severe headache, visual disturbance, epigastric pain), and these symptoms should always be taken seriously. Eclampsia is an absolute indication for delivery - but not until the condition of the mother has been stabilised. Remember, over 40% of fits occur after delivery, so post-natal vigilance is essential – although the disease will resolve spontaneously in all but a few cases. Principles of management of eclamptic fits: Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 8 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia 1. Place patient in the left lateral position and secure the airway. 2. Administer oxygen at 10 L/min. 3. Administer magnesium sulphate - give 4 g. magnesium sulphate as per instructions for loading dose above. Recurrent seizures should be treated by a further bolus dose of 2 - 4g. depending on the patient’s weight; 2g. if less than 70 kg and 4g, if over 70Kg. 4. Mg SO4 is located in the red eclampsia box on the emergency trolley 5. Contact anaesthetist. Magnesium sulphate Dispensed as vials of 50 mL. of 20% magnesium sulphate (1g. in 5mL.) Care should be taken to avoid overdose particularly in renal failure. Signs and symptoms include loss of tendon reflexes, respiratory depression, confusion and cardiac arrest. If toxicity is suspected, the infusion should be stopped immediately and consideration given to measuring levels. Therapeutic levels are 2-4 mmol/L, adverse effects are seen at levels over 5mmol/L and levels over 6mmol/L may be lethal. Antidote to magnesium sulphate is 500 mg. calcium chloride (5 mL. of 10% solution) given IV over 5 min. This is available in pre-filled syringes kept on Delivery Suite. Fluid balance (see Appendix B) It is important to strike a balance between overzealous administration of intravenous fluid (increasing the risk of pulmonary oedema) and under infusion, predisposing to oliguria and renal complications. The objective is to maintain a minimum urine output of 100 mL/4 hours. The principles of fluid management: 1. Accurate recording of fluid balance (including delivery and post partum) 2. Maintenance crystalloid infusion of Hartmann’s 85 mL/hour (minus the volume of any infused drugs) For women who require the post partum syntocinon regimen, this can be safely administered by diluting 20 units of syntocinon in 50mL of 0.9% normal saline and delivering this through a syringe driver set at 25mL/hour. Avoid potential Nephrotoxics – especially Diclofenac or other NSAIDs 3. Selective monitoring of CVP - 4. Selective colloid expansion haemorrhage oliguria significant fall in platelet count liver tenderness - oliguria and low CVP prior to antenatal vasodilatation:epidural labetolol/hydralazine Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 9 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia 5. Diuretics in pulmonary oedema (discuss with anaesthetist) Management 1. Initial fluid therapy of Hartmann’s 85 mL/hour. 2. If initial haematocrit < 35% (< 0.35) continue Hartmann’s 85 mL/hour. 3. If initial haematocrit > 35% (ie. haemoconcentrated) give 500mL colloid 4. Hartmann’s 85 mL/hour. 5. The volume of infused drugs should be subtracted from the Hartmann’s 85 mL/hour. 6. Any oral intake should be also subtracted from the Hartmann’s 85 mL/hour. 7. Prior to epidural analgesia, consider a pre-load of 500 mL Voluven 6%, and then continue the Hartmann’s at 85 mL/hour. Oliguria and CVP (see Appendix B) Oliguria is relatively common in labouring pre-eclamptic patients and may represent a normal response to short-lived pre-renal causes. Principles: Oliguria is defined as <100 mL/4 hours. 1. The anaesthetist will set up and supervise the CVP. 2. Subclavian line insertion is relatively contraindicated if the patient has a coagulopathy. 3. All readings to be taken at the mid axillary line angle with patient lying flat. Ensure left lateral tilt is maintained to avoid aorto-caval compression. Fetal assessment and delivery planning In all cases of severe pre-eclampsia/eclampsia, concerns about stabilising the maternal condition should take priority over any assessment of the fetus. However, once the mother is stable, fetal wellbeing may be assessed in the initial stages by continuous CTG. Consideration should be given to assessing the fetus with a growth scan, liquor assessment and umbilical artery Doppler flow. The mode of delivery to be decided with the consultant obstetrician and will depend on the history, presentation, Bishop score, coagulation defect etc. The precise timing of the delivery may also be determined by factors such as cot availability on NICU and will be arranged following consultation with the consultant obstetrician, Delivery Suite coordinator, anaesthetist and NICU (where appropriate). Anaesthesia Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 10 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia 1. If platelet count is 80 - 100 x 10 9 /L, and the clotting screen is normal, regional anaesthesia is usually acceptable. In all other circumstances, please liaise closely with the obstetric anaesthetist. 2. A pre-load of 500 mL. of Voluven 6% should be considered prior to siting an epidural. 3. Consider the administration of alfentanil 1.0 – 2.0 mg intravenously as part of the rapid sequence technique for laryngoscopy in an attempt to obtund the hypertensive response. A bolus dose of magnesium (40 mg/kg) can also be used for this purpose; this should be reduced to 30 mg/kg if the patient is already receiving magnesium. In cases of severe PET, magnesium and alfentanil can be used together. 4. Do not give NSAIDs – this may worsen renal failure Continuing care 1. Patient should remain in the Delivery Suite and be fully monitored (including laboratory investigations) for at least 24 hours after delivery. Fluids should continue at 85mL/hour, if there is no evidence of pulmonary oedema. 2. Magnesium sulphate infusion should be continued for 24 hours after delivery. 3. Labetalol infusion should be continued as necessary to control BP. The decision for continuing anti-hypertensive treatment with oral therapy should be made by the patient’s consultant - who should also be responsible for the choice and dose of the agent used. 4. Consider the need for thromboprophylaxis. Apply anti-embolism stockings and commence dalteparin, provided platelet count > 100. 5. If there are concerns about the patient’s blood pressure or fluid management, or if her condition deteriorates, consider early referral to HDU/ITU. Postnatal follow-up and final diagnosis 1. An assessment of BP and proteinuria by the GP at the 6 weeks postnatal check should be performed. If there were any biochemical abnormalities peripartum, then a repeat PET screen should be performed, too. If any abnormalities persist, the patient should be referred for further investigations. 2. Women whose pregnancies have been complicated by severe PET or eclampsia should be offered a formal postnatal review to discuss the events of the pregnancy with their obstetrician. This should afford an opportunity to discuss preconception counselling, identification of modifiable risk factors and any preventative therapies. 3. All cases of eclampsia and severe pre-eclampsia should be the subject of multidisciplinary case review, and, where appropriate, action plans approved. Clinical audit standards Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 11 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia The Maternity Services are committed to the philosophy of clinical audit, as part of its Clinical Governance programme. This standards contained in this clinical guideline will be subject to continuous audit, with multidisciplinary review of the audit results at one of the monthly departmental Clinical Governance meetings. The results will also be summarised and a list of recommendations formed into an action plan, with a commitment to re-audit within three years, resources permitting. 1. Rate of documented involvement of consultant obstetrician and anaesthetist in acute management (target 100%, exceptions – none) 2. Proportion of women with a full complement of appropriate investigations (target 100%, exceptions – none) 3. Proportion of women in whom fluid has been restricted to 85 mL/hour (target 100%, unless otherwise determined by a consultant obstetrician) 4. Proportion of women receiving appropriate magnesium sulphate prophylaxis (target 100%, unless otherwise determined by a consultant obstetrician) 5. Proportion of women with eclampsia treated with magnesium sulphate (target 100%, exception - none) 6. Proportion of women with eclampsia and severe PET attending for postnatal review and/or preconception counselling (target 100%, exceptions – patient declines or is unable to eg. patients transferred for delivery from elsewhere). Summary of development and consultation process undertaken before registration and dissemination The author listed above drafted this guideline on behalf of the Obstetric Guidleines Committee who have agreed the final content. During its development it was has been circulated for comment to: all members of the obstetric guideline committee. This version has been endorsed by the Obstetric Guidelines Committee. Distribution list/ dissemination method Electronic Mail Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 12 of 13 Trust Guideline for the Management of: Severe Pre-Eclampsia and Eclampsia References/ source documents 1. The management of severe pre-eclampsia/eclampsia. RCOG Green top Guideline number 10(A). March 2006. RCOG Press: London. 2. Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer – 2006-2008. The eighth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. 2011; 66 – 76. RCOG Press: London. 3. The 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;359:1877-1890. 4. Duley L, Gülmezoglu AM, Henderson-Smart DJ, Chou D. Magnesium sulphate and other anti-convulsants for women with pre-eclampsia. Cochrane Database of Systematic Reviews 2010, Issue 11. 5. Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. 6. Knight M on behalf of UKOSS. Eclampsia in the United Kingdom 2005. BJOG 2007;114:1072-1078. 7. National Institute for Health and Clinical Excellence. “Hypertension in pregnancy. The management of hypertensive disorders during pregnancy”. NICE clinical guideline 107. August 2010. 8. von Dadelszen P et al. Prediction of adverse maternal outcomes in preeclampsia: development and validation of the fullPIERS model. Lancet 2011;377:219-227. Author: Mrs Daisy Nirmal Valid until: 28/10/2018 Document: Management of Severe Pre-eclampsia and Eclampsia Issue: 28/10/ 2015 Guideline Ref No A04 id 887v. 8 Copy of complete document available from the Trust intranet Page 13 of 13