Interventionist versus expectant care for severe pre-eclampsia before term
RHL practical aspects by Lombaard H, Pattinson R
FIRST CONTACT (PRIMARY CARE)
Women with early onset severe pre-eclampsia should be referred to the secondary or tertiary level of health care. Prior to referral, magnesium sulfate should be administered to prevent convulsions and control high blood pressure. Corticosteroids should be administered if the fetus is less than 34 weeks of gestation or the estimated fetal weight is < 2 kg. The entire health care system should use standard definitions for hypertension and pre-eclampsia and these should be clear especially to all staff working in the primary health care setting. The definition proposed by the Australasian Society for the Study of Hypertension in Pregnancy (Expert committee) (1) is recommended because it recognizes that pre-eclampsia affects all organ systems, including the placenta and fetus. According to this definition, hypertension in pregnancy is diagnosed when:
- systolic blood pressure is > 140 mmHg and/or
- diastolic blood pressure (Korotkoff V) is > 90 mmHg. (These blood pressures should be confirmed by repeated readings over several hours in a clinic or day assessment unit or after rest in hospital.)
In the same report (i) pre-eclampsia is defined as hypertension arising after 20 weeks of gestation and the new onset (after 20 weeks of gestation) of one of the following:
- Proteinuria ≥300mg/day or a spot urine protein/creatinine ratio of > 30mg/mmol;
- Renal insufficiency-serum/plasma creatinine > 0.09 mmol/L or oliguria
- Liver disease-raised serum transaminases and/or severe epigastric/right upper quadrant pain;
- Neurological problems-convulsions (eclampsia), hyperreflexia with clonus, severe headaches with hyperreflexia, persistent visual disturbances (scotomata); haematological problems-thrombocytopenia, disseminated intravascular coagulation, haemolysis; and
- Fetal growth restriction.
There should be written protocols available at the primary health care setting for the acute management of women with these conditions and referral policies.
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
After administering the initial treatment—i.e. magnesium sulfate for preventing convulsions, antihypertensive drugs to lower blood pressure and sulfate should be administered to prevent convulsions and control blood pressure. high corticosteroids to prevent neonatal conditions—consideration can be given to expectant management according to the following questions within the resources of the health care facility.
- What is the risk to the mother of continuing the pregnancy?
- What is the risk to the fetus of continuing the pregnancy?
- If delivered now, what would be the chances of survival for the newborn and what complications could be expected?
- If delivery is medically indicated, what would be the risks to the mother?
The overall population level impact of expectant management is small, but for the individual patient it might be very significant. Where resources are insufficient to monitor women safely, she should either be referred to a higher level of care or delivered. In settings where resources for the care of newborn babies are limited but adequate to keep the mother under clinical observation, expectant management may offer some advantage in terms of reduced need for intensive care of the newborn from reduction in neonatal complications such as hyaline membrane disease and necrotising enterocolitis. It is important to understand that the advantage of expectant management is only for the fetus, whereas for the mother it can be life-threatening.
The availability of the following factors indicate whether expectant management can be done safely (PERSONAL OPINION):
- Sufficient dedicated and experienced medical staff.
- 24-hour on-site laboratory service.
- Blood and blood products.
- Operating theatre facilities with experienced anaesthetists familiar with obstetric anaesthesia.
- Written protocol on expectant management.
If one of the above criteria is not met the patient should be delivered or transferred to a unit with better facilities to look after the mother.
In conclusion, the treatment for severe pre-eclampsia remote from term is delivery of the fetus unless the option of expectant management can be implemented safely. Hospitals in developing countries should not practice expectant management routinely. Where they believe that they can practice it safely, the patient should be provided counselling about the advantages and risks and asked to sign informed consent for expectant management (PERSONAL OPINION).
AT HOME OR IN THE COMMUNITY
Not relevant.
References
- Consensus statement. The detection, investigation and management of hypertension in pregnancy: executive summary. Recommendations from the Council of the Australasian Society for the Study of Hypertension in Pregnancy. Web site http://www.racp.edu.au/asshp/asshp.pdf;(visited on 19 January 2005).
This document should be cited as: Lombaard H, Pattinson R. Interventionist versus expectant care for severe pre-eclampsia before term : RHL practical aspects (last revised: 5 August 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.