Clinical Protocols and Guidelines CP–MA50

Maternity (all sites) Preeclampsia and severe preeclampsia guideline

Preeclampsia and severe preeclampsia guideline

Definition
Preeclampsia – is a common medical complication of pregnancy affecting 2-8% of
pregnancies. A clinical diagnosis of preeclampsia can be made when the following criteria
are fulfilled:
Hypertension (defined as systolic blood pressure > 140 mm Hg or diastolic blood pressure
> 90 mm Hg ) arising after 20 weeks gestation and under 7 days postpartum:
And the onset after 20 weeks gestation of one or more of:
• proteinuria (defined as > 300 mg in 24 hours or a spot urine protein creatinine ratio of
> 30 mg/mmol/L).
• 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 disturbances – thrombocytopenia; disseminated intravascular
coagulation (DIC) ; haemolysis
• intrauterine fetal growth restriction (IUGR).
Oedema is not included in the diagnostic features of preeclampsia, occurring as commonly
in normal pregnant women and those with pre eclampsia. The rapid development of
generalised oedema may be a marker of clinical deterioration in women with
preeclampsia.

Expected outcome
Early recognition with prompt and appropriate management.
Why
To reduce maternal and perinatal morbidity or mortality.

Assessment and investigations

Assessment and investigations in women with preeclampsia will depend on the severity of
the condition. Thorough maternal assessment should be aimed at detection and
management of likely complications i.e. HELLP syndrome (haemolysis, elevated liver
enzymes, low platelets), IUGR and eclampsia.

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

Assessment and investigations

Maternal assessment
- antenatal history
- physical examination: general examination (e.g. facial oedema)
- vital signs: blood pressure (frequency of recording dependant upon severity: from
continuous in severe disease to 4 hourly in mild disease)
- neurological (assess headache, visual disturbances, reflexes, clonus)
- abdominal examination -presence or absence of associated complications (eg IUGR or
hepatic pain).

Maternal investigations

- Urine check:
- urinalysis
- mid stream urine (MSU) to exclude infection
- quantification of proteinuria 24 hour or 12 hour urine collection or spot urine
protein/creatinine ratio.
- In severe preeclampsia strict fluid balance chart (FBC) is required including:
o hourly urine measurements
o early morning weighing may be useful.
- full blood examination (FBE) and blood film

- liver function tests (LFT)

- renal function tests

- serum uric acid
- clotting studies if platelets <100×109/L.

Fetal Assessment

Ongoing fetal surveillance may include:

- gestational age
- general assessment fetal size, lie, presentation, movements
- electronic fetal surveillance (CTG).

Ongoing fetal surveillance includes:

- Growth scans.
- Biophysical profile.
- Amniotic Fluid Index (AFI).
- Fetal placental doppler studies (e.g. umbilical arterial, middle cerebral artery etc).

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

Management of pre eclampsia

Management includes:
1. Control of hypertension
2. Seizure prophylaxis
3. Fetal maturation and surveillance
4. Fluid balance
5. Birth and postnatal

1. Control of HYPERTENSION
Antihypertensive drugs are ADVISABLE where:
- Blood pressure ≥ 160/110 mmHg (with aim to maintain BP in range of 130-140/80-90
mmHg).
- Blood pressure < 160/100 associated with other organ markers of severe disease i.e.
proteinuria or abnormal LFT or haematological changes.
Antihypertensive drugs are MANDATORY where :
- Systolic pressure > 170 mmHg or diastolic pressure >110 mmHg
Pressures of these levels may lead to direct vascular damage associated with life
threatening sequelae.

Medications for controlling MODERATE hypertension

Drug Dose/ Route Action Comments

1. Labetalol 200 mg oral stat Peripheral acting First agent of choice

sympatholytic alpha Maternal side effects:
Repeat 200 mg and beta blocker bradycardia, postural hypotension,
oral hourly until induces vascular cold extremities, rebound
control is achieved. relaxation, lower hypertension, sleep or
Maximum 3 doses. peripheral resistance gastrointestinal disturbance.
and cardiac output
Caution: may exacerbate asthma
Maintenance dose with exercise.
and mask hypoglycaemia.
100-400 mg.
6-12 hourly (max Fetal side effects: respiratory
1600mg/day). depression and bradycardia.

Alternative
2. Nifedipine 10 mg oral stat Lowers blood pressure
Tablet may need to be crushed
Repeat 10 mg by relaxing vascular
orally every 30 muscle, blood vessels Maternal side effects: postural
mins. hypotension, flushing, tachycardia,
dilate with lowered nausea, headaches, sleep or
Maximum 3 doses. peripheral resistance. gastrointestinal disturbance.

Maintenance dose Caution: impending eclampsia.

10-20 mg 3-6 Not to be confused with a slow
hourly to maximum release formulation of nifedipine
80-120 mg/day. also available.

Alternative
3. Methyldopa 250 mg oral stat Centrally acting
Maternal side effects: drowsiness
Maintenance 250- Onset of action very and depression, postural
500 mg TDS. slow hypotension.

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Clinical Protocols and Guidelines
Maternity (all sites) Preeclampsia and severe preeclampsia guideline
Medications for SEVERE hypertensive crisis
These medications require medical initiation and close supervision.
Drug Dose / Route
1. Intravascular fluid 250 -500 mL of crystalloid IV over
15-20 mins.
bolus
Not usually repeated.
2. Labetalol Intermittent bolus dose of 20 mg
undiluted IV over 2 minutes.
- Labetalol comes as 100 mg in
20 mL (5 mg / mL).
- Draw up Labetalol 100 mg (20
mL) undiluted and label
syringe clearly.
- Inject 20 mg (4 mL) over 2
minutes.
- Repeat every 10 minutes until
control is achieved. Maximum
300mg.
Maintenance dose
- Remove 50mL of fluid from
250mL infusion bag sodium
chloride 0.9% and discard.
- Add 50mL (250mg Labetalol)
to remaining 200mL sodium
chloride 0.9%. Final
concentration 250mg in
250mL = 1mg/mL.13
- Ongoing Labetalol infusion 20-
160mg/hour (20-160mL/hr)
titrated to achieve an
optimum blood pressure.
3. Hydralazine 5mg slow Intravenous (IV) Repeat
5 mg slow IV bolus over 10 -20
minutes as necessary (up to a
total bolus 20 mg).
Consider need for continuous
intravenous infusion:
50mg hydralazine in 50mL
sodium chloride 0.9% infusion
rate 1-5 mL/hr (1mg/mL).
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CP–MA50
Action
First line management
Acute vasodilation by increasing
intravascular volume.
First line drug management
Peripheral acting sympatholytic
alpha and beta blocker with vascular
relaxation, lower peripheral
resistance and cardiac output
evident with exercise.
Observations:
Continuous electronic fetal
surveillance (CTG) is required
with Labetalol IV administration.
During bolus record blood
pressure and pulse every 5
minutes.
During Labetalol infusion record
blood pressure and pulse every
15 - 30 minutes until stabilised,
then record every hour as
required.
If blood pressure decreases
precipitously, halve the infusion rate
or cease (depending on severity).
Blood pressure should not be lowered
below 140 / 85 mm Hg.
Caution. If higher doses required
aim to keep total fluid infusion to
1mL/kg/hour if possible.
Alternative drug management
Smooth muscle relaxer, arterial
dilator.
Maternal side effects: headache,
Tachycardia, palpitations,
gastrointestinal disturbance,
flushing, hypotension.
Observations:
- As above.
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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

When controlling ACUTE SEVERE Hypertension :

- IV access (16 g) jelco (to allow acute volume expansion)

- continuous CTG should be considered

- second IV line required if considering magnesium sulfate infusion

- titrate antihypertensive medication to maternal response

- monitor and reassess for signs of deterioration

- urinary catheter.

2. Seizure PROPHYLAXIS

Prophylaxis with MAGNESIUM SULFATE (MgSO4) should be considered when:

• warning signs of eclampsia eg neurological irritability
• all women with severe preeclampsia during labour, birth and immediate postpartum.

Drug Dose/ Route Action Comments

Magnesium Loading dose 4 gm IV Prevents cerebral Eclamptic seizure prophylaxis

Sulfate undiluted given over vasospasm.
Administer slowly via a syringe
10 minutes.4,12 driver using a Peripheral
intravenous line (not CVP line).

Therapeutic range :
2-4 mmol/L.
Maintenance dose
Maternal side effects: local
1gm/hr for at least 24 burning and pain at injection
site; nausea.
hours post birth.
Caution : excreted by kidneys
therefore toxicity likely if urine
output poor.

Contraindications: heart block or

myocardial damage.

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

Preparing MgSO4

Use undiluted 49.3% (treat as 50% solution). Draw up 60 mLs of magnesium sulfate in 60 mL
syringe.
Initially give 4 gm loading dose:
- set syringe pump volume to be infused at 8 mLs
- set rate at 48 mLs /hr to infuse over 10 minutes
- pump will alarm and stop after 8 mLs infused.
Follow with 1gm/hr maintenance dose
- reset pump rate at 2 mLs/hr
- set volume to be infused at 50 mLs
- pump will alarm after and stop after 50 mLs infused.

Consideration should be given to cardiac monitoring and oxygen saturation

monitoring with the commencement of MgSO4.

Assessment during Magnesium Sulfate infusion

Monitor vital signs 5 minutely during loading dose.
Thereafter :
- hourly vital signs (BP, pulse, respiratory rate)
- hourly urine output
- hourly patellar reflexes
- continuous electronic fetal surveillance (CTG)
- check pump and IV site hourly to ensure dose correct
- consider monitoring serum levels of magnesium in women with oliguria (< 100 mL in
4 hrs). Therapeutic range 1.7- 3.5 mmol/L.

Signs of Magnesium Sulfate toxicity

- loss of patellar reflexes
- respiratory rate < 12 minute
- nausea, vomiting
- slurred speech, weakness, extreme sleepiness
- double vision
- muscle paralysis
- respiratory/ cardiac arrest.

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

Maternity staff should have access to and be familiar with :

- adult resuscitation equipment
- maternity eclampsia box.

To reverse Magnesium Sulfate toxicity.

Drug Dose/ Route Action Comments

1 gm IV slow injection Antidote for Administer slowly.

Calcium
over 10 minutes. magnesium sulfate
Gluconate
toxicity.

3. Fetal Maturation and Surveillance

- Corticosteroids: (betamethasone (Celestone Chronodose®)11.4 mg IM x 2 doses 24 hours

apart) for promotion of fetal lung maturation should be administered if gestation is
below 34 - 36 weeks.
- With management of acute HT, continuous CTG surveillance is usually required.

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

4. Fluid Balance

Careful maternal fluid balance is required in all women with preeclampsia.

In severe preeclampsia maternal fluid retention can lead to severe acute pulmonary
oedema.
- Total fluid input should be restricted to 80mL/hr or 1mL/kg/hr.
- Monitor output: hourly urine measurements with indwelling urinary catheter (IDC).

Where urine output if less than 20 mLs per hour for 3 consecutive hours
immediate management includes:
- review by medical staff

- assessment of renal function

- in presence of sustained oliguria and renal impairment consider transfer to an

Intensive Care Unit (ICU) for more intensive haemodynamic monitoring.

5. Birth and postnatal

Expediting birth is likely to be indicated if

- woman is at term (>37 weeks)

- inability to control BP despite maximum anti-hypertensive therapy

- deteriorating liver function

- deteriorating renal function

- progressive thrombocytopenia

- neurological complications

- placental abruption

- concern for fetal well being.

Stabilisation of maternal condition may be indicated at times prior to expediting

the birth.

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

Mode of birth
Mode of birth depends on:
- Fetal presentation, well being and favourability of the cervix.
- Consultation between the woman, obstetric, midwifery, paediatric, and
anaesthetic staff.
- If caesarean section is required epidural or spinal anaesthesia is preferred over
general anaesthetic (GA).

- If vaginal birth, epidural analgesia is appropriate if clotting profile and platelet

count are satisfactory.

Active management of third stage is recommended.

- 10 units IM oxytocin (Syntocinon®) or 5 units IV given slowly.

- Avoid ergometrine or Syntometrine® for third stage.

Post Birth Management

Almost half of all eclampsia occurs postnatally, possibly due to inadequate management.
While it is expected that the woman’s condition will steadily improve management
includes:

1. Mild moderate pre eclampsia:

- Maintain anti-hypertensive therapy until BP is adequately controlled. Then wean

off gradually.

2. Severe pre eclampsia:

- maintain BP with anti-hypertensive therapy to maintain diastolic BP at 90 mm Hg

- if commenced MgSO4 maintain for a further 24 hours post birth

- while MgSO4 infusion is maintained an obstetric review (by registrar or above) is

required at minimum 4 hourly

- continue strict fluid balance chart (with hourly urine measurements )

- monitor biochemistry markers until stable/improving.

Discharge and follow up

- Decision and timing of discharge to be made in consultation with senior obstetric
staff.
- Consideration should be given to the risk of late seizures.
- Offer appropriate postnatal review according to postnatal review options at each site.
Either in a specialist obstetrician clinic or private rooms.

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Clinical Protocols and Guidelines CP–MA50
Maternity (all sites) Preeclampsia and severe preeclampsia guideline

If an adverse event (actual or ‘near miss’) is associated with guideline, document

details in the health record and complete an incident report on Riskman.

1. Altman, D, Carroli, G., Duley, L., Farrell, B. Moodley, J., Neilson, J., Smith, D. The

Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their
babies, benefit from magnesium sulfate? The Magpie Trial: a randomised
placebo-controlled trail. Lancet 2002; 359: 1877-90.
2. Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, Peek MJ, Rowan
JA , Walters BNJ. The detection, investigation and management of hypertension
in pregnancy: Full consensus statement form Council of Australian Society of the
study of hypertension in pregnancy. Aust NZ J Obstet Gynaecol 2000; 40;2;139-
155
3. Department of Human Services (DHS) Victoria; Three Centres Consensus
Guidelines on Antenatal Care: October 2001.
4. Department of Human Services (DHS) Victoria; Maternity Services Education
Program (MSEP) Magnesium Sulfate (MgSO4) Infusion, Maternity Emergency
Program, 2008.
5. Duley, L. (2006) Evidence and practise: the magnesium sulfate story. Best
Practise and Research Clinical Obstetrics and Gynaecology. 19(1) February 54-
74
6. Duckitt K, Harrington D. risk factors for pre eclampsia at antenatal booking
:systematic review of controlled studies .BMJ 2005;330:565-71
7. Duley L ,Meher S,Abalos E. management of pre-eclampsia BMJ 2006;332;463-
468
8. Eclampsia Trial Collaborative Group (1995) Which anticonvulsant for women with
eclampsia? Evidence from the Collaborative Eclampsia Trial. The Lancet.
th
345(8963) 10 June 1455-1463
9. Magee L.A, Cham C, Waterman E.J, Ohlsson A, Von Dadelszen P. Hydralazine
for treatment of severe hypertension in pregnancy: meta-analysis. BMJ 2003;
327:955-960.
10. Roberts J, Cooper D. pathogenesis and genetics of pre eclampsia. Lancet 2001;
357:53-6.
11. Royal College of Obstetrics and Gynaecologists. The Management of Severe
Pre-Eclampsia. Guideline No 10A. London : RCOG Press 2006
12. Sweetman, S.C. (Editor) (2002) The complete drug reference. 33rd. Edition.
London: Pharmaceutical Press. (Chapter 'Electrolyes' pp. 1180-1197)
13. Society of Hospital Pharmacists of Australia, (2008), Australian Injectable Drug
Handbook (AIDH) 4th edition.

SH Policy Patient Care ACHS Clinical

Reviewer Maternity Guideline Development Group Last review date March 2010
Therapeutics Committee
Authoriser Maternity Executive Committee Next review date December 2012

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Disclaimer
These clinical practice guidelines and protocols have been developed having regard to general circumstances. It is the
responsibility of every clinician to take account of both the particular circumstances of each case and the application of these
guidelines. In particular, clinical management must always be responsive to the needs of the individual woman and particular
circumstances of each pregnancy.
These guidelines have been developed in light of information available to the authors at the time of preparation. It is the
responsibility of each clinician to have regard to relevant information, research or material which may have been published or
become available subsequently. Please check this site regularly for the most current version.

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