reprolineplus.orgreprolineplus.org/system/files/resources/pee... · web viewan abdominal...

Copyright © 2011, 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: Participant’s Notebook. Baltimore: Jhpiego; 2011.

Prevention and management of pre-eclampsia and eclampsia

Participant’s Notebook

2011

Maternal and Child Health Integrated Project (MCHIP)

This project 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 Cooperative Agreement No. GHS-A-00-08-00002-00. 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.

Table of contents

1Key definitions

5Understanding pre-eclampsia and eclampsia

5Summary of the session

5Learning objectives for the session

6Learning activities - Classroom

9Learning activities - Individual

11Identifying pre-eclampsia



12Job aid

13Learning activities

15Prevention of pre-eclampsia and/or eclampsia



16Job aid


19Management of pre-eclampsia and eclampsia



20Job aids

25Learning activities – classroom

27Clinical simulation: Management of headache, high blood pressure, blurred vision, loss of consciousness

28Learning activities – individual

31Management during a convulsion / fit



32Job aids

34Learning activities - Classroom

36Learning activities - Individual

37Birth preparedness and complication readiness




41Suggested answers for learning activities

41Understanding pre-eclampsia and eclampsia

42Identifying pre-eclampsia

44Prevention of pre-eclampsia and/or eclampsia

45Management of pre-eclampsia and eclampsia

52Managing convulsions

55Birth preparedness and complication readiness

59Learning guides

59Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but < 110 mm Hg

63Learning guide: Management of severe pre-eclampsia / eclampsia

65Learning guide: Administering magnesium sulfate

69Learning guide: Management during and after an eclamptic fit/seizure

71Checklists

71Checklist for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but < 110 mm Hg

73Checklist: Management of severe pre-eclampsia / eclampsia

75Checklist: Administering loading dose of magnesium sulfate

77Checklist: Administering maintenance dose of magnesium sulfate

79Checklist: Management during and after an eclamptic fit/seizure

81Final Evaluation Form

Acknowledgements

Susheela Engelbrecht led development of the learning materials, with technical assistance and feedback from members of the MCHIP Training and Quality Assurance Task Force, one of the five Task Forces formed under the Pre-Eclampsia/Eclampsia Technical Working Group. Members of the task force include Patricia Gomez, Diane Sawchuck, Peter von Dadelszen, Abdelhadi Eltahir, Frances Ganges, Ann Davenport, Deborah Armbruster, Nahed Matta, Jeffrey Smith, Annette Briley, and Bridget Lynch. The writing team is grateful to the following people, who provided invaluable assistance with this effort:

· Contributing editors

· Reviewers: Ahmet Metin Gulmezoglu

· Proofreader

· Illustrator .

About MCHIP

For more information or additional copies of this manual, please contact:

Acronyms

BP

blood pressure

BPP

birth preparedness plan

CRP

complication readiness plan

dBP

diastolic blood pressure

DIC

disseminated intravascular coagulation

HELLP

Hemolysis, ELevated Liver enzymes, and low Platelet count syndrome

HIP

hypertension in pregnancy

IUGR

intrauterine growth restriction

Magpie Trial

magnesium sulfate for prevention of eclampsia trial

MAP

mean arterial pressure

MCHIP

maternal and child health integrated project

RCT

randomized controlled trial

sBP

systolic blood pressure

STI

sexually transmitted infections

UTI

urinary tract infection

USAID

United States Agency for International Development

WHO

World Health Organization

Key definitions

Albumin: Also known as "albumen" when pertaining to egg whites, refers generally to any protein that is water soluble, which is moderately soluble in concentrated salt solutions, and experiences heat coagulation (protein denaturation).

Avoidable factors: Factors causing or contributing to maternal death where there is departure from generally accepted standards of care.

Chronic Hypertension: Refers to pre- existing hypertension or hypertension diagnosed in the first half of pregnancy. If associated with proteinuria and other features of pre-eclampsia in the second half of pregnancy, it is called chronic hypertension with superimposed pre-eclampsia.

Coagulation cascade: Coagulation is an important part of hemostasis (the cessation of blood loss from a damaged vessel), wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel. The coagulation cascade leads to fibrin formation. Normally, the coagulation cascade happens as a result of injury and is essential for stopping bleeding; in the case of severe pre-eclampsia, it may be part of the disease process.

Creatinine: Creatinine is a breakdown product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body (depending on muscle mass). Creatinine is chiefly filtered out of the blood by the kidneys. If the filtering of the kidney is deficient, blood levels rise.

Disseminated intravascular coagulation (DIC): A pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood vessels throughout the body. As the small clots consume coagulation proteins and platelets, normal coagulation is disrupted and abnormal bleeding occurs. The small clots also disrupt normal blood flow to organs (such as the kidneys), which may malfunction as a result.

Fetal compromise: Suboptimal blood flow to the fetus during the antepartum period (before labor) or intrapartum period (birth process) may result in fetal compromise. During the antenatal period, this may result in restricted growth; during labor and childbirth, this is usually referred to as “fetal distress.”

Fibrinogen: A protein present in blood plasma that converts to fibrin when blood clots.

Gestational hypertension: Formerly known as “pregnancy induced hypertension.” Defined as hypertension in the second half of pregnancy (20 weeks and above) without proteinuria.

HELLP (Hemolysis, ELevated Liver enzymes, and low Platelet count) syndrome: 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:

· Fibrin forms cross-linked networks in the small blood vessels.

· This leads to destruction of red blood cells because of narrowing or obstruction of small blood vessels (microangiopathic hemolytic anemia): the mesh causes destruction of red blood cells as if they were being forced through a strainer.

· Additionally, platelets are consumed. As the liver appears to be the main site of this process, downstream liver cells suffer from lack of adequate blood flow to support the normal functioning (ischemia), leading to the localized death of living cells situated around the portal vein of the liver (periportal necrosis). Other organs can be similarly affected.

· HELLP syndrome leads to a form of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding.

Hypertension in pregnancy (HIP): Defined as a diastolic blood pressure of ≥90 mmHg measured on 2 separate occasions more than 6 hours apart OR a single reading at any stage of pregnancy of a diastolic BP of ≥110mmHg.

Insulin resistance: A physiological condition in which the natural hormone, insulin, becomes less effective in lowering blood sugars. The resulting increase in blood glucose may raise levels outside the normal range and cause adverse health effects.

Intervillous space: "inter" means between, and "villous" means vessels, so the intervillous space is the "space between the vessels" of the mother and the embryo.

Mean arterial pressure: Term used to describe an average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle.

Neuro-Developmental Delay: Describes the omission or arrest of a stage of early development. The brain develops in stages, beginning with lower levels of function. Optimal function of each stage is dependent upon complete development of the preceding levels. If there is a disruption or delay in early development, the higher brain cannot function at its potential and this can result in difficulties, particularly with learning.

Normotensive: Having normal blood pressure.

Perinatal: The period occurring "around the time of birth", specifically from 22 completed weeks (154 days) of gestation (the time when birth weight is normally 500 g) to seven completed days after birth. Legal regulations in different countries include gestation age beginning from 16 to 28 weeks (7 months) before birth or from 500 to 1,000 g birthweight.

Pre-eclampsia: A condition that can occur after the 20th week of pregnancy, which includes high blood pressure and protein in the urine. This condition is accompanied by metabolic disturbances that can threaten the health of the pregnancy as well as the lives of the fetus and pregnant woman.

Pressor agent: Any agent that causes a narrowing of an opening of a blood vessel.

Proteinuria: Means the presence of an excess of serum proteins in the urine.

Randomized controlled trial (RCT): A type of scientific experiment most commonly used in testing the efficacy or effectiveness of healthcare services (such as medicine or nursing) or health technologies (such as pharmaceuticals, medical devices or surgery). RCTs involve the random allocation of different interventions (treatments or conditions) to subjects. The most important advantage of proper randomization is that "it eliminates selection bias, balancing both known and unknown prognostic factors, in the assignment of treatments."

Risk factors: Factors which make a condition more likely to happen or more dangerous

Trophoblast: The tissue of the developing embryo responsible for implantation and formation of the placenta.

Trophoblastic invasion: The invasion of a specific type of trophoblast (extravillous trophoblast) into the maternal uterus is a vital stage in the establishment of pregnancy. A theory about the etiology of pre-eclampsia is the failure of the trophoblast to invade sufficiently. If there is too firm an attachment, it may lead to placenta accreta.

Vasodilation: Refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When vessels dilate, the flow of blood is increased due to a decrease in vascular resistance. Therefore, dilation of arterial blood vessels (mainly arterioles) leads to a decrease in blood pressure.

Vasospasm: Refers to a condition in which blood vessels spasm, leading to vasoconstriction. This can lead to tissue ischemia and death (necrosis).

Understanding pre-eclampsia and eclampsia

Summary of the session

During this session, you will review: 1) the evolution of pre-eclampsia and eclampsia, 2) epidemiology of pre-eclampsia and eclampsia, 3) the pathophysiology of pre-eclampsia and eclampsia, 4) factors that influence the survival of women with pre-eclampsia/eclampsia and their fetuses/newborn, and 5) morbidity and mortality associated with severe pre-eclampsia and eclampsia.

Learning objectives for the session

At the end of the session, participants will be able to:

· Describe the progression of gestational hypertension into severe pre-eclampsia or eclampsia

· List factors that may predispose some women to the disease

· Describe the pathophysiology of pre-eclampsia and eclampsia

· List maternal, community, and health service factors that influence the survival of women and their newborns

· List maternal and fetal complications associated with severe pre-eclampsia or eclampsia

Learning activities - Classroom

1. List the factors that influence maternal and perinatal outcomes.

2. Mark the factors that are avoidable or can be anticipated.

3. State the steps that must be taken to prevent these avoidable factors, or to reduce the risk.

One example is provided for each category of factors.

Maternal factors

Predisposing factors

Avoidable? Yes / No

Steps to avoid occurrence

Pre-existing medical conditions

May be avoidable

· Prevent pregnancy until condition is stable or avoid pregnancy

Community factors


Avoidable? Yes / No


Lack of awareness about signs and symptoms of pre-eclampsia, severe pre-eclampsia and eclampsia and the importance of early and regular antenatal care

Yes

· Good antenatal care

· Birth preparedness and complication readiness plans

· Community sensitization

Health service factors


Avoidable? Yes / No


Inadequate availability and access to antenatal care

Yes

· Political commitment to increase access to care

· Create alternatives to traditional health care system

Learning activities - Individual

Instructions: Complete the following phrases with the appropriate word or words.

1. In normal pregnancies :

a. Blood volume _________

b. Peripheral vascular resistance _________

c. Progesterone induced arterial _________ occurs

d. Fibrinogen is _________

e. Factor XIII (fibrin stabilizing factor) is _________.

2. The following pathophysiologic changes are associated with pre-eclampsia and eclampsia:

a. Blood pressure begins to _________ after 20 weeks of pregnancy

b. Perfusion is _________ to virtually all organs, which is secondary to intense _________ due to an increased sensitivity of the vasculature to any pressor agent

c. Perfusion to the kidneys is _________, resulting in sodium retention that leads to _________ of intravascular plasma volume, _________ extracellular volume (edema) and increased _________ to pressor agents

d. Loss of normal _________ of uterine arterioles results in decreased _________ perfusion

e. _________ intravascular volume results in increased _________ of the blood and a corresponding rise in hematocrit, and activation of the _________.

3. The system of risk categorization, or the “risk approach, _________ useful for predicting which women will suffer from pre-eclampsia.

4. Maternal and perinatal outcomes in pre-eclampsia depend on _________, _________, and _________ factors.

5. The main causes of maternal death in eclampsia are :

a. __________________

b. _________ complications

c. _________ failure

d. _________ failure

e. failure of _________one organ.

Identifying pre-eclampsia


During this session, you will review 1) screening for pre-eclampsia, 2) diagnosing hypertensive disorders of pregnancy, and 3) the differential diagnosis of hypertensive disorders in pregnancy and the postpartum.



· Describe routine screening for hypertensive disorders during pregnancy and the postpartum

· Correctly measure protein in the urine

· Correctly measure blood pressure

· Make a differential diagnosis of hypertensive disorders in pregnancy and the postpartum

· Test reflexes in women with elevated blood pressure

Job aid

Differential diagnosis of hypertensive disorders in pregnancy

Diagnosis

Diagnostic criteria

Chronic hypertension

Diastolic BP 90 mm Hg or more prior to first 20 weeks of gestation

Preeclampsia superimposed on chronic hypertension

· Women with chronic hypertension

· Any of the following are seen after 20 weeks’ gestation:

· New or worsening proteinuria

· Sudden increase in BP in a woman whose hypertension has previously been well controlled

· One or more adverse conditions associated with pre-eclampsia and/or eclampsia

Gestational hypertension

· Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, no proteinuria.

· Postpartum:

· Transient hypertension of pregnancy if pre-eclampsia is not present at the time of delivery and blood pressure returns to normal by 12 weeks postpartum (a retrospective diagnosis) or

· Chronic hypertension if the elevation persists beyond 12 weeks postpartum.

Mild pre-eclampsia

Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart, proteinuria up to 2+

Severe pre-eclampsia

Diastolic BP 110 mm Hg or more, proteinuria 3+ or more

Eclampsia

A pregnant woman or a woman who has recently given birth is found unconscious or having convulsions (fits), diastolic BP 110 mm Hg or more, proteinuria 2+ or more

Learning activities


1. Methods to evaluate proteinuria include:

a. __________________

b. __________________

c. __________________

d. __________________

2. Gestational hypertension is a _________ diagnosis made _________ weeks post partum if diastolic blood pressure was greater than 90 mmHg but _________ was not present at the time of delivery and blood pressure returned to _________.

3. BP readings are prone to inaccuracy due not only to observer error, but also to variability of blood pressure and to:

a. __________________

b. __________________

c. __________________

d. __________________

4. When testing reflexes, it is the _________ of the response, not how _________ the limb moves, that tells you if her reflexes are normal.

5. When the pre-pregnancy BP is not known, the BP taken before _________ weeks is considered the woman's normal BP

6. The measure of proteinuria is a _________ predictor of either maternal or fetal complications in women with pre-eclampsia.

7. Although proteinuria is most commonly associated with pre-eclampsia or eclampsia, a woman's urine can test positive for protein if:

a. __________________

b. __________________

c. __________________

d. __________________

8. Read the signs and symptoms in the first column and then write the diagnosis in the second column:

Diagnostic criteria

Diagnosis


In women with hypertension and proteinuria before 20 weeks’ gestation any of the following are seen:

· New-onset proteinuria

· sudden increase in proteinuria,

· sudden increase in blood pressure in a woman whose hypertension has previously been well controlled



Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, no proteinuria


Prevention of pre-eclampsia and/or eclampsia


During this session, you will review interventions for 1) primary, 2) secondary, and 3) tertiary prevention of pre-eclampsia and/or eclampsia.



· Define the different levels of prevention

· Describe evidence-based interventions to promote for primary prevention of pre-eclampsia/eclampsia

· Describe evidence-based interventions to promote for secondary prevention of pre-eclampsia/eclampsia

· Describe evidence-based interventions to promote for tertiary prevention of pre-eclampsia/eclampsia

Job aid

Overview of interventions to prevent pre-eclampsia and eclampsia

Prevention

Intervention

Pregnancy outcome

Recommendation

Primary

Prevention of IUGR

Theoretically contributes to primary prevention of pre-eclampsia (and IUGR) in the next generation

Recommended

Family planning

Potential to reduce pregnancies at risk for pre-eclampsia

Recommended

Pre-conceptual prevention and/or treatment of obesity

Potential to reduce pre-eclampsia

Recommended

Smoking

Reduces risk of pre-eclampsia

Not recommended

Low-dose aspirin

Reduces pre-eclampsia

Reduces fetal or neonatal deaths

Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin daily from 12 weeks gestation until the birth of the baby.

Calcium supplementation

Reduces pre-eclampsia in those at high risk and with low baseline dietary calcium intake

No effect on perinatal outcome

Advise women at risk of gestational hypertension living in communities with low dietary calcium intake, to take 1 G of calcium daily from 12 weeks gestation until the birth of the baby.

Magnesium or zinc supplementation

No reduction in pre-eclampsia

Insufficient evidence to recommend*

Fish oil supplementation and other sources of fatty acids

No effect on low- or high-risk populations


Heparin or low-molecular weight heparin

Reduces pre-eclampsia in women with renal disease and thrombophilia


Anti-oxidant vitamins (C, E)

Reduced pre-eclampsia in one trial


Secondary

BP and urinary protein screening during antenatal and postnatal visits


Reduces some adverse maternal and fetal sequelae associated with symptoms

Assists in preventing progression to eclampsia

Recommend for all pregnant women

Prevention

Intervention

Pregnancy outcome

Recommendation

Tertiary

Protein or salt restriction



Anti-convulsive drugs

Magnesium sulfate

Reduces the risk of eclampsia without any substantive effect on longer-term morbidity and mortality for the women or children

Recommend for women with severe pre-eclampsia and eclampsia

Diazepam

When compared to diazepam, magnesium sulfate was associated with a reduction in the risk of maternal death and in the risk of recurrence of convulsions.

When compared to diazepam, magnesium sulfate was associated with a reduction in the risk of an Apgar score <7 at 5 min and in length of stay in a special care baby unit (SCBU) >7 days.

Recommend if magnesium sulfate is not available

Anti-hypertensive drugs

Improves maternal outcome.

May permit prolongation of the pregnancy and thereby improve fetal maturity. Acute falls in maternal systemic blood pressure can result in fetal compromise.

Recommend if BP Diastolic BP 110 mm Hg or more

Induction of labor

Improves maternal and fetal outcome when carried out according to recommendations for severe pre-eclampsia and eclampsia

Consider for women beyond 37 weeks’ gestation with mild pre-eclampsia.

Recommend based on severity of the disease, gestational age, and maternal and fetal condition

* Insufficient evidence=small trials or inconclusive results

Learning activities


1. _________ prevention of pre-eclampsia will be difficult to achieve because the cause is not well understood and most factors associated with it are difficult to avoid or manipulate.

2. List two interventions that are recommended for primary prevention of pre-eclampsia:

a. __________________

b. __________________

3. _________ is associated with a 30–40% decrease in the risk of pre-eclampsia but is not recommended.

4. For prevention of recurrent convulsions/fits in women with eclampsia, _________is the most effective anti-convulsant medication.

5. Do NOT give _________, _________, or _________ to pregnant women for the treatment of convulsions.

6. Administration of a powerful vasodilator will result in a _________ intervillous blood flow.

7. In severe pre-eclampsia, delivery should occur within _________ hours of the onset of symptoms.

8. In eclampsia, delivery should occur within _________ hours of the onset of convulsions/fits.

9. When the gestational hypertension is mild, induction of labor should be advised for women beyond _________ weeks’ gestation.

10. Diuretics are _________ in pregnancy in settings in which uteroplacental perfusion is already reduced (preeclampsia and intrauterine growth restriction).

Management of pre-eclampsia and eclampsia


During this session, you will review management of: 1) gestational hypertension, 2) mild pre-eclampsia, and 3) severe pre-eclampsia / eclampsia.



· Describe management of gestational hypertension and mild pre-eclampsia

· Describe management of severe pre-eclampsia and eclampsia

· Describe the appropriate level of care to manage hypertensive disorders in pregnancy

· Provide care for women with severe pre-eclampsia and eclampsia according to recommended standards

· Appropriately refer women to tertiary care facilities

Job aids

BOX 1 Loading dose for magnesium sulfate for management of severe pre-eclampsia and eclampsia BOX 2 Monitoring respiratory rate, deep tendon reflexes, and urinary output before administering an additional dose of magnesium sulfate

BOX 3 Maintenance dose for magnesium sulfate for management of severe pre-eclampsia and eclampsia

Give 5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2% IM every 4 hours into alternate buttocks.

· Take one 20 mL sterile syringe.

· Draw 5 ampoules of MgSO4 50% (10 mL = 5 gm) into the syringe.

· Add 1 mL of 2% Lignocaine in the syringe.

· Verify in which buttock the last magnesium sulfate injection was given.

· Give deep IM injection in the alternate buttock.

Learning activities – classroom

Source: All learning activities for this session were copied from: MNH/Jhpiego. Managing Complications in Pregnancy and Childbirth: Learning Resource Package - Guide for Teachers.

CASE STUDY # 1

Available at: http://www.reproline.jhu.edu/english/2mnh/2mcpc/5_Learning_Pkg/C_05_Headaches_etc/05-CS-5.2.htm

DIRECTIONS

Read and analyze this case study individually. When the others in your group have finished reading it, answer the case study questions. Consider the steps in clinical decision-making as you answer the questions. The other groups in the room are working on the same or a similar case study. When all groups have finished, we will discuss the case studies and the answers each group has developed.

CASE STUDY

Mrs. B. is 16 years old. She is 30 weeks pregnant and has attended the antenatal clinic three times. All findings were within normal limits until her last antenatal visit 1 week ago. At that visit it was found that her blood pressure was 130/90 mm Hg. Her urine was negative for protein. The fetal heart sounds were normal, the fetus was active and uterine size was consistent with dates. She has come to the clinic today, as requested, for followup.

ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests)

1. What will you include in your initial assessment of Mrs. B., and why?

2. What particular aspects of Mrs. B.'s physical examination will help you make a diagnosis, and why?

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs. B., and why?

DIAGNOSIS (Identification of Problems/Needs)

You have completed your assessment of Mrs. B. and your main findings include the following:

Mrs. B.'s blood pressure is 130/90 mm Hg, and she has proteinuria 1+.

She has no adverse symptoms (headache, visual disturbance, upper abdominal pain, convulsions or loss of consciousness.

The fetus is active and fetal heart sounds are normal. Uterine size is consistent with dates.

4. Based on these findings, what is Mrs. B.'s diagnosis, and why?

CARE PROVISION (Planning and Intervention)

5. Based on your diagnosis, what is your plan of care for Mrs. B., and why?

EVALUATION

Mrs. B. attends antenatal clinic on a twice-weekly basis, as requested. Her blood pressure remains the same; she continues to have proteinuria 1+. Fetal growth is normal. Four weeks later, however, her blood pressure is 130/110 mm Hg and she has proteinuria 2+. Mrs. B. has not suffered headache, blurred vision, upper abdominal pain, convulsions or loss of consciousness and says that she feels well. However, she finds it very tiring to have to travel to the clinic by bus twice weekly for followup and wants to come only once a week.

6. Based on these findings, what is your continuing plan of care for Mrs. B., and why?

Clinical simulation: Management of headache, high blood pressure, blurred vision, loss of consciousness

Scenario 1Key Reactions/Responses

Mrs. H. is 20 years old. She is 38 weeks pregnant. This is her second pregnancy. Her mother-in-law has brought Mrs. H. to the health center this morning because she has had a severe headache and blurred vision for the past 6 hours. Mrs. H. says she feels very ill.

1. What will you do?

Mrs. H.’s diastolic blood pressure is 96 mm Hg, her pulse 100 beats/minute and respiration rate 20 breaths/minute. She has hyper-reflexia. Her mother-in-law tells you that Mrs. H. has had no symptoms or signs of the onset of labor.

2. What is Mrs. H.’s problem?

3. What will you do now?

4. What is your main concern at the moment?

After 15 minutes, Mrs. H. is resting quietly. She still has a headache and hyper-reflexia.


6. What will you do during the next hour?

It is now 1 hour since treatment for Mrs. H. was started. Her diastolic blood pressure is still 96 mm Hg, pulse 100 beats/minute and respiration rate 20 breaths/minute. She still has hyper-reflexia. You detect that the fetal heart rate is 80.

7. What is your main concern now?


Learning activities – individual

CASE STUDY #2

Available at:

http://www.reproline.jhu.edu/english/2mnh/2mcpc/5_Learning_Pkg/C_05_Headaches_etc/05-CS-5.3.htm

DIRECTIONS

Read and analyze this case study individually. When the others in your group have finished reading it, answer the case study questions. Consider the steps in clinical decision-making as you answer the questions. The other groups in the room are working on the same or a similar case study. When all groups have finished, we will discuss the case studies and the answers each group has developed.

Mrs. C. is 23 years old. She is 37 weeks pregnant and has attended the antenatal clinic four times. No abnormal findings were detected during antenatal visits, the last of which was 1 week ago. Mrs. C. has been counseled about danger signs in pregnancy and what to do about them. Her husband has brought her to the emergency department of the district hospital because she developed a severe headache and blurred vision this morning.


1. What will you include in your initial assessment of Mrs. C., and why?

2. What particular aspects of Mrs. C.'s physical examination will help you make a diagnosis or identify her problems/needs, and why?

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs. C., and why?


You have completed your assessment of Mrs. C. and your main findings include the following:

Mrs. C.'s blood pressure is 160/110 mm Hg, and she has proteinuria 3+.

She has a severe headache that started 3 hours ago. Her vision became blurred 2 hours after the onset of headache. She has no upper abdominal pain and has not suffered convulsions or loss of consciousness. Her reflexes are normal.


4. Based on these findings, what is Mrs. C.'s diagnosis, and why?


5. Based on your diagnosis, what is your plan of care for Mrs. C., and why?

EVALUATION

Two hours following the initiation of treatment, Mrs. C.'s diastolic blood pressure is 100 mm Hg. She has not had a convulsion, but still has a headache. She does not have coagulopathy. During the past 2 hours, however, Mrs. C.'s urinary output has dropped to 20 mL/hour. The fetal heart rate has ranged between 120 and 140 beats/minute.

6. Based on these findings, what is your continuing plan of care for Mrs. C., and why?

Management during a convulsion / fit


Not all women with pre-eclampsia will develop eclampsia, but both her life and the life of her baby are in danger when a pregnant woman has fits. During this session, you will review how to care for pregnant and postpartum women who are fitting.



· Describe stages of an eclamptic fit

· Describe steps to follow for managing convulsions / fits in a pregnant or postpartum woman

· Make a differential diagnosis of fits / convulsions during pregnancy and the postpartum

Job aids

Differential diagnosis of convulsions/fits in pregnancy

Presenting symptom and other symptoms and signs typically present

Symptoms and signs sometimes present

Probable diagnosis

· Convulsions / Fits

· Diastolic BP 90 mm Hg or more after 20 weeks gestation

· Proteinuria 2+ or more

· Coma (unconscious)

· Other signs and symptoms of severe pre-eclampsia

· Headache (increasing frequency, unrelieved by regular analgesics)

· Blurred vision

· Oliguria (passing less than 400 mL in 24 hours)

· Upper abdominal pain (epigastric pain or pain in upper right quadrant)

· Pulmonary edema

Eclampsia

· Trismus (difficulty opening mouth and chewing)

· Spasms of face, neck, trunk

· Arched back

· Spontaneous violent spasms

Tetanus

· Convulsions/fits

· Past history of convulsions/fits

· Normal blood pressure

Epilepsy

· Fever

· Chills/rigor

· Headache

· Muscle/joint pain

· Coma

· Anemia

· Convulsions/Fits

· Jaundice

Severe / complicated malaria

· Headache

· Stiff neck

· Photophobia

· Fever

· Convulsions/Fits

· Confusion

· Drowsiness

· Coma

Meningitis or Encephalitis

Learning activities - Classroom

Scenario 2

Key Reactions/Responses

Mrs. G. is 16 years old and is 37 weeks pregnant. This is her first pregnancy. She has presented to the labor unit with contractions and says that she has had a bad headache all day. She also says that she cannot see properly. While she is getting up from the examination table she falls back onto the pillow and begins to have a convulsion.


Discussion Question 1:

After 5 minutes, Mrs. G. is no longer convulsing. Her diastolic blood pressure is 110 mm Hg and her respiration rate is 20 breaths/minute.

2. What is Mrs. G.’s problem?

3. What will you do next?

4. What should the aim be with respect to controlling Mrs. G.’s blood pressure?

5. What other care does Mrs. G. require now?

Discussion Question 2:

After another 15 minutes, Mrs. G.’s blood pressure is 94 mm Hg and her respiration rate is 16 breaths/minute.


It is now 1 hour since treatment was started for Mrs. G. She is sleeping but is easily roused. Her blood pressure is now 90 mm Hg and her respiration rate is still 16 breaths/minute. She has had several more contractions, each lasting less than 20 seconds.


Scenario 2


It is now 2 hours since treatment was started for Mrs. G. Her blood pressure is still 90 mm Hg and her respiration rate is still 16 breaths/minute. All other observations are within expected range. She continues to sleep and rouses when she has a contraction. Contractions are occurring more frequently but still last less than 20 seconds. Mrs. G.’s cervix is 100% effaced and 3 cm dilated. There are no fetal heart abnormalities.


9. When should childbirth occur?

Learning activities - Individual

1. Match the signs with the stage of an eclamptic fit:

A= premonitory

C = clonic

B = tonic

D = coma

Sign

Stage

Woman’s teeth are clenched

Example: B

Woman’s face and hand muscles twitch

Woman breathes noisily

Woman’s breathing stops

Woman’s eyes roll

Woman’s face is congested

Woman foams at the mouth

Woman’s arms and legs are rigid

2. Put a number next to the step to indicate the correct order in which to carry out the following interventions (1 is the first intervention).

Give oxygen at 4–6 L per minute by mask or cannulae.

Airway: Turn the woman onto her left side to reduce the risk of aspiration of secretions, vomit and blood.

If absent, initiate CPR and call arrest team

Ensure the woman’s airway is open

Breathing: Assess breathing

1

SHOUT FOR HELP to urgently mobilize available personnel.

Protect her from injury but do not actively restrain.

Gather equipment (airway, suction, mask and bag, oxygen)

If the woman is not breathing, begin resuscitation measures

Circulation: Evaluate pulse

Birth preparedness and complication readiness

Source: JHPIEGO/MNH. Birth Preparedness and Complication Readiness. Baltimore, MD: JHPIEGO/MNH, 2001.


When delays occur in recognizing problems and referring women to appropriate health care facilities, the result can lead to maternal and newborn deaths. One solution to combat these problems is to work with the pregnant woman and her family to develop two plans: a birth-preparedness plan and a complication-readiness plan.

Because all pregnancies carry risks, providers must work with all pregnant women and their families to develop a birth-preparedness plan. This planning helps women receive high-quality, timely care for both normal and complicated pregnancy, labor, and childbirth. The following topic provides information on developing a birth-preparedness plan (BPP) and a complication-readiness plan (CRP).



· List elements of the birth preparedness plan

· List elements of the complication-readiness plan.

Learning activities

Read the following case studies carefully and answer the questions that follow. Justify your responses.

Case study #1: Ms. K’s (age 32) first antenatal visit is at 32 weeks. Her village is 15 km away, and she arrived in the back of an open truck—the only transportation available. Her traditional birth attendant suggested she come to the health center for antenatal care.

She has given birth eight times, and only two of her children are alive today. Her last baby was stillborn, the result of a long, difficult labor; she says the baby was moving well until the end of labor. After 24 hours of labor, the traditional birth attendant decided to send her to the health center. Because her husband was away at the time and no one wanted to take responsibility for her, they waited another day for her husband to return home. Although the husband decided to send her to the health center, it took several hours for him to gather enough money for the trip. The doctor delivered the baby with a vacuum, and after the birth, Ms. K bled significantly.

Questions

10. What about Ms. K’s case indicates why it is important she have a birth plan and plan in case of complications?

11. Where do you recommend Ms. K give birth?

12. List the important topics to address in birth-preparedness and complication-readiness plans.

Case study #2: Read the story of Ms. Kebede and identify the delays which led to her death.

Ms. Kebede is a grand multipara who lives in a village where there are no health services. She did not have a prenatal consultation and when labor began, she called on members of her family. After a while, the family members realized that her labor was not progressing normally.

The family called on the traditional birth attendant who said that the labor was not normal.

She was then referred to a higher level of service, but first means of transporting her had to be found.

Ms. Kebede arrived at the health center at 12:10 p.m. on March 23.

When she arrived, the service providers noted that the head of the baby was at the vulva and that Ms. Kebede was no longer having contractions.

Ms. Kebede was kept at the health center for 4 hours before a decision was made at 4:50 p.m. on March 23 to evacuate her to the district hospital (DH) because she “refused to make the effort to push.”.

Nothing was done to provide first aid (not even an IV, etc.).

Evacuation was delayed because the family had to seek some means of transportation.

Ms. Kebede arrived at the DH at 8:30 a.m. on March 24.

The general surgeon does not operate on uterine ruptures; furthermore, another woman was already waiting for a cesarean because she had a scarred uterus. Therefore, Ms. Kebede had to be evacuated to the regional hospital.

The decision to evacuate her was made at 8:52 a.m., means of transportation were found at 9:00 a.m., Ms. Kebede left the DH at 10:30 a.m.

Ms. Kebede arrived at the regional hospital at 12:30 p.m. The staff tried to stabilize her and took her to the operating room at 1:00 p.m.

Ms. Kebede died in the operating room at 1:15 p.m. as she was receiving general anesthesia.

1. Identify the delays that led to her death.

2. List the delays that could have been prevented if Ms Kebede had received quality obstetric care.

Suggested answers for learning activities

Understanding pre-eclampsia and eclampsia

1. In normal pregnancies :

a. Blood volume increases

b. Peripheral vascular resistance decreases

c. Progesterone induced arterial dilatation occurs

d. Fibrinogen is increased

e. Factor XIII (fibrin stabilizing factor) is decreased.

2. The following pathophysiologic changes are associated with pre-eclampsia and eclampsia:

a. Blood pressure begins to rise after 20 weeks of pregnancy

b. 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

c. 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

d. Loss of normal vasodilation of uterine arterioles results in decreased placental perfusion

e. Decreased intravascular volume results in increased viscosity of the blood and a corresponding rise in hematocrit, and activation of the coagulation cascade.

3. The system of risk categorization, or the “risk approach, is not useful for predicting which women will suffer from pre-eclampsia.

4. Maternal and perinatal outcomes in pre-eclampsia depend on maternal, community, and health care factors.

5. The main causes of maternal death in eclampsia are :

a. intracerebral hemorrhage

b. pulmonary complications

c. kidney failure

d. liver failure

e. failure of more than one organ.

Identifying pre-eclampsia

1. Methods to evaluate proteinuria include:

a. Quantitation of a timed collection (12 hours or 24 hours)

b. Urinary protein:creatinine ratio

c. Urine dipsticks

d. Boiling urine

2. Gestational hypertension is a retrospective diagnosis made 12 weeks post partum if diastolic blood pressure was greater than 90 mmHg but pre-eclampsia was not present at the time of delivery and blood pressure returned to normal.

3. BP readings are prone to inaccuracy due not only to observer error, but also to variability of blood pressure and to:

a. device error

b. variability of blood pressure

c. rise in BP caused by anxiety/fear

d. rise in BP due to the effects of attendance at the clinic (white-coat hypertension)

4. When testing reflexes, it is the speed of the response, not how far the limb moves, that tells you if her reflexes are normal.

5. When the pre-pregnancy BP is not known, the BP taken before 20 weeks is considered the woman's normal BP

6. The measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia.

7. Although proteinuria is most commonly associated with pre-eclampsia or eclampsia, a woman's urine can test positive for protein if:

a. she is severely anemic

b. she has kidney disease

c. she has a UTI

d. the urine has been contaminated by blood, vaginal discharge, or amniotic fluid.

8. Read the signs and symptoms in the first column and then write the diagnosis in the second column:

Diagnostic criteria

Diagnosis


Severe pre-eclampsia

In women with hypertension and proteinuria before 20 weeks’ gestation any of the following are seen:

· New-onset proteinuria

· sudden increase in proteinuria,

· sudden increase in blood pressure in a woman whose hypertension has previously been well controlled

Preeclampsia superimposed on chronic hypertension


Chronic hypertension


Mild pre-eclampsia

Two readings of diastolic BP 90 mm Hg or more but below 110 mm Hg 4 hours apart after 20 weeks gestation, no proteinuria

Gestational hypertension


Eclampsia

Prevention of pre-eclampsia and/or eclampsia

1. Primary prevention of pre-eclampsia will be difficult to achieve because the cause is not well understood and most factors associated with it are difficult to avoid or manipulate.

2. List two interventions that are recommended for primary prevention of pre-eclampsia:

a. Prevention of or effective treatment of obesity

b. Family planning to delay the first pregnancy until the woman is at least 20 or 21 years of age and to limit pregnancies beyond 35 years of age

3. Cigarette smoking is associated with a 30–40% decrease in the risk of pre-eclampsia but is not recommended.

4. For prevention of recurrent convulsions/fits in women with eclampsia, magnesium sulfate is the most effective anti-convulsant medication.

5. Do NOT give lytic cocktail, phenobarbital, or phenytoin (Dilantin) to pregnant women for the treatment of convulsions.

6. Administration of a powerful vasodilator will result in a decreased intervillous blood flow.

7. In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms.

8. In eclampsia, delivery should occur within 12 hours of the onset of convulsions/fits.

9. When the gestational hypertension is mild, induction of labor should be advised for women beyond 37 weeks’ gestation.

10. Diuretics are contraindicated in pregnancy in settings in which uteroplacental perfusion is already reduced (preeclampsia and intrauterine growth restriction).

Management of pre-eclampsia and eclampsia

CASE STUDY # 1

Mrs. B. is 16 years old. She is 30 weeks pregnant and has attended the antenatal clinic three times. All findings were within normal limits until her last antenatal visit 1 week ago. At that visit it was found that her blood pressure was 130/90 mm Hg. Her urine was negative for protein. The fetal heart sounds were normal, the fetus was active and uterine size was consistent with dates. She has come to the clinic today, as requested, for followup.


1. What will you include in your initial assessment of Mrs. B., and why?

· Mrs. B. should be greeted respectfully and with kindness.

· She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner.

· Mrs. B. should be asked how she is feeling and whether she has had headache, blurred vision or upper abdominal pain since her last clinic visit.

· She should be asked whether fetal activity has changed since her last visit.

· Her blood pressure should be checked and her urine tested for protein (the presence of proteinuria, together with a diastolic blood pressure greater than 90 mm Hg, is indicative of pre-eclampsia).

2. What particular aspects of Mrs. B.'s physical examination will help you make a diagnosis, and why?

· Blood pressure should be measured.

· An abdominal examination should be done to check fetal growth and to listen for fetal heart sounds (in cases of pre-eclampsia/eclampsia reduced placental function may lead to low birth weight; there is an increased risk of hypoxia in both the antenatal and intranatal periods, and an increased risk of abruptio placentae).

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs. B., and why?

· As mentioned above, urine should be checked for protein.


You have completed your assessment of Mrs. B. and your main findings include the following:

Mrs. B.'s blood pressure is 130/90 mm Hg, and she has proteinuria 1+.

She has no adverse symptoms (headache, visual disturbance, upper abdominal pain, convulsions or loss of consciousness.


5. Based on these findings, what is Mrs. B.'s diagnosis, and why?

· Mrs. B.'s signs and symptoms (e.g., diastolic blood pressure 90110 mm Hg after 20 weeks gestation and proteinuria up to 2+) are consistent with mild pre-eclampsia.


4. Based on your diagnosis, what is your plan of care for Mrs. B., and why?

· Mrs. B. should be provided reassurance and counseled about the danger signs related to severe pre-eclampsia and eclampsia (severe headache, blurred vision, upper abdominal pain, and convulsions or loss of consciousness) and the need to seek help immediately if any of these occur. She should be advised of the possible consequences of pregnancy-induced hypertension.

· She should be encouraged to take additional periods of rest and to eat a normal diet (salt restriction should be discouraged as this does not prevent pregnancy-induced hypertension).

· Mrs. B. should be asked to return to the clinic twice weekly to have her blood pressure, urine and fetal condition monitored.

· Mrs. B.'s management should not include the use of anticonvulsives, antihypertensives, sedatives or tranquilizers (these should not be given unless the blood pressure or urinary protein level increases).

· Basic antenatal care (early detection and treatment of problems, prophylactic interventions, birth plan development/revision, plan for newborn feeding) should be provided, as needed.

· She should be advised to plan for childbirth in the hospital.

EVALUATION

Mrs. B. attends antenatal clinic on a twice-weekly basis, as requested. Her blood pressure remains the same; she continues to have proteinuria 1+. Fetal growth is normal. Four weeks later, however, her blood pressure is 130/110 mm Hg and she has proteinuria 2+. Mrs. B. has not suffered headache, blurred vision, upper abdominal pain, convulsions or loss of consciousness and says that she feels well. However, she finds it very tiring to have to travel to the clinic by bus twice weekly for followup and wants to come only once a week.

5. Based on these findings, what is your continuing plan of care for Mrs. B., and why?

· Mrs. B. needs to be monitored on a twice-weekly basis, especially since her diastolic blood pressure and proteinuria have increased. Since this will be difficult on an outpatient basis because travel to the clinic twice weekly is making Mrs. B. very tired, she should be admitted to the district hospital.

· The need for close followup should be explained to Mrs. B. In relation to this, she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance.

· Her care in hospital should be as follows:

· Normal diet

· Blood pressure monitored twice daily

· Urine tested for protein daily

· Fetal condition monitored twice daily

· No anticonvulsants, antihypertensives, sedatives or tranquilizers

· If Mrs. B.'s blood pressure returns to normal or her condition is stable, she could be discharged, providing arrangements can be made for twice-weekly followup (e.g., it may be possible for her to attend antenatal clinic once a week and be monitored at home once a week by a community midwife).

· If her condition remains unchanged, she should remain in the hospital and be monitored as described above.

· Basic antenatal care should continue to be provided, as needed.

· If Mrs. B. develops signs of fetal growth restriction, early childbirth should be considered.

· If fetal and maternal condition are stable, she should be allowed to go into spontaneous labor and may deliver vaginally without the need for vacuum extraction or forceps.

Clinical simulation

Scenario 1


Mrs. H. is 20 years old. She is 38 weeks pregnant. This is her second pregnancy. Her mother-in-law has brought Mrs. H. to the health center this morning because she has had a severe headache and blurred vision for the past 6 hours. Mrs. H. says she feels very ill.


· Shouts for help to urgently mobilize all available personnel

· Places Mrs. H. on the examination table on her left side

· Makes a rapid evaluation of Mrs. H.’s condition, including vital signs (temperature, pulse, blood pressure, and respiration rate), level of consciousness, color and temperature of skin

· Simultaneously asks about the history of Mrs. H.’s present illness

Mrs. H.’s diastolic blood pressure is 96 mm Hg, her pulse 100 beats/minute and respiration rate 20 breaths/minute. She has hyper-reflexia. Her mother-in-law tells you that Mrs. H. has had no symptoms or signs of the onset of labor.

2. What is Mrs. H.’s problem?


4. What is your main concern at the moment?

· States that Mrs. H.’s symptoms and signs are consistent with severe pre-eclampsia

· Has one of the staff who responded to her shout for help start oxygen at 4–6 L/minute

· Prepares and gives magnesium sulfate 20% solution, 4 g IV over 5 minutes

· Follows promptly with 10 g of 50% magnesium sulfate solution, 5 g in each buttock deep IM injection with 1 mL of 2% lignocaine in the same syringe

· At the same time, tells Mrs. H. (and her mother-in-law) what is going to be done, listens to them and responds attentively to their questions and concerns

· States that the main concern at the moment is to prevent Mrs. H. from convulsing

After 15 minutes, Mrs. H. is resting quietly. She still has a headache and hyper-reflexia.


6. What will you do during the next hour?

· Has one of the staff assisting with the emergency insertion of an indwelling catheter to monitor urinary output and proteinuria

· Starts an IV infusion of normal saline or Ringer’s lactate

· Listens to the fetal heart

· States that during the next hour will continue to monitor vital signs, reflexes and fetal heart, and maintain a strict fluid balance chart

It is now 1 hour since treatment for Mrs. H. was started. Her diastolic blood pressure is still 96 mm Hg, pulse 100 beats/minute and respiration rate 20 breaths/minute. She still has hyper-reflexia. You detect that the fetal heart rate is 80.

7. What is your main concern now?


· States that main concern now is fetal heart abnormality

· States that Mrs. H. should be prepared to go the operating room for cesarean section

· Tells Mrs. H. (and her mother-in-law) what is happening, listens to their concerns and provides reassurance

CASE STUDY #2

Mrs. C. is 23 years old. She is 37 weeks pregnant and has attended the antenatal clinic four times. No abnormal findings were detected during antenatal visits, the last of which was 1 week ago. Mrs. C. has been counseled about danger signs in pregnancy and what to do about them. Her husband has brought her to the emergency department of the district hospital because she developed a severe headache and blurred vision this morning.


1. What will you include in your initial assessment of Mrs. C., and why?

· Mrs. C. and her husband should be greeted respectfully and with kindness.

· They should be told what is going to be done and listened to carefully. In addition, their questions should be answered in a calm and reassuring manner.

· A rapid assessment should be done to check level of consciousness and blood pressure. Temperature and respiration rate should also be checked. Mrs. C. should be asked how she is feeling, when headache and blurred vision began, whether she has had upper abdominal pain and whether there has been a decrease in urinary output during the past 24 hours.

· Mrs. C.'s urine should be tested for protein.

2. What particular aspects of Mrs. C.'s physical examination will help you make a diagnosis or identify her problems/needs, and why?

· Mrs. C. should be checked for elevated blood pressure and protein in her urine (the presence of proteinuria, together with a diastolic blood pressure greater than 90 mm Hg, is indicative of pre-eclampsia).

· An abdominal examination should be done to check fetal condition and to listen for fetal heart sounds (in cases of pre-eclampsia/eclampsia reduced placental function may lead to low birth weight; there is an increased risk of hypoxia in both the antenatal and intranatal periods, and an increased risk of abruptio placentae).

· Note that a diagnosis should be made rapidly, within a few minutes.

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs. C., and why?

· As mentioned above, urine should be checked for protein.


You have completed your assessment of Mrs. C. and your main findings include the following:

Mrs. C.'s blood pressure is 160/110 mm Hg, and she has proteinuria 3+.

She has a severe headache that started 3 hours ago. Her vision became blurred 2 hours after the onset of headache. She has no upper abdominal pain and has not suffered convulsions or loss of consciousness. Her reflexes are normal.


4. Based on these findings, what is Mrs. C.'s diagnosis, and why?

· Mrs. C.'s symptoms and signs (e.g., diastolic blood pressure 110 mm Hg or more after 20 weeks gestation and proteinuria up to 3+) are consistent with severe pre-eclampsia.


5. Based on your diagnosis, what is your plan of care for Mrs. C., and why?

· An antihypertensive drug should be given to lower the diastolic blood pressure and keep it between 90 mm Hg and 100 mm Hg to prevent cerebral hemorrhage.

· Anticonvulsive therapy should be started. Magnesium sulfate is the drug of choice for preventing and treating convulsions in severe pre-eclampsia and eclampsia; however, if it is not available, diazepam may be used.

· Equipment to respond to a convulsion (airway, suction, mask and bag, oxygen) should be available at her bedside.

· Mrs. C. should not be left alone if she has a convulsion.

· An IV of normal saline or Ringer's lactate should be started to administer IV drugs.

· An indwelling catheter should be inserted to monitor urine output and proteinuria (magnesium sulfate should be withheld if the urine output falls below 30 mL/hour over 4 hours).

· A strict record of intake and output should be kept to ensure that there is no fluid overload.

· Vital signs (blood pressure and respiration rate, in particular), reflexes and fetal heart rate should be monitored hourly (magnesium sulfate should be withheld if the respiration rate falls below 16 breaths/minute or if patellar reflexes are absent).

· Auscultate the lung bases hourly for rales indicating pulmonary edema.

· A bedside clotting test should be done to rule out coagulopathy (coagulopathy can be triggered by eclampsia).

· The steps taken to manage the complication should be explained to Mrs. C. and her husband. In addition, they should be encouraged to express their concerns, listened to carefully, and provided emotional support and reassurance.

EVALUATION

Two hours following the initiation of treatment, Mrs. C.'s diastolic blood pressure is 100 mm Hg. She has not had a convulsion, but still has a headache. She does not have coagulopathy. During the past 2 hours, however, Mrs. C.'s urinary output has dropped to 20 mL/hour. The fetal heart rate has ranged between 120 and 140 beats/minute.

6. Based on these findings, what is your continuing plan of care for Mrs. C., and why?

· Do not repeat the dose of magnesium sulfate until the urine output is greater than 30 mL/hour.

· Plans should be made to deliver Mrs. C.:

· If the cervix is favorable (soft, thin, partly dilated), membranes should be ruptured and labor should be induced using oxytocin or prostaglandins.

· If vaginal delivery is not anticipated within 24 hours, if there are fetal heart abnormalities (less than 100 or more than 180 beats/minute), or if the cervix is unfavorable, Mrs. C. should be delivered by cesarean section.

· The steps taken for continuing management of the complication should be explained to Mrs. C. and her husband. In addition, they should be encouraged to express their concerns, listened to carefully, and provided continuing emotional support and reassurance.

· After childbirth:

· Anticonvulsive therapy should be continued for 24 hours.

· Antihypertensive drugs should be continued if Mrs. C.'s diastolic blood pressure is 110 mm Hg or more, and her urinary output should continue to be monitored.

Managing convulsions

Scenario 2


Mrs. G. is 16 years old and is 37 weeks pregnant. This is her first pregnancy. She has presented to the labor unit with contractions and says that she has had a bad headache all day. She also says that she cannot see properly. While she is getting up from the examination table she falls back onto the pillow and begins to have a convulsion.


· Shouts for help to urgently mobilize all available personnel

· Checks airway to ensure that it is open, and turns Mrs. G. onto her left side

· Protects her from injuries (fall) but does not attempt to restrain her

· Has one of the staff members who responded to her shout for help take Mrs. G.’s vital signs (temperature, pulse, blood pressure and respiration rate) and check her level of consciousness, color and temperature of skin

· Has another staff member start oxygen at 4–6 L/minute

· Prepares and gives magnesium sulfate 20% solution, 4 g IV over 5 minutes

· Follows promptly with 10 g of 50% magnesium sulfate solution, 5 g in each buttock deep IM injection with 1 mL of 2% lignocaine in the same syringe

· At the same time, explains to the family what is happening and talks to the woman as appropriate

Discussion Question 1: What would you do if there was no magnesium sulfate in the hospital?

Expected Response: Use diazepam 10 mg slowly over 2 minutes.

After 5 minutes, Mrs. G. is no longer convulsing. Her diastolic blood pressure is 110 mm Hg and her respiration rate is 20 breaths/minute.

2. What is Mrs. G.’s problem?

3. What will you do next?

4. What should the aim be with respect to controlling Mrs. G.’s blood pressure?

5. What other care does Mrs. G. require now?

· States that Mrs. G.’s symptoms and signs are consistent with eclampsia

· Gives hydralazine 5 mg IV slowly every 5 minutes until diastolic blood pressure is lowered to between 90–100 mm Hg

· States that the aim should be to keep Mrs. G.’s diastolic blood pressure between 90 mm Hg and 100 mm Hg to prevent cerebral hemorrhage

· Has one of the staff assisting with the emergency insertion of an indwelling catheter to monitor urinary output and proteinuria

· Has a second staff member start an IV infusion of normal saline or Ringer’s lactate and draws blood to assess clotting status using a bedside clotting test

· Maintains a strict fluid balance chart

Discussion Question 2: Would you give additional hydralazine after the first dose?

Expected Response: Repeat hourly as needed, or give 12.5 mg IM every 2 hours as needed.

Scenario 2


After another 15 minutes, Mrs. G.’s blood pressure is 94 mm Hg and her respiration rate is 16 breaths/minute.


· Stays with Mrs. G. continuously and monitors blood pressure, pulse, respiration rate, patella reflexes and fetal heart

· Checks whether Mrs. G. has had any further contractions

It is now 1 hour since treatment was started for Mrs. G. She is sleeping but is easily roused. Her blood pressure is now 90 mm Hg and her respiration rate is still 16 breaths/minute. She has had several more contractions, each lasting less than 20 seconds.


· Continues to monitor blood pressure, pulse, respiration rate, reflexes and fetal heart

· Monitors urine output and IV fluid intake

· Monitors for the development of pulmonary edema by auscultating lung bases for rales

· Assesses Mrs. G.’s cervix to determine whether it is favorable or unfavorable

It is now 2 hours since treatment was started for Mrs. G. Her blood pressure is still 90 mm Hg and her respiration rate is still 16 breaths/minute. All other observations are within expected range. She continues to sleep and rouses when she has a contraction. Contractions are occurring more frequently but still last less than 20 seconds. Mrs. G.’s cervix is 100% effaced and 3 cm dilated. There are no fetal heart abnormalities.


9. When should childbirth occur?

· Continues to monitor Mrs. G. as indicated above

· States that membranes should be ruptured using an amniotic hook or a Kocher clamp and labor induced using oxytocin or prostaglandins

· States that childbirth should occur within 12 hours of the onset of Mrs. G.’s convulsions

1. Match the signs with the stage of an eclamptic fit:

A= premonitory

C = clonic

B = tonic

D = coma

Sign

Stage

Woman’s teeth are clenched

Example: B

Woman’s face and hand muscles twitch

A

Woman breathes noisily

D

Woman’s breathing stops

B

Woman’s eyes roll

A

Woman’s face is congested

D

Woman foams at the mouth

C

Woman’s arms and legs are rigid

B

2. Put a number next to the step to indicate the correct order in which to carry out the following interventions (1 is the first intervention).

7

Give oxygen at 4–6 L per minute by mask or cannulae.

3

Airway: Turn the woman onto her left side to reduce the risk of aspiration of secretions, vomit and blood.

9

If absent, initiate CPR and call arrest team

4

Ensure the woman’s airway is open

5

Breathing: Assess breathing

1

SHOUT FOR HELP to urgently mobilize available personnel.

10

Protect her from injury but do not actively restrain.

2

Gather equipment (airway, suction, mask and bag, oxygen)

6

If the woman is not breathing, begin resuscitation measures

8

Circulation: Evaluate pulse

Birth preparedness and complication readiness

Case study #1: Ms. K

Questions

1. What about Ms. K’s case indicates why it is important she have a birth plan?

Geographic and transportation issues:

· Her village is 15 km away.

· She travels in an open truck because is the only form of transport available.

Financial and decision-making issues:

· After labor had gone on for 24 hours, the traditional birth attendant decided to send her to the health center, but her husband had been away and no one wanted to take the responsibility of sending her, so they had to wait another day until the husband came home.

· Even though the husband decided to send her to the health center, it took him several hours to get enough money to send her.

Previous obstetric complications:

· She has given birth 11 times, only 2 of her children are alive; her last baby was stillborn, and apparently died during a long, hard labor (she says the baby was moving well until the end of labor).

· The doctor delivered the last baby with a vacuum.

· After the birth, she says she bled a lot.

2. Where do you recommend Ms. K give birth?

· Ms. K should give birth with a skilled provider, most likely in a health center where vacuum birth/cesarean operation are possible, or she should give birth at the hospital.

3. List the important topics to address in the BPP.

Developing a BPP

· Make plans for the birth.

· Place of birth.

· Chosen skilled provider.

· 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?

· Prepare the necessary items for birth.

· Establish a financing plan/scheme.

· How much money will be required and how to get access to this money

Case study #2: Ms. Kebede. 1. Identify the delays that led to Ms. Kebede’s death.

2. List the delays that could have been prevented if Ms Kebede had received quality obstetric care.

· Adequate preparation during antenatal care and development of a BPP would have prevented the following delays:

· Delay in receiving care

· Ms K would have planned to give birth with a skilled birth attendant.

· Ms K would have planned for transport and funds.

· Ms K did not receive quality care until she reached the national hospital, when it was too late.

· Delay in recognizing the problem—Ms K and her family would have recognized the need to seek care earlier if they had been taught the danger signs.

Learning guides

Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but < 110 mm Hg

Training facilitators or participants can use the following learning guide to gauge progress while learning to care for pregnant women with diastolic BP between 90-110 mm Hg.

Directions

Rate the performance of each step or task using the following rating scale:

1 = Performs the step or task completely and correctly.

0 = Unable to perform the step or task completely or correctly or the step/task was not observed.

N/A (not applicable) = Step was not needed.

Learning guide for hypertension in pregnancy: Diastolic Blood Pressure is >90 mm Hg but < 110 mm Hg

STEP/TASK

OBSERVATIONS

GETTING READY

1.Greet the woman respectfully and with kindness.

2. Tell the woman what is going to be done and encourage her to ask

questions.

3.Listen to what the woman has to say.

4.Provide emotional support and reassurance.

Initial assessment

1. Take a good personal and family history of:

· Epilepsy

· Hypertension

· Renal or heart disease

· Cerebro-vascular accident (CVA)

2. Take a good symptom history (danger signs). ASK if she has or had any:

· Epigastric pain (heartburn)

· Headaches

· Visual problems (double vision, partial vision, rings around lights)

3. Calculate gestational age

4. Check that the right size BP cuff was used and that the BP machine is functioning properly

5. Have the woman lie on her left side for 20 minutes, then recheck it again with her sitting up

· If the blood pressure is normal, this is not hypertension.

· If the blood pressure is still elevated, plan to check the BP again in 4 hours.

· If the BP is still elevated 4 hours after the first reading, this is considered hypertension.

6. Check a mid-stream “clean catch” urine sample for protein regardless of subsequent BP measurement.

7. If there is greater than 1+ protein in the urine:

· Verify that the sample was a mid-stream/clean-catch sample. Make sure the urine is not contaminated by vaginal secretion.

· Check for sexually transmitted infections (STI)

· Rule out a urinary tract infection, schistosomiasis (in endemic areas), and kidney infections.

· Rule-out anemia

8. If diastolic BP is >90 mm Hg, gestational age is at least 20 weeks, and there is proteinuria, check the biceps and patellar reflexes.

9. If the reflexes are brisk (+3 or +4), refer her to a hospital/doctor regardless of BP and/or proteinuria.

Identify problems / needs

1. Analyze the data collected and make a differential diagnosis:

· Chronic hypertension: Diastolic BP >90 but <110 without proteinuria, detected before 20 weeks gestation

· Gestational hypertension: Diastolic BP >90 without proteinuria, detected after 20 weeks gestation

· Mild pre-eclampsia: Diastolic BP >90 but <110 with 1+ proteinuria

2. Make a decision about management or referral.

3. Assess educational needs of the woman and make a plan for counseling and follow-up.

Make a plan of care

1. Share your findings with the woman:

· State of health

· Blood pressure

2. Discuss any complications / problems detected during the visit:

· Complications / problems

· Possible cause(s)

· Preventive measures

3. Explain management, based on diagnosis, and the importance for pregnancy, labor, and delivery

4. Write and / or explain any prescriptions:

· How and when to use

· Contraindications

· Possible reactions

4. If the woman has to be referred, explain the need for referral and, if possible, accompany her.

5. Determine where the woman should deliver, and assist her in developing a birth preparedness and complication readiness plan.

6. Counsel the woman.

Follow-up

1. Inform the woman about next steps – either arrange for hospitalization, referral, or follow-up as an outpatient.

2. Check the woman’s understanding of findings and next steps.

3. Remind the woman to report any time she has questions/concerns/danger signs and not to wait for the scheduled visit

4. Record drug administration and findings on the woman’s record

5. Give the woman her antenatal and / or appointment cards.

6. Bid the woman farewell.

Learning guide: Management of severe pre-eclampsia / eclampsia

Training facilitators or participants can use the following learning guide to gauge progress while learning to care for women with severe pre-eclampsia and eclampsia.

Directions





Learning guide: Management of severe pre-eclampsia / eclampsia

STEP/TASK

OBSERVATIONS

Getting ready [These steps should be occurring at the same time as immediate management]

1. Greet the woman respectfully and with kindness.

2. Tell the woman what is going to be done and encourage her to ask questions.

3. Listen to what the woman has to say.

4. Provide emotional support and reassurance.

Immediate management

1. Urgently mobilise available personnel.

2. Encourage the woman to lie on her side to reduce the risk of aspiration of secretions, vomit and blood.

3. Ensure the woman’s airway is open.

4. Observe color for cyanosis and need for oxygen

5. If available, give oxygen at 4–6 L per minute by mask or cannulae.

6. Check pulse, respirations, temperature, and fetal heart

10. Check the biceps or patellar reflexes.

7. Auscultate the lung bases for rales.

8. Start an intravenous drip of normal saline or Ringer’s lactate

9. If diastolic blood pressure remains above 110 mm Hg, give antihypertensive drugs. Reduce the diastolic blood pressure to less than 100 mm Hg but not below 90 mm Hg.

10. Give anti-convulsive drugs to prevent or treat convulsions / fits (see Learning Guide for administering magnesium sulfate)

11. Insert an indwelling urinary catheter to monitor urine output and proteinuria

12. Check urine for proteinuria.

13. Assess clotting status with a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy

14. If the woman begins having a convulsion, provide for care during the convulsion (see Learning Guide for care during a convulsion)

15. Never leave the woman alone. A convulsion followed by aspiration of vomit may cause death of the woman and fetus.

16. Check for signs of labor (see Learning Guide for vaginal examination of a pregnant woman)

17. Record drug administration, interventions, and findings on the woman’s record

Communicate with the woman

1. Share your findings with the woman and, as appropriate, her partner or family member

2. Discuss any complications / problems detected:

· Complications / problems

· Possible cause(s)

3. Explain management, based on diagnosis, and the importance for pregnancy, labor, and delivery

7. If the woman has to be referred, explain the need for referral

8. Check the woman’s understanding of findings and next steps and answer any questions.

9. Inform the family that the woman should never be left alone.

Monitor women with severe pre-eclampsia / eclampsia

1. Maintain a strict fluid balance chart and monitor the amount of fluids administered and urine output to ensure that there is no fluid overload.

2. Check BP, pulse, and respirations hourly, or more frequently as needed.

3. Check fetal heart rate hourly, or more frequently as needed

4. Check urinary output hourly, or more frequently as needed

5. Check reflexes hourly, or more frequently as needed

6. Observe color for cyanosis and need for oxygen hourly.

7. Auscultate the lung bases hourly for rales indicating pulmonary edema

8. If rales are heard, withhold fluids

9. If rales are heard, give furosemide 40 mg IV once.

10. Check temperature every four hours (hyperpyrexia may occur).

11. Check for signs of labor.

12. Never leave the woman alone. A convulsion followed by aspiration of vomit may cause death of the woman and fetus.

13. Record all findings on the woman’s record

14. Share findings with the woman and, as appropriate, her partner/family member.

Learning guide: Administering magnesium sulfate

Training facilitators or participants can use the following learning guide to gauge progress while learning to administer magnesium sulfate and care for women receiving it.

Directions





Learning guide: Administering magnesium sulfate

STEP/TASK

OBSERVATIONS

Administering Loading Dose of Magnesium Sulfate

1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

2. Put clean exam gloves on both hands.

Prepare magnesium sulfate 20% solution, 4 g

3. Take one 20 mL sterile syringe

4. Draw 4 ampoules of MgSO4 50% (8 mL = 4 gm) into the syringe

5. Add 12 mL of sterile water for injection to make it 20%

6. Tell the woman that she may experience a feeling of warmth when magnesium sulfate is given.

7. Carefully clean the injection site with an alcohol wipe.

8. Give magnesium sulfate 20% solution, 4 g by IV injection SLOWLY over 5 minutes.

9. Dispose of used needle and syringe in a sharps disposal box

Prepare 2 syringes with 5 g of 50% magnesium sulfate solution with 1 mL of 2% Lignocaine in the same syringe.

10. Take two 20 mL sterile syringes

11. Draw 5 ampoules of MgSO4 50% (10 mL = 5 gm) into each syringe.

12. Add 1 mL of 2% Lignocaine in each syringe


14. Give 5 g by DEEP IM injection in one buttock.


16. Carefully clean the injection site in the alternate buttock with an alcohol wipe.

17. Give 5 g by DEEP IM injection into the other buttock.


19. Dispose of gloves in a 0.5% decontamination solution


21. Record drug administration and findings on the woman’s record.

22. Explain findings and drug administration to the woman

If convulsions recur AFTER 15 minutes, give 2 g magnesium sulfate (50% solution) IV over 5 minutes.






28. Give magnesium sulfate 50% solution, 2 g by IV injection SLOWLY over 5 minutes.




32. Record drug administration and findings on the woman’s record.

33. Explain findings and drug administration to the woman

34. Plan to monitor the woman at least hourly (see Learning Guide for management of women with severe pre-eclampsia/eclampsia)

Monitoring women for toxicity

Before repeating the 4-hourly dose of magnesium sulphate:

1. Count respiration rate for one minute

2. Calculate urinary output over the last 4 hours

3. Check patellar reflexes

4. WITHHOLD or DELAY drug if:

· Respiratory rate falls below 16 per minute.

· Patellar reflexes are absent.

· Urinary output falls below 30 ml per hour over the preceding 4 hours.

5. If respiratory arrest occurs:

· Assist ventilation.

· Give calcium gluconate 1 g (10 mL of 10% solution) by IV injection SLOWLY until respiration begins.

6. Record findings on the woman’s record.

7. Explain findings to the woman

Administering Maintenance Dose of Magnesium Sulfate

1. Provide maintenance dose of magnesium sulphate (5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2% IM every 4 hours) if:

· Respiratory rate is at least 16 per minute.

· Patellar reflexes are present.

· Urinary output is at least 30 ml per hour over 4 hours.



Prepare 5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2% :



6. Add 1 mL of 2% Lignocaine in each syringe

7. Verify in which buttock the last magnesium sulfate injection was given.


9. Give 5 g by DEEP IM injection [Make sure that this injection is given in the alternate buttock from the most previous injection].



12. Wash hands thoroughly with soap and water and dry with a clean

reprolineplus.orgreprolineplus.org/system/files/resources/pee... · web viewan abdominal...

Documents