Prehospital Management in Pre-Eclampsia
Introduction
Pre-eclampsia is a serious pregnancy condition that can affect the mother and baby. In the prehospital setting, it is important to be able to recognize and manage pre-eclampsia so that the mother and baby can receive the best possible care.
Pre-eclampsia can vary in severity, ranging from mild to severe. Severe pre-eclampsia is characterised by more pronounced symptoms, including severe hypertension, significant proteinuria, organ damage (such as liver or kidney dysfunction), neurological symptoms, and potentially life-threatening complications like eclampsia (seizures) and HELLP syndrome (a severe form of pre-eclampsia involving haemolysis, elevated liver enzymes, and low platelet count).
Pre-eclampsia requires medical management and close monitoring to prevent complications. Treatment may involve medications to control blood pressure and prevent seizures, bed rest, dietary changes, and delivery of the baby, depending on the severity of the condition and gestational age.
Early detection, along with proper medical interventions, can help mitigate the risks associated with pre-eclampsia and improve outcomes for both mother and baby.
Prevalence
Hypertensive disorder is a common medical problem that affects around 10-15% of all pregnancies. Of these, approximately 15% will develop pre—eclampsia.
Pre-eclampsia rates range from 1.5-7.7% in the UK. Around 4.1% of women in their first pregnancy will develop pre-eclampsia, and 1.7% on their second pregnancy.
If pre-eclampsia is left untreated, it can lead to eclampsia which complicates 2.7 per 10,000 births.
Prognosis of pre-eclampsia in PreHospital
The prognosis of pre-eclampsia depends upon several factors, such as the severity of the condition, the gestational age at which it develops, and the presence of other associated complications.
In general, the earlier the onset of pre-eclampsia, the increased risk of maternal and fetal complications. Prognosis tends to be poorer if pre-eclampsia occurs before 34 weeks’ gestation.
Pre-eclampsia accounted for 13.6% of maternal deaths related to pregnancy causes.
The prognosis of pre-eclampsia depends upon several factors, such as the severity of the condition, the gestational age at which it develops, and the presence of other associated complications.
In general, the earlier the onset of pre-eclampsia, the increased risk of maternal and fetal complications. Prognosis tends to be poorer if pre-eclampsia occurs before 34 weeks’ gestation.
Pre-eclampsia accounted for 13.6% of maternal deaths related to pregnancy causes.
Pre-eclampsia can also affect the prognosis of future pregnancies. Depending upon the timing of pre-eclampsia in the first pregnancy will dictate the risk of pre-eclampsia in future pregnancies.
Between 28-34-weeks’ gestation, the risk of future pre-eclampsia is around 33%.
Between 34-37 weeks’ gestation, the risk of future pre-eclampsia is around 23%.
There are several risk factors that may increase the likelihood of developing pre-eclampsia.
Risk Factors
- First pregnancy.
- Advanced Maternal Age (women over 35 tend to be at increased risk).
- Twins or higher multiples.
- Obesity.
- Diabetes.
- Family history of pre-eclampsia.
- Ethnicity (African or Caribbean descent are at increased risk).
- Short intervals between pregnancies.
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Pathophysiology
Pre-eclampsia is a condition that affects pregnancy women that causes hypertension during pregnancy and after labour.
Pre-eclampsia is diagnosed in the UK as an increase in blood pressure above 140/90 mmHG, oedema and proteinuria.
Although the underlying pathophysiology is not fully understood, pre-eclampsia is predominantly a placental condition linked with inadequate placental perfusion, which frequently results in a foetus that is growth restricted.
Pre-eclampsia is usually seen and diagnosed at antenatal visits and can be categorised into mild, moderate, or severe.
Clinical Features
Pre-eclampsia often have no symptoms. However, severe pre-eclampsia may be seen in patients with mild pre-eclampsia with often no or little warning.
Mild/Moderate Pre-eclampsia – raised blood pressure (>140/90 mmHg, proteinuria and oedema).
Server pre-eclampsia – blood pressure (>160/110 mmHg, one or more of the clinical findings below).
Clinical Findings
Typical clinical findings of pre-eclampsia can include:
- Hypertension (160/110 mmHg or more, diagnosis of pre-eclampsia should be considered).
- Proteinuria
- Epigastric tenderness
- Right-sided upper abdominal tenderness
- Muscle twitching/tremor
History
Typical history findings may include:
- Severe, frontal headache
- Nausea & vomiting
- Confusion
- Reduced urine output
- Visual disturbances
- Abdominal pain
Assessment
Any time-critical features???
If any of the following time-critical features are present, undertake a time-critical transfer to the nearest obstertic unit whilst continuing patient management enroute. Time-critical features include:
- Major <C>ABCD problems,
- Any signs of severe pre-eclampsia
After a <C>ABCDE assessment has been carried out, providing no major problems have been identified, a through secondary survey, including fetal assessment should be conducted.
Management
Any <C>ABCDE problems should be corrected promptly. If any time-critical features have been identified, a time-critical transfer to the nearest obstetric unit should be undertaken. Caution with ‘lights and sirens’ are needed as it may precipitate convulsions.
Mild/Moderate Pre-Eclampsia
If pregnant > 20 weeks and systolic blood pressure is > 140/90 mmHg, discuss with obstetric unit or midwife.
Severe Pre-Eclampsia Management
Time-critical transfer to nearest obstetric unit, provide a pre-alert.
Monitor <C>ABCDE en-route.
Obtain IV access (preferable a large bore cannula) en-route.
Administer Magnesium Sulphate if available. (Magnesium sulphate will help prevent seizures and can also help prolong delivery for up to two days)
Complications
If pre-eclampsia is not identified complications may include:
- Multi-organ dysfunction
- Placental abruption
- HELLP Syndrome
- Eclampsia
- Intracranial haemorrhage
- Renal and liver failure
Eclampsia
Find out more information about eclmapsia here!
Eclampsia
Differential Diagnoses
It is critical to distinguish between other pregnant hypertensive diseases such as:
- Chronic hypertension
- Gestational hypertension
Key Points
- Pre-eclampsia can occur as early as 20 weeks gestation but commonly occurs past 24-28 weeks.
- Diagnosis of pre-eclampsia is defined as increase in blood pressure above 140/90 mmHg, proteinuria, and oedema.
- Severe pre-eclampsia and eclampsia are time-critical emergencies and require transfer to nearest obstetric unit.
- If available, administer magnesium sulphate en route to hospital for severe pre-eclampsia.
Introduction
Pre-eclampsia is a serious pregnancy condition that can affect the mother and baby. In the prehospital setting, it is important to be able to recognize and manage pre-eclampsia so that the mother and baby can receive the best possible care.
Pre-eclampsia can vary in severity, ranging from mild to severe. Severe pre-eclampsia is characterised by more pronounced symptoms, including severe hypertension, significant proteinuria, organ damage (such as liver or kidney dysfunction), neurological symptoms, and potentially life-threatening complications like eclampsia (seizures) and HELLP syndrome (a severe form of pre-eclampsia involving haemolysis, elevated liver enzymes, and low platelet count).
Pre-eclampsia requires medical management and close monitoring to prevent complications. Treatment may involve medications to control blood pressure and prevent seizures, bed rest, dietary changes, and delivery of the baby, depending on the severity of the condition and gestational age.
Early detection, along with proper medical interventions, can help mitigate the risks associated with pre-eclampsia and improve outcomes for both mother and baby.
Prognosis of pre-eclampsia in PreHospital
The prognosis of pre-eclampsia depends upon several factors, such as the severity of the condition, the gestational age at which it develops, and the presence of other associated complications.
In general, the earlier the onset of pre-eclampsia, the increased risk of maternal and fetal complications. Prognosis tends to be poorer if pre-eclampsia occurs before 34 weeks’ gestation.
Pre-eclampsia accounted for 13.6% of maternal deaths related to pregnancy causes.
The prognosis of pre-eclampsia depends upon several factors, such as the severity of the condition, the gestational age at which it develops, and the presence of other associated complications.
In general, the earlier the onset of pre-eclampsia, the increased risk of maternal and fetal complications. Prognosis tends to be poorer if pre-eclampsia occurs before 34 weeks’ gestation.
Pre-eclampsia accounted for 13.6% of maternal deaths related to pregnancy causes.
Pre-eclampsia can also affect the prognosis of future pregnancies. Depending upon the timing of pre-eclampsia in the first pregnancy will dictate the risk of pre-eclampsia in future pregnancies.
Between 28-34-weeks’ gestation, the risk of future pre-eclampsia is around 33%.
Between 34-37 weeks’ gestation, the risk of future pre-eclampsia is around 23%.
There are several risk factors that may increase the likelihood of developing pre-eclampsia.
Risk Factors
- First pregnancy.
- Advanced Maternal Age (women over 35 tend to be at increased risk).
- Twins or higher multiples.
- Obesity.
- Diabetes.
- Family history of pre-eclampsia.
- Ethnicity (African or Caribbean descent are at increased risk).
- Short intervals between pregnancies.
Pathophysiology
Pre-eclampsia is a condition that affects pregnancy women that causes hypertension during pregnancy and after labour.
Pre-eclampsia is diagnosed in the UK as an increase in blood pressure above 140/90 mmHG, oedema and proteinuria.
Although the underlying pathophysiology is not fully understood, pre-eclampsia is predominantly a placental condition linked with inadequate placental perfusion, which frequently results in a foetus that is growth restricted.
Pre-eclampsia is usually seen and diagnosed at antenatal visits and can be categorised into mild, moderate, or severe.
Clinical Features
Pre-eclampsia often have no symptoms. However, severe pre-eclampsia may be seen in patients with mild pre-eclampsia with often no or little warning.
Mild/Moderate Pre-eclampsia – raised blood pressure (>140/90 mmHg, proteinuria and oedema).
Server pre-eclampsia – blood pressure (>160/110 mmHg, one or more of the clinical findings below).
Clinical Findings
Typical clinical findings of pre-eclampsia can include:
- Hypertension (160/110 mmHg or more, diagnosis of pre-eclampsia should be considered).
- Proteinuria
- Epigastric tenderness
- Right-sided upper abdominal tenderness
- Muscle twitching/tremor
History
Typical history findings may include:
- Severe, frontal headache
- Nausea & vomiting
- Confusion
- Reduced urine output
- Visual disturbances
- Abdominal pain
Assessment
Any time-critical features???
If any of the following time-critical features are present, undertake a time-critical transfer to the nearest obstertic unit whilst continuing patient management enroute. Time-critical features include:
- Major <C>ABCD problems,
- Any signs of severe pre-eclampsia
After a <C>ABCDE assessment has been carried out, providing no major problems have been identified, a through secondary survey, including fetal assessment should be conducted.
Management
Any <C>ABCDE problems should be corrected promptly. If any time-critical features have been identified, a time-critical transfer to the nearest obstetric unit should be undertaken. Caution with ‘lights and sirens’ are needed as it may precipitate convulsions.
Mild/Moderate Pre-Eclampsia
If pregnant > 20 weeks and systolic blood pressure is > 140/90 mmHg, discuss with obstetric unit or midwife.
Severe Pre-Eclampsia Management
Time-critical transfer to nearest obstetric unit, provide a pre-alert.
Monitor <C>ABCDE en-route.
Obtain IV access (preferable a large bore cannula) en-route.
Administer Magnesium Sulphate if available. (Magnesium sulphate will help prevent seizures and can also help prolong delivery for up to two days)
Complications
If pre-eclampsia is not identified complications may include:
- Multi-organ dysfunction
- Placental abruption
- HELLP Syndrome
- Eclampsia
- Intracranial haemorrhage
- Renal and liver failure
Differential Diagnoses
It is critical to distinguish between other pregnant hypertensive diseases such as:
- Chronic hypertension
- Gestational hypertension
Key Points
- Pre-eclampsia can occur as early as 20 weeks gestation but commonly occurs past 24-28 weeks.
- Diagnosis of pre-eclampsia is defined as increase in blood pressure above 140/90 mmHg, proteinuria, and oedema.
- Severe pre-eclampsia and eclampsia are time-critical emergencies and require transfer to nearest obstetric unit.
- If available, administer magnesium sulphate en route to hospital for severe pre-eclampsia.
Bibliogpraphy
Joint Royal Colleges Ambulance Liaison Committee and Association of Ambulance Chief Executives (2022). JRCALC Clinical Guidelines 2022. Class Professional Publishing.
National Institute for Health and Care Excellence (2022). Hypertension in pregnancy. [online] NICE. Available at: https://cks.nice.org.uk/topics/hypertension-in-pregnancy/management/pre-eclampsia/
