Education, resources, and training to improve Preeclampsia awareness

By Paula Wellde, MSN, RNC-OB, C-EFM

In May alone, there are forty-six health awareness observances and celebratory dates listed on?Healthgrades for 2022 . With so many areas being covered from mental health and arthritis to my personal favorite, International No Diet Day, it can be too overwhelming of a challenge to follow every issue in detail and give each the attention they deserve.

I would be remiss not to mention that National Nurses Week takes place in May, and it’s a special time to recognize nurses for their ongoing service and sacrifices. The global pandemic placed increasingly exhaustive burdens on nurses, and many are still feeling like they’re at their breaking point. Unfortunately, there aren’t enough tokens of appreciation or words of gratitude that could heal those wounds nor make the seemingly endless struggle disappear as fast as we want. It will take time to recover, and we need to be patient and gentle with each other throughout the process.

For thirty-one years I’ve had the privilege of being a nurse, with much of that time spent at the bedside in labor and delivery. That experience has presented opportunities to provide education and training on pregnancy-related health issues within hospitals and, more recently, to the perinatal industry.

May is Preeclampsia Awareness Month, and I chose the topic as the feature for my first At the Nurse’s Station with OBIX publication since the condition is so closely tied to maternal health and morbidity concerns.

Preeclampsia occurs only during pregnancy, usually after the 20th week, and in the postpartum period (up to 4-6 weeks after delivery). It is a disorder that affects both the mother and the unborn baby. Globally, preeclampsia and other hypertensive disorders are the leading cause of maternal mortality and infant prematurity. It is a rapidly progressive condition characterized by high blood pressure and can create a predisposition to:

• Placental abruption
• DIC (disseminated intravascular coagulation)
• Cerebral hemorrhage
• CVA (cerebral vascular accident)
• Hepatic (liver) failure
• Acute renal (kidney) failure

In recent years, preeclampsia has received more mainstream attention following the experiences shared by well-known celebrities like?Beyoncé, Kim Kardashian, and Mariah Carey . Still, even with that exposure, the numbers have not improved, according to the?Centers for Disease Control .

There is currently no evidence that early screening improves maternal-fetal outcomes, and there is no single test that reliably predicts preeclampsia. That’s why it’s vital to continue drawing attention to preeclampsia so that practitioners and pregnant women are armed with facts to identify the warning signs. Then, if the condition develops, they can be proactive and seek out potentially life-saving medical attention. Again, early detection and treatment are key.

Seasoned labor and delivery nurses are typically well versed with preeclampsia, but even experienced clinicians can have difficulty recognizing a worsening condition. Newer nurses, peers on other units, and patients may overlook, dismiss, and/or misunderstand the signs and symptoms, which could lead to potentially detrimental outcomes. In the case of postpartum hypertension and preeclampsia, if the patient’s medical record is not available, treating personnel may have no knowledge the patient has recently delivered, resulting in a decreased index of suspicion.

Here are some of the symptoms that are a cause for concern:

• Swelling of the face and hands
• Sudden weight gain (2-5 lbs/week)
• Refractory headaches
• Vision changes: spots or floaters
• Nausea or vomiting
• Epigastric pain (upper right belly pain)
• Difficulty breathing

The most common classifications of hypertension in pregnancy are:

Chronic hypertension

• Preceding pregnancy or is diagnosed before 20 weeks
• Systolic 140 mm Hg or higher and/or diastolic 90 mm Hg or higher at least 4 hours apart (When faced with severe hypertension, the diagnosis can be confirmed within a shorter interval to facilitate timely antihypertensive therapy)

Gestational hypertension

• Systolic blood pressure ≥ 140 mm Hg or diastolic ≥ 90 mm Hg
• Diagnosed after 20 weeks without proteinuria or other diagnostic criteria for preeclampsia

Preeclampsia (with and without severe features)

• Hypertension
• 140/90 mmHg X 2 (4 hours apart)
• 160/110 mmHg X 2 (minutes apart)

Proteinuria

• Protein/creatinine (PC) ratio 0.3 or more
• 300 mg or more after 24-hour urine collection (or this amount extrapolated from a timed collection)
• Urine dipstick of 2+ or higher (used only if other quantitative methods are not available)

In the absence of proteinuria, new-onset hypertension with new onset of any of the following:

• Thrombocytopenia (Platelet count less than 100,000)
• Renal insufficiency (Serum creatinine concentration greater than 1.1 mg/dl or a doubling of the serum creatinine concentration in the absence of another renal disease)
• Impaired liver function (ALT/AST twice normal)
• Pulmonary edema
• New onset headache refractory to medication and not accounted for by alternative diagnoses or visual symptoms

Preeclampsia with severe features (one or more of the following):

• Hypertension
• BP systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg at least 4 hours apart (unless antihypertensive therapy is initiated before this time)
• Cerebral or visual disturbances (headache, blurred vision, scotomata, blindness)
• Pulmonary edema
• Impaired liver function (ALT/AST twice normal, right upper quadrant pain, epigastric pain)
• Renal insufficiency (proteinuria; CR > 1.1 or 2-fold rise [no cutoff for severe])
• Thrombocytopenia (< 100K)

Superimposed preeclampsia or eclampsia on chronic hypertension

• New onset proteinuria in a woman with hypertension prior to 20 weeks
• Sudden increase in proteinuria if already present in early gestation
• Sudden increase in blood pressure
• Development of HELLP syndrome
• Development of cerebral or visual changes

Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome (HELLP)

Hemolysis

• Elevated LDH (> 600 IU/L)
• Microangiopathic hemolytic anemia or peripheral blood smear or
• Low haptoglobin (< 25 mg/dL)
• Elevated indirect bilirubin

Elevated Transaminases

• Serum AST ≥ 70 IU/L or twice baseline values

Thrombocytopenia

• Platelet count ≤ 100K

General inpatient management includes:

• Vigilant assessment for signs and symptoms of disease progression
• Lab monitoring
• Optimization of maternal hemodynamic status
• Antihypertensives (as indicated) and seizure prophylaxis
• Fetal neuroprotection & steroid administration based on gestational age

During my tenure as a clinical educator, I taught classes covering preeclampsia to the clinical staff who treated pregnant patients in the emergency department and the intensive care unit. One of the things I would tell them is if someone comes in with a severe headache or elevated blood pressure and they’re pregnant or recently delivered, to assume it’s preeclampsia until proven otherwise and perform frequent blood pressure checks. Then, if still elevated, contact the patient’s obstetrician, and treat diligently to prevent seizure/stroke. Obviously, this is oversimplified, and your facility will likely have more detailed standards. The key takeaway here is that training is vital between units that intersect labor and delivery.

Luckily, we live in a time where access to free education and training resources are readily available. The information and materials can be used within your facility and shared with your community, especially those who may have limited access to maternal care. The links below have information related to preeclampsia to help get you started:

• Preeclampsia Foundation
• National Institute of Child Health and Human Development (NICHD)
• American College of Obstetricians and Gynecologists (ACOG)
• Alliance for Innovation on Maternal Health (AIM)
• Centers for Disease Control and Prevention (CDC)
• Society for Maternal-Fetal Medicine
• Mayo Clinic
• Cleveland Clinic
• March of Dimes

In addition, OBIX has a?Preeclampsia infographic ?that’s free to use.

As we strive to improve maternal outcomes as a nation, and where minutes and seconds count, it is important that we are proactively doing everything we can to make a difference.

Thank you for reading, and see you at the nurse’s station!

Paula Wellde, MSN, RNC-OB, C-EFM, has been a nurse for 31 years and has performed in a variety of roles in the perinatal setting, including staff nurse, director, perinatal systems manager, clinical nurse educator, and perinatal safety nurse. She has also served as adjunct faculty at Franklin Pierce University in New Hampshire.

References:

American College of Obstetricians and Gynecologists (2020). Gestational hypertension and preeclampsia. Obstetrics and Gynecology, 135(6), e237-e260

Druzin M, Shields L, Peterson N, Sakowski C, Cape V, Morton C. Improving Health Care Response to Hypertensive Disorders of Pregnancy, a California Maternal Quality Care Collaborative Quality Improvement Toolkit, 2021.

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