1. 1 Critical Pathways to manage preeclampsia and severe preeclampsia Preeclampsia Working Group Canada – Mexico – USA

2. 2 Figure 1. SCREENING FOR PREECLAMPSIA DURING FIRST PRENATAL VISIT AFTER 20 WEEKS OF GESTATION Perform clinical history, define gestational age, identify risk factors and carry out physical exam FIRST PRENATAL VISIT risk factors? See Table 1 no yes Hypertension? See Table 1 yes Close monitoring of BP and proteinuria during prenatal visits in primary care facilitiies Every two weeks Begin activities to confirm diagnosis of hypertensive disorder of pregnancy and to classify the patient no Pre-existing hypertension autoinmune disease DM, chronic renal disease, multiple pregnancy, polihydramnios See continuation of the process of care Go to Figure 2 Refer to ob/gyn to continue management FIRST LEVEL OF CARE Measure blood pressure Continue routine prenatal care at family medicine clinic presence of alarm signs? See Table 2 no yes Refer to the ob/gyn to evaluate severity of the disease yes no

3. 3 RISK FACTORS FOR THE DEVELOPMENT OF PREECLAMPSIA: History of Preeclampsia/Eclampsia in previous pregnancies  3 pregnancies Family history of Preeclampsia/Eclampsia in first degree relative Obesity (get data from physical exam. Obesity criteria: BMI > 27) Primigravida PHYSICAL EXAM must include following data: Blood pressureWeight HeightBody mass index Uterine sizeFetal movements Table 1. ASPECTS THAT MUST BE CONSIDERED DURING EVERY PRENATAL CARE VISIT. DEFINITION OF HYPERTENSION IN PREGNANCY SBP > 140 mm Hg or above or DPB > 90 mm Hg or above Mean arterial presure above 106 mm Hg Increase of 30 mmHg of SBP or increase above 15 mm Hg of DPB above baseline measures Measure twice blood pressure on the left arm and the muffling of the sound (5th Korotkoff). The patient should be seated and external stimuli should be eliminated FIRST LEVEL OF CARE : Responsible: Family Physician and maternal and child health nurse

4. 4 The family physician must confirm diagnosis of hypertensive disorder of pregnancy taking into account gestational age and by carrying out urinalysis and/or dipstick Proteinuria + hypertension no yes Gestational hypertension Close monitoring of clinical conditions and periodic examination looking for proteinuria Every week Figure 2. STEPS TO CONFIRM HYPERTENSIVE DISORDER OF PREGNANCY AND/OR REFERRAL TO NEXT LEVEL OF CARE. FIRST LEVEL OF CARE : Responsible: Family Physician and maternal and child health nurse The patient must be referred to the hospital to be classified and clinically evaluated by the ob/gyn Go to Figure 3. Preeclampsia Refer to Ob/Gyn Criteria to evaluate dipstick o urinalysis results for the presence of proteinuria: Negative: 0 to + Positive ++ to ++++ The urinalysis should be performed within 24 hrs after hypertension was detected + = 30 mg/dl ++ = 100 mg/dl

5. 5 FIRST LEVEL OF CARE : Responsible: Family Physician and maternal and child health nurse ALARM SIGNS OF PREECLAMPSIA THAT SHOULD PROMPT URGENT REFERRAL TO THE HOSPITAL Headache ++Nausea ++ Drowsiness ++Vomiting ++ Epigastric painHepatic tenderness Sudden BlindnessScotomas Hematemesis Oliguria/Anuria Proteinuria (identified by dipstick) Shortness of breath Seizures (indicates severe morbidity) Hematuria/Hemoglobinuria TABLE 2. CLINICAL DATA

6. 6 Clinical history, physical exam, and following laboratory exams: Protein excretion in 24-hour urine collection (If there is proteinuria on labstix) Complete blood test, including platelet count LFT -AST, ALT and bilirrubin-. (See Table 4) Figure 3. Activities that the ob/gyn should carry out to evaluate and classify the hypertensive disorder CLASSIFY THE PATIENT ACCORDING TO THE SEVERITY OF THE DISEASE (SEE CRITERIA ON TABLE 3) Mild Preeclampsia Go to Figure 4 Severe PreeclampsiaSevere morbidity Severe conditions? noyes SECOND LEVEL OF CARE. Responsible: OB\ GYN

7. 7 CHARACTERISTIC BLOOD PRESSURE CLINICAL DATA One or more of the following symptoms Without severe conditions Mild Preeclampsia DBP  90 to < 110 mm Hg MAP  106 to < 126 Mild symptoms such as headache, nausea etc. or No symptoms Protein excretion in 24-h urine colection > 0.3 g to < 3 g With severe conditions Severe preeclampsia DBP  110 mm Hg MAP >126 mm Hg Frontal headache, Blurred vision, severe nausea and vomiting, persistence of abdominal pain (right upper quadrant), dizziness, tinnitus, drowsiness. Elevated liver enzyme level Thrombocytopenia (< 100,000 x 10 9 /L) Oliguria (< 500 ml/d) Proteinuria > 3 g Severe Morbidity DBP  90 mm Hg Same conditions as above and/or: Convulsions (eclampsia) HELLP syndrome Abruptio placentae Pulmonary edema Deterioration in the level of consciousness Coma Acute renal failure Cerebral bleeding Intravaascular diseminated coagulation Adult progresive respiratory distress syndrome Hepatic bleeding Proteinuria > 3 g Table 3. CRITERIA TO CLASSIFY THE HYPERTENSIVE DISORDERS OF PREGNANCY Levels of responsibility: Second and Third levels of care (ob/gyn)

8. 8 Pregnant women with less than 36 weeks of pregnancy and clinically stable preeclampsia Treatment should be provided by OB/GYN Goals: monitor the patient every third day to ensure DBP below 90 mm Hg and timely identification of appearance of manifestations of severe preeclampsia Figure 4. MANAGEMENT OF PREECLAMPSIA AT SECONDARY CARE LEVEL Patient clinically stable, without progression of the disease yesno Continue monitoring Delivery according to Institucional standards See Table 4 Hospitalization and/or refer immediately to the emergency room to identify whether the patient is progressing to severe preeclampsia Go to Figure 5 DEFINITION OF A CLINICALLY UNSTABLE PATIENT Patients showing irregular increase in DBP (above 95 but below 110 mm hg) and/or proteinuria, or beginning of CNS symptoms, will be considered as unstable

9. 9 Table 4. Ambulatory Management of Mild Preeclampsia at Secondary Level of Care MotherFetus Monitoring: The patient must be seen every third day until admission for delivery ClinicalExams (weekly)ClinicalExams Blood pressure Weight Look for CNS, Rena l cardiovascular or gastrointestinal symptoms in every visit Blood count (including platelet count) Urinalysis (proteinuria) every 24 h or Dipstick Liver Function Tests(Bilirrubin, AST, ALT) Fetal movements Fetal cardiac rate Cardiotocography: NST (every 5 to 7 days) Ultrasononography (measure fetal growth, maturity and placental locationa and amniotic fluid index) Treatment Bed rest at homeAntihypertensives (controversial) Methyldopa Nifedipine Hydralazine Induction of pulmonary maturity using dexamethasone or betametasone – in patients with gestational age before 34 weeks.

10. 10 Figure 5. MANAGEMENT OF CLINICALLY UNSTABLE PREECLAMPSIA Evaluate clinical conditions and age of pregnancy of the patient After 24 hrs re-evaluate clinical conditions (severity and/or response to the treatment) Hospitalize the patient Patient and fetus are stable? yesno Discharge and continue ambulatory medical management See Table 4 The patient will continue conservative in-hospital management See Table 5 Send to a Tertiary care facility to begin treatment Go to Figure 6 yes Progression to severe preeclampsia no

11. 11 Table 5. Hospital Management of clinically unstable Mild Preeclampsia at the Secondary Level of Care MotherFetus Monitoring: The patient must be hospitalized ClinicalExams as often as neededClinicalExams as often as needed Blood pressure Weight Look for CNS, Rena l cardiovascular or gastrointestinal symptoms in every visit Blood count (including platelet count) Urinalysis (proteinuria) every 24 h or Dipstick every eight hours Liver Function Tests (bilirrubin, AST, ALT) Fetal movements Fetal cardiac rate Cardiotocography: NST Ultrasonography to measure fetal growth and status of the placenta (site where the placenta is inserted and maturity) and amniotic fluid vclume Treatment Bed restAntihypertensives (controversial) Methyldopa Nifedipine Hydralazine Anticonvulsants: Magnesium sulphate Induction of pulmonary maturity dexamethasone or betametasone in patients with gestational age less than 34 weeks

12. 12 Figure 6. Management of Severe Preeclampsia at Tertiary care facilities Hospital care: UIT Start management in three components: Monitoring of clinical status of the mother and the fetus Laboratory tests Medical management The patient is more than 34 weeks pregnant yes no yes Evaluate conservative management until 34 wks and deliver –Controversial- and according to the level of care where the patient is being treated. See Table 7 Continue hemodynamic stabilization of the mother as well as monitoring of the fetus See Table 6 Stabilize the patient and Interrupt pregnancy within 24 hrs Patient clinically stable after24 hrs? Stabilize the patient and Interrupt pregnancy Progression to severe morbidity? no yes Treatment must be provided according to the complication in the intensive care unit

13. 13 Table 6. Hospital antepartum management of a patient with severe preeclampsia (Under 34 weeks and stable) (Unit of Intensive Care) MotherFetus Monitoring ClinicalExamsClinicalExams Blood pressure Weight Look for CNS, renal, cardiovascular or gastrointestinal symptoms and signs Blood count (including platelet count) Serum creatinin Urinalysis (proteinuria) every 24 hrs Dipstick every eight hours Liver function tests (Bilirrubin, AST, ALT) Fetal movements Fetal cardiac rate Cardiotocography Nonstress testing Ultrasound: Evaluate fetal growth, site where the placenta is inserted and its maturity Biophysical profile Amniotic fluid assessment Amniocentesis (selected cases) Treatment Bed restAntihypertensives Alphametildopa Nifedipine Hydralazine Anticonvulsants Magnesium sulphate ? Induction of pulmonary maturity (patients under 34 weeks of gestation) Dexamethasone Betamethasone

14. 14 Table 7. CRITERIA FOR EXPEDITED DELIVERY AND CONSERVATIVE MANAGEMENT IN PATIENTS WITH SEVERE PREECLAMPSIA EXPEDITED DELIVERY Maternal Clinical Data: Cardiovascular: Uncontrolled hypertension DBP> 110 mm Hg, retinal hemorrhage or retinal detachment Renal: compromised renal function such as Oliguria, increase in serum creatinine ( > 2mg/dl) or decrease in creatinina clearence, Proteinuria > 3 g/24 hrs CNS: convulsions, coma, amaurosis or visual changes, drowsiness Hematologic: Platelet count < 100,000 mm3 Liver: AST or ALT > 2 times upper limit of normal values and epigastric pain or pain in RUQ, data of hepatic insufficiency Fetal clinical data Retardation in intrauterine growth measured by ultrasonography with evidence of fetal distress Oligohydramnios ( amniotic fluid index < 2 ) Biophysical profile < 6 Abruptio placentae Absent or reversed diastolic flow on Doppler CONSERVATIVE MANAGEMENT IS CONTROVERSIAL, SOME SUGGESTED CRITERIA INCLUDE: Maternal Clinical Data Fetal Clinical Data Cardiovascular: Controlled hypertension(< 110 mm Hg)No retardation in intrauterine growth Renal: Proteinuria 6 CNS: Absence of clinical dataNo evidence of fetal maturity Blood test: platelet count > 100,000 Hemodynamic and clinically stable