The midwife's role in assessment and diagnosis

1. The midwife's role in assessment and diagnosis early detection and referral by the midwife monitoring and treatment can be implemented to minimize the severity of the condition must receive appropriate antenatal care women who do not receive antenatal care are more likely to die from complications related to the hypertensive disorders of pregnancy a comprehensive history taking will identify the following risk factors

2. 1-nulliparity 2-previous history of pre-eclampsia 3-raised blood pressure at booking (diastolic ≥80 mmHg, systolic ≥130 mmHg) 4-raised body mass index (BMI ≥35 kg/m2) before pregnancy or booking 5-maternal age ≥40 years 6-an interval of >10 years since a previous pregnancy 7-the presence of underlying medical disorders for example: pre-existing hypertension, renal disease, diabetes, antiphospholipid syndrome and autoimmune disease such as lupus,& multiple pregnancy

3. -The two essential features of pre-eclampsia, hypertension and proteinuria,after 20 weeks gestation are assessed for at regular intervals .

4. Blood pressure measurement -the midwife should take the woman's blood pressure early in pregnancy and compare this with all subsequent recordings, taking into account the normal pattern in pregnancy

5. - consider several factors in assessing blood pressure • 1-Blood pressure machines should be calibrated for use in pregnancy and regularly maintained. • 2-Mercury sphygmomanometer is still considered the gold standard for blood pressure measurement • 3- automated blood pressure measuring devices such as the Dinamap need to be calibrated and checked regularly • 4-Blood pressure should not be taken immediately after a woman has experienced anxiety, pain, a period of exercise or has smoked. A 10 min rest period is recommended before measuring the blood pressure in these circumstances.

6. 5-The position, The supine and right lateral positions are not recommended in view of the effect of the gravid uterus on venous return resulting in postural hypotension. • Women should be seated or lying in the left lateral position at an angle of 45°, with the sphygmomanometer cuff approximately level with the heart • 6- using a sphygmomanometer cuff of inadequate size relative to the arm circumference. • 7-The rounding off of the blood pressure measurements should be avoided

7. Urinalysis • -Proteinuria in the absence of urinary tract infection is indicative of glomerular endotheliosis. • - A significant increase in proteinuria with diminished urinary output indicates renal impairment. • - Vaginal discharge, blood, amniotic fluid and bacteria can contaminate the specimen and give a false positive reading. • - A 24 hrs urine collection for total protein measurement will be required to be certain about the presence or absence of proteinuria • -A finding of >300 mg/24 hrs is considered to be indicative of mild-moderate pre-eclampsia, and >3 g/24 hrs is considered to be severe.

8. Oedema and excessive weight gain • -Clinical oedema may be mild or severe. • -Oedema of the ankles in late pregnancy is a common occurrence. It is of a dependent nature, usually disappears overnight and is not significant in the absence of raised blood pressure and proteinuria. • -sudden severe widespread appearance of oedema is suggestive of pre-eclampsia. This oedema pits on pressure and may be found in non-dependent anatomical areas such as the face, hands, lower abdomen, vulval and sacral areas.

9. Laboratory tests • The following alterations in the hematological and biochemical parameters are suggestive of the onset of pre-eclampsia: • -increased hemoglobin( Haemoglobin11.1–12 g/dL) and haematocrit levels(Haematocrit33–39%) • -thrombocytopenia (150–400 × 109/L) • -prolonged clotting times(Fibrinogen3.63–4.23 g/L)

10. -raised serum creatinine and urea levels • -Liver functionALT10–30 IU/LAST6–32 IU/LGGT5–43 IU/LAlbumin28–35 g/Total protein48–65 g/L • -raised serum uric acid level • -abnormal liver function tests, particularly raised aspartate transaminase (AST) and alanine aminotransferase (ALT) (>50 U/L).

12. Care and management • monitor the condition of the woman and her • -The ultimate aim is to prolong the pregnancy until the fetus is sufficiently mature to survive, while safeguarding the mother's life. • - woman may requires admission to hospital, She is likely to be anxious about the well-being of her children and visiting should be encouraged • -The midwife has a key role in providing psychosocial support for these women

13. Antenatal care • Gestational hypertension will require close monitoring and if pre-eclampsia develops, then admission to hospital • Rest • -rest as much as possible, but rest does not prevent the development of pre-eclampsia. • - It is preferable for the woman to rest at home and to have regular visits by the midwife or GP and in some instances, this can be highly effective • -When proteinuria develops in addition to hypertension the risks to the mother and fetus are considerably increased. Admission to hospital is required to monitor and evaluate the maternal and fetal condition.

14. Diet • -a diet rich in protein, fiber and vitamins may be recommended. • - There is some evidence to suggest that prophylactic fish oil in pregnancy may act as an anti-platelet agent, thereby preventing hypertension and proteinuria, pre-eclampsia • -Calcium supplementation appears to be beneficial for women at high risk of developing hypertension in pregnancy and in communities with low dietary calcium intake . • -the Vitamins in Pre-eclampsia (vitamins C (1000 mg) and E (400 IU) does not prevent pre-eclampsia in women at risk, but does increase the rate of babies born with low birth weight. Therefore, these high dose should not be given in pregnancy .

15. Weight gain • weight gain may be useful for monitoring the progression of pre-eclampsia in conjunction with other parameters. • The initial BMI is considered a more useful predictor of hypertension in pregnancy, since this is higher in women who subsequently develop pre-eclampsia

16. Blood pressure and urinalysis • -the blood pressure is monitored daily at home . • - Urine should be tested for protein daily. • -a 24 hrs urine collection is required in order to determine the amount of proteinuria. • -The level of protein indicates the degree of vascular damage. • - Reduced kidney perfusion is indicated by proteinuria, reduced creatinine clearance and increased serum creatinine and uric acid.

17. Abdominal examination • -Abdominal examination is carried out daily. • -Any discomfort or tenderness should be recorded and reported immediately to a doctor, as this may be a sign of placental abruption. • -Upper abdominal pain is highly significant and indicative of HELLP syndrome

18. Doppler assessment of uterine arteries • -Doppler assessment of uterine arteries can demonstrate increased placental vascular resistance as a result of failure of the trophoblastic invasion of the spiral arteries early in pregnancy (<20 weeks).

19. Fetal assessment • -Biophysical profile assessment is recommended in order to determine fetal health and well-being. • - This can be done by the use of the following: • 1-fetal movement charts • 2-CTG monitoring • 3- serial ultrasound scans to check for fetal growth, assessment of liquor volume and fetal breathing movements and umbilical artery Doppler blood flow

20. Laboratory studies • -full blood count (hemoglobin, haematocrit and platelet count) • -urea and electrolytes, serum creatinine level, serum uric acid level • - liver function tests including albumin levels • -clotting studies if platelet count <100 × 109/L. • - In severe pre-eclampsia, there should be blood studies undertaken every 12–24 hrs

22. Antihypertensive therapy • -The use of antihypertensive therapy as prophylaxis is controversial • - The aim of treatment is to gradually reduce the blood pressure to a level that is safe for both mother and fetus and to maintain the systolic blood pressure between 140–155 mmHg and the diastolic 90–100 mmHg. • -there is no one antihypertensive which is preferable to others • -Methyldopa is the most widely used drug in women with mild to moderate gestational hypertension.

23. - Drowsiness is a common side effect and it can cause depression, however it is considered to be safe and effective for both mother and fetus. • - An α- and β-blocker such as labetalol is an alternative and is considered safe in pregnancy except for women with asthma or congestive heart failure. • - Atenolol used over the long term is not recommended as this is linked with fetal growth restriction

24. -the use of angiotensin-converting enzyme (ACE) inhibitors are contraindicated in pregnancy. • - Calcium channel blockers such as nifedipine, are increasingly used to treat severe hypertension in pregnancy • - These act on arteriolar smooth muscle to induce vasodilatation by blocking calcium entry into cells thus decreasing cerebral vasospasm and increasing urinary output and uteroplacental blood flow. • -Maternal side-effects include tachycardia, palpitations and headache

25. Antithrombotic agents • the use of anticoagulants or antiplatelet agents has been considered for the prevention of pre-eclampsia and fetal growth restriction. • Aspirin is thought to inhibit the production of the platelet-aggregating agent thromboxane A2. • Women who receiving antiplatelet agents had a 10% reduced risk of: developing pre-eclampsia, pre-term birth before 34 weeks' gestation and having a pregnancy with serious adverse outcome .

26. Intrapartum care • -Timing and mode of delivery is dependent on the maternal and fetal condition as well as the gestation of the pregnancy. - The midwife should remain with the woman throughout the course of labour as pre-eclampsia can suddenly worsen at any time. • - It is essential to monitor the maternal and fetal condition carefully. • - Marked deviations should be noted and medical assistance sought.

27. Vital signs • -Blood pressure is measured half-hourly • - 15–20 min in severe pre-eclampsia. • -measurement of the MAP. As mentioned earlier this can be calculated manually or by the use of an automated blood pressure recorder such as the Dinamap. • - Observation of the respiratory rate (>14/min) • - pulse oximetry in severe pre-eclampsia, gives an indication of the degree of maternal hypoxia. • - Temperature should be recorded as necessary. • - In severe pre-eclampsia, examination of the optic fundi can give an indication of optic vasospasm and papilloedema. • - Cerebral irritability can be assessed by the degree of hyper-reflexia or the presence of clonus

28. Fluid balance • circulatory overload, pulmonary oedema, adult respiratory distress syndrome and ultimately death • In severe pre-eclampsia, a central venous pressure (CVP) line may be considered in order to monitor the fluid status -If the value is >10 mmHg, then 20 mg furosemide (frusemide), a diuretic drug, should be considered. • Intravenous fluids are administered using infusion pumps and the total recommended fluid intake in severe pre-eclampsia is 85 mL/hr.

29. Oxytocin should be administered with caution as it has an anti-diuretic effect. • Urinary output should be monitored closely • urinalysis undertaken every 4 hrs to detect the presence of protein, ketones and glucose. • In severe pre-eclampsia a urinary catheter should be in situ and urine output is measured hourly; a level >30 mL/hr reflects adequate renal function.

30. Plasma volume • -Although women with pre-eclampsia have oedema, they are hypovolaemic. • -The blood volume is low, as shown by a high hemoglobin concentration and a high haematocrit level. • -This results in movement of fluid into the extra vascular compartment causing oedema. • -The oedema initially occurs in dependent tissues, but as the disease progresses oedema occurs in the liver and brain - Treatment is controversial as colloids can seep into the tissues and ‘hold’ fluid there and they can thus cause even worse pulmonary oedema than crystalloids. Any fluids are therefore given with caution.

32. Pain relief • -Epidural analgesia the best pain relief, reduce the blood pressure and facilitate rapid caesarean section should the need arise. • -It is important to ensure a normal clotting screen and a platelet count >100 × 109/L prior to insertion of the epidural.

33. Fetal condition • -The fetal heart rate should be monitored closely and deviations from the normal reported and acted upon. • Birth plan • -the obstetrician and pediatrician should be ready. • -The midwife will continue her care of the woman and will usually assist the woman during the birth. • -A short second stage may be preferred depending on the maternal and fetal conditions;

34. -a ventouse extraction or forceps delivery will be performed by the obstetrician. • - If the maternal or fetal condition shows significant deterioration during the first stage of labour, a caesarean section will be undertaken. • -Oxytocin is recommended for the management of the third stage of labour. • -Ergometrine and Syntometrine will cause peripheral vasoconstriction and increase hypertension and therefore should not normally be used in the presence of any degree of pre-eclampsia unless there is severe hemorrhage.