Critical pathways for the management of preeclampsia and severe preeclampsia in institutionalised health care settings

Abstract

BackgroundPreeclampsia is a complex disease in which several providers should interact continuously and in a coordinated manner to provide proper health care. However, standardizing criteria to treat patients with preeclampsia is problematical and severe flaws have been observed in the management of the disease. This paper describes a set of critical pathways (CPs) designed to provide uniform criteria for clinical decision-making at different levels of care of pregnant patients with preeclampsia or severe preeclampsia.MethodsClinicians and researchers from different countries participated in the construction of the CPs. The CPs were developed using the following steps: a) Definition of the conceptual framework; b) Identification of potential users: primary care physicians and maternal and child health nurses in ambulatory settings; ob/gyn and intensive care physicians in secondary and tertiary care levels. c) Structural development.ResultsThe CPs address the following care processes: 1. Screening for preeclampsia, risk assessment and classification according to the level of risk. 2. Management of preeclampsia at primary care clinics. 3. Evaluation and management of preeclampsia at secondary and tertiary care hospitals: 4. Criteria for clinical decision-making between conservative management and expedited delivery of patients with severe preeclampsia.ConclusionSince preeclampsia continues to be one of the primary causes of maternal deaths and morbidity worldwide, the expected impact of these CPs is the contribution to improving health care quality in both developed and developing countries. The CPs are designed to be applied in a complex health care system, where different physicians and health providers at different levels of care should interact continuously and in a coordinated manner to provide care to all preeclamptic women. Although the CPs were developed using evidence-based criteria, they could require careful evaluation and remodelling according to each system's demands. Additionally, the CPs need to be tested in large-scale, multi-level studies in order to thoroughly examine and evaluate their efficacy and effectiveness.

Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap

“…Apart from delivery, correct drug dosages, IV Fluid type and volume administered being critical to outcome, improvement in labour monitoring using the partogram is also pivot in the management of all patients who were undelivered hence the general improvement in the re-audit [14-16]. Management of eclamptic patient must focus on three components namely: monitoring maternal clinical status and fetal wellbeing by using a simple and locally accepted tool (partograph), performing laboratory tests for vital maternal functions and providing appropriate obstetrical intervention [13,17]. …”

Economic assessment of screening for pre‐eclampsia

“…Once the disease develops around term (‘late pre‐eclampsia’), prompt induction of labor is usually the rule . When pre‐eclampsia develops remote from term – before 34 weeks (‘early pre‐eclampsia’) – early delivery is usually required and often steroids are used to enhance fetal lung maturation while treatment with magnesium sulfate and antihypertensives often allows a limited prolongation of pregnancy, for the sake of reducing the risk for neonatal morbidity and mortality …”

“…4 When pre-eclampsia develops remote from termbefore 34 weeks ('early preeclampsia')early delivery is usually required and often steroids are used to enhance fetal lung maturation while treatment with magnesium sulfate and antihypertensives often allows a limited prolongation of pregnancy, for the sake of reducing the risk for neonatal morbidity and mortality. [4][5][6] During 1992, $18bn to $22bn of direct healthcare costs were allocated in the United States to treat women with pre-eclampsia and their neonates. 7,8 Moreover, pre-eclampsia is associated with long-term maternal and neonatal increased risk of cardiovascular diseases, 9 diabetes, and metabolic syndrome.…”

The Momedemameter: An Affordable Pre-Eclampsia Detector for Low Resource Environments

“…Furthermore, for measuring an elevated blood pressure, a very basic problem is that, both in developing and developed countries, the blood pressure is often wrongly measured and recorded [2,5–7]. In addition, the blood pressure equipment needs to be maintained properly for it to work.…”