Management of Hypertension on the Labor and Delivery Unit: Delivering Care in the Era of Protocols and Algorithms

Eclampsia reduction with maternal early warning trigger tool

OBJECTIVES

To observe the incidence of eclampsia before and after implementing Maternal Early Warning Trigger (MEWT) tool.

STUDY DESIGN

A retrospective observational study to evaluate the effect of introduction of MEWT tool in a tertiary referral center with 10,000 annual births. Two epochs of five years duration were compared before and after implementing MEWT tool. MEWT tool has triggers for early identification of clinical deterioration and pathways for four most important maternal morbidity causes including hypertension. Hypertension pathway has emphasis on rapid control of severe acute hypertension, lab tests and magnesium sulfate prophylaxis. All pregnant women who registered and delivered at the study institute were included.

MAIN OUTCOMES MEASURES

Primary outcome was effect of MEWT tool on the incidence of eclampsia. A subset analysis was done to study the effect of MEWT tool on maternal and perinatal outcomes in women with hypertensive disease. Maternal ICU admissions, HELLP, pulmonary oedema, intracranial bleed and maternal deaths, and perinatal mean birthweight and gestational age, NICU admissions, prematurity, stillbirths, and neonatal deaths were compared.

RESULTS

The study period had 37,043 and 45,637 women in pre- and post-MEWT periods. The incidence of eclampsia reduced by 45.4 % from 1.1 to 0.6 per 1000 women (p 0.001). The most significant reduction was seen with antepartum eclampsia (0.8 to 0.3 per 1000, p = 0.02). There was significant reduction in all maternal and perinatal outcomes in women with hypertensive disorders (3,506 and 6,016 in pre- and post- MEWT periods) after introduction of MEWT tool.

CONCLUSION

Integrating the MEWT tool into the obstetric practice helps in reducing the incidence of eclampsia and improving maternal and fetal outcomes.

Perinatal Outcome and Its Association with Blood Pressure Levels in Women with Preeclampsia

Background: Timing and mode of delivery in women with preeclampsia remains challenging, often balancing the risk of severe maternal complications and preterm delivery with its risks for the newborn. It is known that women with very high blood pressure levels in pregnancy have more unfavourable outcomes, but there is little data on neonatal outcome in these cases and the effect of the delivery mode. Methods: We included 158 preeclamptic women in our single-centre retrospective cohort study. Patients were divided into three subgroups depending on blood pressure levels, and delivery mode as well as neonatal outcomes were analysed. Furthermore, the effect of gestational age at delivery was assessed. Results: Maternal blood pressure levels correlated negatively with gestational age at delivery (p = 0.007) and positively with delivery via caesarean section (p = 0.003). Induction of labour was more frequent in women with lower blood pressure levels (p = 0.008) and higher gestational age (p < 0.001). If labour was induced, vaginal delivery was achieved equally often in all gestational ages. Neonatal outcome appears to be more favourable after vaginal delivery compared to planned caesarean section (p < 0.001). Conclusions: Induction of labour should be discussed generously in preeclamptic women, even if blood pressure levels are high and/or gestational age is young, as success rates seem to be adequate and neonatal outcome is more favourable after vaginal delivery. Large prospective trials are needed to better evaluate success rates, risks and complications of induced labour and the effects of delivery mode on neonatal outcome in preeclampsia.

Knowledge and Practice of and Attitude Toward Epidural Analgesia Among Pregnant Women in Jazan Region of Saudi Arabia

The aim of this study was to assess the knowledge, sources of knowledge, attitudes (fears and misconceptions) toward epidural analgesia (EA), and practices of parturient delivery in the Jazan region of Saudi Arabia. A cross-sectional study was conducted using a self-administered survey questionnaire distributed in the antenatal care clinics of the obstetric departments of major hospitals. A total of 454 women participated in this study. Of the participants, 219 (48%) belonged to the 31 to 40-year age group and 134 (30%) to the 21 to 30-year age group. Most participants (344, 76%) had a bachelor's degree. The prevalence of epidural catheter use was 23.6% among pregnant women. Statistically significant differences in educational level and residence were found between the women (p < 0.001). The two most common sources of information cited by the pregnant women were healthcare staff and family and friends. The most common motive reported by women was to relieve labor pain effectively, and the most frequently cited barriers preventing women from receiving EA were the possibility of injury to important organs and the inability to walk after EA. The present study demonstrates a low level of knowledge about EA among pregnant women in the region. More awareness and guidance about EA are warranted.