Gloria Adoyi

The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice.

This set of recommendations from ISSHP is designed to assist clinicians throughout the world in the recognition and management of the hypertensive disorders of pregnancy; the document includes sections written by those working in low and middle income countries so as to ensure applicability in all parts of the world. Some key points include: ISSHP does not recommend classifying pre-eclampsia as ‘mild’ or ‘severe’ because the condition may progress rapidly and unpredictably. Proteinuria is not mandatory for a diagnosis of pre-eclampsia. The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low platelets) is one (serious) manifestation of pre-eclampsia and not a separate disorder. ISSHP supports first trimester screening for risk of pre-eclampsia when this can be integrated into the local health system, although the cost effectiveness of this approach remains to be established. ISSHP recommends that women with established strong clinical risk factors for pre-eclampsia (i.e., prior pre-eclampsia, chronic hypertension, pre-gestational diabetes, maternal BMI >30 kg/m2, antiphospholipid syndrome and receipt of assisted reproduction) be treated, ideally before 16 weeks but definitely before 20 weeks, with low dose aspirin (defined as 75–162 mg/day, as studied in RCTs). ISSHP recommends at this stage against the routine clinical use of ‘rule-in’ or ‘rule-out’ tests (specifically PlGF or sFLT-1/PlGF ratio) for pre-eclampsia. Regardless of the hypertensive disorder of pregnancy, blood pressure requires urgent treatment in a monitored setting when severe (>160/110 mmHg). For pre-eclampsia, target diastolic blood pressure is 85 mmHg in the office/clinic (and systolic blood pressure of 110–140 mmHg). Women with pre-eclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms, should receive magnesium sulphate (MgSO4) for convulsion prophylaxis. Annual medical review is advised life-long and all such women should adopt a healthy lifestyle that includes exercise, eating well and aiming for ideal body weight.

Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice

These recommendations from the International Society for the Study of Hypertension in Pregnancy (ISSHP) are based on available literature and expert opinion. It is intended that this be a living document, to be updated when needed as more research becomes available to influence good clinical practice. Unfortunately, there is a relative lack of high-quality randomized trials in the field of hypertension in pregnancy compared with studies in essential hypertension outside of pregnancy, and ISSHP encourages greater funding and uptake of collaborative research in this field. Accordingly, the quality of evidence for the recommendations in this document has not been graded although relevant references and explanations are provided for each recommendation. The document will be a living guideline, and we hope to be able to grade recommendations in the future. Guidelines and recommendations for management of hypertension in pregnancy are typically written for implementation in an ideal setting. It is acknowledged that in many parts of the world, it will not be possible to adopt all of these recommendations; for this reason, options for management in less-resourced settings are discussed separately in relation to diagnosis, evaluation, and treatment. This document has been endorsed by the International Society of Obstetric Medicine and the Japanese Society for the Study of Hypertension in Pregnancy. All units managing hypertensive pregnant women should maintain and review uniform departmental management protocols and conduct regular audits of maternal and fetal outcomes. The cause(s) of preeclampsia and the optimal clinical management of the hypertensive disorders of pregnancy remain uncertain; therefore, we recommend that every hypertensive pregnant woman be offered an opportunity to participate in research, clinical trials, and follow-up studies. ### Classification 1. Hypertension in pregnancy may be chronic (predating pregnancy or diagnosed before 20 weeks of pregnancy) or de novo (either preeclampsia or gestational hypertension). 2. Chronic hypertension is associated with adverse …

Obstetric knowledge of nurse-educators in Nigeria: Levels, regional differentials and their implications for maternal health delivery

Objective: To assess the knowledge of nurse-midwife educators on the major causes of maternal mortality in Nigeria. Setting: Schools of nursing and midwifery in Nigeria. Method: A total of 292 educators from 171 schools of nursing and midwifery in Nigeria were surveyed for their knowledge of the major causes of maternal mortality as a prelude to the design and implementation of a train-the-trainer intervention geared towards improved maternal health-care delivery. Results: There was paucity of knowledge across all major causes. Only 57.2% and 62.7% of educators could diagnose pre-eclampsia and severe pre-eclampsia, respectively. While 86% knew about magnesium sulphate (MgSO4) as the ‘gold standard’ for treating eclampsia, only 16.8% knew of calcium gluconate as an antidote to MgSO4 toxicity. Of the educators, 63.7% could not describe the components of active management of third stage of labour, while 29.5% were not aware of uterine atony as a cause of postpartum haemorrhage. Furthermore, 65.4% believed that misoprostol is the preferred oxytocic for hospital delivery. Other potentially harmful knowledge gaps were also found, such as 47.3% of the participants reporting that they would perform episiotomies on all primigravidae. Conclusion: Nurse/midwife educators in Nigeria are not as knowledgeable as previously thought, especially concerning the causes of maternal mortality. In order to scale up the quality of obstetric care, updated pre-service curricula should be implemented fully while in-service appraisal and continuing education should be introduced.