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Table 4 ‘Key discussion points’ and the consensus reached during the HDP guideline development process

From: Bottom-up development of national obstetric guidelines in middle-income country Suriname

Hypertensive disorders of pregnancy “Key discussion points” Consensus
Definition
1 Can you diagnose severe pre-eclampsia without proteinuria? Yes, if severe hypertension is accompanied by hematologic, renal, neurological, hepatic or pulmonary complications [26, 27].
Prevention
2 Which women should receive aspirin therapy for the prevention of pre-eclampsia? All women with an obstetric history of pre-eclampsia should be administered 100mg of aspirin during their 16th and 37th week. Women with cardiovascular risk factors may be counselled for its use as well [26, 28].
Therapy
3 Which antihypertensive therapy is preffered? Methyldopa is first choice, followed by hydralazine or labetalol. Nifedipine is first choice postpartum.
4 In severe HDP, what should be given first: antihypertensives or magnesiumsulfate? Magnesium sulfate (4 gram in 30 minutes, followed by 1 gram per hour) is initiated immediately; hypertensive medication will be added depending on the blood pressures.
5 Can magnesium sulfate be administered by nurses or midwives according to protocol in eclampsia prior to consultation with a doctor? In emergency situations nurses or midwives can administer magnesium sulfate before or during consultation with a doctor. It should never be administered over the same tap as oxytocin.
6 Is magnesium sulfate therapy without a loading dose an option when severe pre-eclampsia presents without clinical symptoms? International evidence and recommendations suggest always using a loading dose, as the maintenance dose does not give the magnesium plasma rise that is necessary to prevent a seizure [29]. When magnesium sulfate is given, it should be given adequately and not stopped during (caesarean) delivery.
7 Should magnesium sulfate therapy be continued in caesarean section with spinal analgesia? Magnesium sulfate should be continued during the delivery or caesarean section, as the intra partum risk of eclampsia is highest [26, 28].
8 Can nifedipine and magnesium sulfate therapy be combined? There is a potential theoretical interaction between the two, leading to hypotension and neuromuscular blockade effects, although this is seldom reported. Regular monitoring is recommended and if hypotension occurs, nifedipin and magnesium sulphate administration should cease [30].
9 Should a fluid preload be administration before intravenous antihypertensive or magnesium sulfate therapy? No, because the risk of fluid overload (and subsequent pulmonary oedema) is high in severe pre-eclampsia [26]. Fluid preloading is acceptable in hypovolemia or anticipated epidural anaesthesia and low blood pressures. Early consultation of an anaesthesiologist is advised.
10 Is diazepam of added value to magnesium sulfate in the treatment of eclampsia? Magnesium sulfate is the drug of choice for treating eclamptic seizures. Diazepam is not advised by international guidelines [26]. During the discussion it was decided upon that diazepam use should be limited to unremitting seizures.
Other
12 How can we define “stabilization” in eclampsia or severe pre-eclampsia? The definition of stabilization of pre-eclampsia and eclampsia is: (1) stable blood pressure (RR 130-150 / 70-100); (2) adequate magnesium sulfate (loading dose must be administered); (3) platelets of >80); (4) fluid restriction of <1.5 liters. Stabilization is not time-dependent and can be reached even within an hour if management is adequate [26].
13 When and how should the pregnancy be terminated in eclampsia or severe pre-eclampsia? The delivery should not be terminated until the mother is stable (see point 13). The termination of pregnancy is on maternal indication. Vaginal delivery should be strived for whenever feasible without fetal compromise [26].
13 How often should vital signs be checked and what should be checked? Every 15 minutes (4 times), every 30 minutes (4 times), every hour (4 times), every two hours (4 times), followed by regular checks in case of normal blood pressures.
14 When is admission to the Intensive Care Unit indicated? In any case of organ dysfunction, such as pulmonary oedema, neurological complications, HELLP, etc.