Quality statement 5: Admission to hospital for women with pre-eclampsia

Quality statement

Women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns, are admitted to hospital and monitored.

Rationale

Women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns for the wellbeing of the woman or baby, should be admitted to hospital to enable their condition to be fully assessed and its progress monitored. High-quality care should include an integrated package of care for these women that includes admission and monitoring. Some women may need to stay in hospital until after the birth of their baby. For other women, monitoring may be possible if pre-eclampsia is stable and if the woman has access to monitoring services, and can be readmitted to hospital if her clinical condition deteriorates.

Quality measures

Structure

a) Evidence of local arrangements to ensure that women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns, are admitted to hospital.

Data source: Local data collection.

b) Evidence of local arrangements for women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events or if there are any clinical concerns, to receive an integrated package of care that includes monitoring of their condition.

Data source: Local data collection.

Process

The proportion of women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns, who are admitted to hospital and monitored.

Numerator – the number of women in the denominator who are admitted to hospital and monitored.

Denominator – the number of women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that local arrangements are in place for women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns for the wellbeing of the woman or baby, to be admitted to hospital and for their condition to be monitored.

Healthcare practitioners admit women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if they have any clinical concerns for the wellbeing of the woman or baby, to hospital and monitor their condition.

Commissioners ensure they commission services that admit women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns for the wellbeing of the woman or baby, to hospital and monitor their condition.

Women with pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) are admitted to hospital if they have very high blood pressure or a high risk of complications, or if their healthcare professional has concerns about the wellbeing of the mother or baby. The women have their condition monitored while in hospital and in the community if they go home before their baby is born.

Source guidance

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.5.2 and 1.5.5

Definitions of terms used in this quality statement

Pre-eclampsia

New hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) presenting after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:

  • Proteinuria (urine protein:creatinine ratio of 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or

  • other maternal organ dysfunction:

    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)

    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)

    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata

    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis

  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.

[NICE's guideline on hypertension in pregnancy, terms used in this guideline]

Severe hypertension

Blood pressure over 160 mmHg systolic or over 110 mmHg diastolic,

[NICE's guideline on hypertension in pregnancy, terms used in this guideline]

High risk of adverse events

High risk of adverse events suggested by the fullPIERS or PREP-S risk prediction models.

[NICE's guideline on hypertension in pregnancy, recommendation 1.5.5, table 2]

Clinical concerns

Concerns for the wellbeing of the woman or baby that could include any of the following:

  • sustained systolic blood pressure of 160 mmHg or higher

  • any maternal biochemical or haematological investigations that cause concern, for example, a new and persistent:

    • rise in creatinine (90 micromol/litre or more, 1 mg/100 ml or more) or

    • rise in alanine transaminase (over 70 IU/litre, or twice upper limit of normal range) or

    • fall in platelet count (under 150,000/microlitre)

  • signs of impending eclampsia

  • signs of impending pulmonary oedema

  • other signs of severe pre-eclampsia

  • suspected fetal compromise

  • any other clinical signs that cause concern.

[NICE's guideline on hypertension in pregnancy, recommendation 1.5.2]

Admitted to hospital and monitored

Monitoring should include blood pressure measurements, proteinuria testing, blood tests and fetal assessments in accordance with those set out in the NICE guideline on hypertension in pregnancy.

[NICE's guideline on hypertension in pregnancy, recommendation 1.5.5, table 2]