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## Complete Summary

#### GUIDELINE TITLE

The management of severe pre-eclampsia/eclampsia.

#### BIBLIOGRAPHIC SOURCE(S)

Tuffnell DJ, Shennan AH, Waugh JJ, Walker JJ. The management of severe
pre-eclampsia/eclampsia. London (UK): Royal College of Obstetricians and
Gynaecologists; 2006 Mar. 11 p. (Guideline; no. 10(A)). \[52
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Severe pre-eclampsia

-   Eclampsia

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Anesthesiology\
Family Practice\
Internal Medicine\
Obstetrics and Gynecology

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To standardize the management approach of severe pre-eclampsia and
eclampsia in the immediate pre- and post- delivery period in order to
improve patient and newborn outcome

#### TARGET POPULATION

-   Women with severe pre-eclampsia

-   Women with eclampsia

**Note**: Mild pre-eclampsia is not covered in this guideline.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment and Diagnosis**

*Assessment of the Woman*

1.  Blood pressure measurement (automated blood pressure device vs.
    mercury sphygmomanometers)

2.  Urine dipstick testing

3.  Protein/creatinine ratio

4.  24-hour urine collection

5.  Full blood count

6.  Liver function testing

7.  Renal function testing

8.  Clotting studies

9.  Monitoring and charting of fluid balance

*Assessment of the Fetus*

1.  Cardiotocography

2.  Continuous electronic fetal monitoring

3.  Ultrasound measurement of fetal size

4.  Umbilical artery Doppler

5.  Serial estimation of liquid volume

**Management/Treatment**

*Management of the Woman*

1.  Antihypertensive treatment (labetolol, nifedipine, hydralazine,
    methyldopa)

2.  Avoidance of atenolol, angiotensin converting enzyme (ACE)
    inhibitors, angiotensin receptor-blocking drugs (ARB), and diuretics

3.  Magnesium sulphate

4.  Oxygen administration

5.  Pulse oximetry

6.  Diazepam, phenytoin, and thiopentone (only as second-line treatment)

7.  Fluid restriction

8.  Planning mode of delivery

9.  Syntocinon for third-stage labor management

10. Use of corticosteroids

11. Conservative management of delivery

12. Continuation of antihypertensives following delivery

13. Formal postnatal follow-up and review

14. Preconceptual counseling

#### MAJOR OUTCOMES CONSIDERED

-   Predictive value of diagnostic tests

-   Risk for and incidence of eclamptic seizures

-   Maternal and fetal fatality rates

-   Rate of maternal and fetal complications

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Cochrane Library and the Cochrane Register of Controlled Trials were
searched for relevant randomized controlled trials, systematic reviews
and meta-analyses. Recent consensus documents were also studied,
including an Royal College of Obstetricians and Gynaecologists (RCOG)
Study Group proceedings. A search of MEDLINE and PUBMED (electronic
databases) from 1966 to 2005 was also carried out. Search words
included: \'pregnancy\', \'hypertension\', \'pre-eclampsia\',
\'eclampsia\' and \'toxaemia\'.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Ia**: Evidence obtained from meta-analysis of randomized controlled
trials.

**Ib**: Evidence obtained from at least one randomized controlled trial.

**IIa**: Evidence obtained from at least one well-designed controlled
study without randomization.

**IIb**: Evidence obtained from at least one other type of well-designed
quasi-experimental study.

**III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies
and case studies.

**IV**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grading of Recommendations**

**Grade A** - Requires at least one randomized controlled trial as part
of a body of literature of overall good quality and consistency
addressing the specific recommendation. (Evidence levels Ia, Ib)

**Grade B** - Requires the availability of well controlled clinical
studies but no randomized clinical trials on the topic of
recommendations. (Evidence levels IIa, IIb, III)

**Grade C** - Requires evidence obtained from expert committee reports
or opinions and/or clinical experiences of respected authorities. 
Indicates an absence of directly applicable clinical studies of good
quality. (Evidence level IV)

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Following discussion in the Guidelines and Audit Committee, each
green-top guideline is formally peer reviewed. At the same time the
draft guideline is published on the Royal College of Obstetricians and
Gynaecologists (RCOG) website for further peer discussion before final
publication.

The names of author(s) and nominated peer reviewers are included in the
original guideline document.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*In addition to these evidence-based recommendations, the guideline
development group also identifies points of best clinical practice in
the original guideline document.*

Grading of recommendations (A-C) and levels of evidence (Ia-IV) are
defined at the end of the \"Major Recommendations\" field.

**Assessment and Diagnosis**

**C** - Although the classification of severity is primarily based on
the level of blood pressure and the presence of proteinuria, clinicians
should be aware of the potential involvement of other organs when
assessing maternal risk, including placental disease with fetal
manifestations.

Some women will present with convulsions, abdominal pain or general
malaise. In these cases, pre-eclampsia should always be considered and
the blood pressure taken and the urine analyzed. Clinical symptoms are
important components of worsening disease, particularly headache and
abdominal pain. However, increasing edema is not in itself a sign that
should determine management. Maternal tendon reflexes, although useful
to assess magnesium toxicity, are not of value in assessing the risk of
convulsion, although the presence of clonus may be. Continuous oxygen
saturation monitoring with a pulse oximeter is valuable, as it will
often give early signs of pulmonary edema. \[Evidence level IV\]

**A** - When taking blood pressure, the woman should be rested and
sitting at a 45-degree angle. The blood pressure cuff should be of the
appropriate size and should be placed at the level of the heart.
Multiple readings should be used to confirm the diagnosis. Korotkoff
phase 5 is the appropriate measurement of diastolic blood pressure. The
method used should be consistent and documented.

**B** - Automated blood pressure methods need to be used with caution,
as they may give inaccurate blood pressure readings in pre-eclampsia.

**C** - The usual screening test for proteinurea is visual dipstick
assessment. A two plus dipstick measurement can be taken as evidence of
proteinuria but ideally a more accurate test (either a spot protein
creatinine ratio or ideally a 24-hour urine collection) is required to
confirm this.

In view of the high false positive rates with dipsticks, laboratory
testing, usually by 24-hour urine collection, is recommended to confirm
significant proteinuria, unless the clinical urgency dictates immediate
delivery. \[Evidence level IV\]

**B** - In the acute setting, an initial assessment of the fetus with
cardiotocography should be undertaken. This gives information about
fetal wellbeing at that time but does not give any predictive
information.

**B** - Women in labor with severe pre-eclampsia should have continuous
electronic fetal monitoring.

**A** - If conservative management is planned then further assessment of
the fetus with ultrasound measurements of fetal size, umbilical artery
Doppler and liquor volume should be undertaken. Serial assessment will
allow timing of delivery to be optimised.

**C** - The value of Doppler in other fetal vessels has yet to be
clarified.

Cardiotocography (non-stress test) is the mainstay of fetal monitoring
in most units. It can be repeated regularly and easily without need of
expensive equipment or highly skilled personnel. It gives information
concerning fetal wellbeing at that time but has little predictive value.
If the woman is in labor then continuous electronic fetal monitoring is
appropriate. \[Evidence level III\]

The main pathology affecting the fetus, apart from prematurity, is
placental insufficiency leading to intrauterine growth restriction
(IUGR). IUGR occurs in around 30% of pre-eclamptic pregnancies.
Ultrasound assessment of fetal size, at the time of the initial
presentation with hypertension, is a valuable one-off measurement to
assess fetal growth.  Growth restriction is usually asymmetrical so
measurement of the abdominal circumference is the best method of
assessment. Reduced liquor volume is also associated with placental
insufficiency and fetal growth restriction. Serial estimations of liquor
volume can detect fetal compromise. \[Evidence level Ia\]

**Management of Severe Pre-eclampsia**

**C** - Antihypertensive treatment should be started in women with a
systolic blood pressure over 160 mmHg or a diastolic blood pressure over
110 mmHg. In women with other markers of potentially severe disease,
treatment can be considered at lower degrees of hypertension.

**A** - Labetalol, given orally or intravenously, nifedipine given
orally or intravenous hydralazine can be used for the acute management
of severe hypertension.

**C** - In moderate hypertension, treatment may assist prolongation of
the pregnancy. Clinicians should use agents with which they are
familiar.

**B** - Atenolol, angiotensin converting enzyme (ACE) inhibitors,
angiotensin receptor-blocking drugs (ARB) and diuretics should be
avoided.

There has been a general consensus that blood pressure greater than
170/110 mmHg requires treatment in the maternal interest, although this
is not supported by randomized trials. There is, however, a clear
rationale supported by the desire to prevent the known risk of vascular
damage due to uncontrolled hypertension.

There is also a consensus that, if the blood pressure is below 160/100
mmHg, there is no immediate need for anti-hypertensive therapy. An
exception may be if there are markers of potentially more severe
disease, such as heavy proteinuria or disordered liver or hematological
test results. Since, in this situation, alarming rises in blood pressure
may be anticipated, anti-hypertensive treatment at lower blood pressure
levels may be justified. There is continuing debate concerning women
with a blood pressure between 100 mmHg and 110 mmHg diastolic. Maternal
treatment is associated with a reduction of severe hypertensive crises
and a reduction in the need for further anti-hypertensive therapy;
however, there appears to be a small reduction in infant birth weight.
With treatment a prolongation of pregnancy of an average of 15 days is
possible as long as there is no other reason to deliver. \[Level Ia, but
small trials of mixed quality\]

**A** - Magnesium sulphate should be considered for seizure prevention
in women with pre-eclampsia for whom there is concern about the risk of
eclampsia. This is usually in the context of severe pre-eclampsia once a
delivery decision has been made and in the immediate postpartum period. 
In women with less severe disease the decision is less clear and will
depend on individual case assessment.

If magnesium sulphate is given, it should be continued for 24 hours
following delivery or 24 hours after the last seizure, whichever is the
later, unless there is a clinical reason to continue. When magnesium
sulphate is given, regular assessment of the urine output, maternal
reflexes, respiratory rate and oxygen saturation is important.
\[Evidence level Ia\]

**C** - The principles of seizure management should follow the basic
principles of airway, breathing and circulation.

**A** - Magnesium sulphate is the therapy of choice to control seizures.
A loading dose of 4 g should be given by infusion pump over 5 to 10
minutes, followed by a further infusion of 1 g/hour maintained for 24
hours after the last seizure.

**A** - Recurrent seizures should be treated with either a further bolus
of 2 g magnesium sulphate or an increase in the infusion rate to 1.5 g
or 2.0 g/hour.

Do not leave the woman alone but call for help, including appropriate
personnel such as the anesthetist and senior obstetrician. Ensure that
it is safe to approach the woman and aim to prevent maternal injury
during the convulsion. Place the woman in the left lateral position and
administer oxygen. Assess the airway and breathing and check pulse and
blood pressure. Pulse oximetry is helpful. Once stabilized, plans should
be made to deliver the woman but there is no particular hurry and a
delay of several hours to make sure the correct care is in hand is
acceptable, assuming there is no acute fetal concern such as a fetal
bradycardia. The woman\'s condition will always take priority over the
fetal condition. \[Evidence level IV\]

Magnesium toxicity is unlikely with these regimens and levels do not
need to be routinely measured. Magnesium sulphate is mostly excreted in
the urine. Urine output should be closely observed and if it becomes
reduced below 20 ml/hour the magnesium infusion should be halted.
Magnesium toxicity can be assessed by clinical assessment as it causes a
loss of deep tendon reflexes and respiratory depression. If there is
loss of deep tendon reflexes, the magnesium sulphate infusion should be
halted. Calcium gluconate 1 g (10 ml) over 10 minutes can be given if
there is concern over respiratory depression. \[Evidence level Ia\]

In the collaborative eclampsia trial, a further bolus of 2 g magnesium
sulphate was administered for recurrent seizures. An alternative is to
increase the rate of infusion of magnesium sulphate to 1.5 g or 2.0
g/hour. If there are repeated seizures then alternative agents such as
diazepam or thiopentone may be used, but only as single doses, since
prolonged use of diazepam is associated with an increase in maternal
death. If convulsions persist, intubation is likely to be necessary to
protect the airway and maintain oxygenation. Transfer to intensive care
facilities with intermittent positive pressure ventilation is
appropriate in these circumstances. \[Evidence level Ib\]

**C** - Fluid restriction is advisable to reduce the risk of fluid
overload in the intrapartum and postpartum periods. In usual
circumstances, total fluids should be limited to 80 ml/hour or 1
ml/kg/hour.

Over the last 20 years, pulmonary edema has been a significant cause of
maternal death. This has often been associated with inappropriate fluid
management. There is no evidence of the benefit of fluid expansion and a
fluid restriction regimen is associated with good maternal outcome.
There is no evidence that maintenance of a specific urine output is
important to prevent renal failure, which is rare. The regime of fluid
restriction should be maintained until there is a postpartum diuresis,
as oliguria is common with severe pre-eclampsia. If there is associated
maternal haemorrhage, fluid balance is more difficult and fluid
restriction is inappropriate.

**C** - The decision to deliver the fetus should be made once the woman
is stable and with appropriate senior personnel present.

**A** - If the fetus is less than 34 weeks of gestation and delivery can
be deferred, corticosteroids should be given, although after 24 hours
the benefits of conservative management should be reassessed.

**A** - Conservative management at very early gestations may improve the
perinatal outcome but must be carefully balanced with maternal
wellbeing.

**C** - The mode of delivery should be determined after considering the
presentation of the fetus and the fetal condition, together with the
likelihood of success of induction of labor after assessment of the
cervix.

The delivery should be well-planned, done on the best day, performed in
the best place, by the best route and with the best support team. A few
hours\' delay in delivery may be helpful if it allows the neonatal unit
to be more organized or to transfer a mother to a place where a cot is
available. This assumes the mother is stable before delivery and prior
to transfer. \[Evidence level IV\]

If the gestation is greater than 34 weeks, delivery after stabilization
is recommended. If less than 34 weeks and the pregnancy can be prolonged
in excess of 24 hours, steroids help to reduce fetal respiratory
mortality. There is probable benefit from steroid therapy even if
delivery is less than 24 hours after administration. \[Evidence level
Ia\]

Prolonging the pregnancy at very early gestations may improve the
outcome for the premature infant but can only be considered if the
mother remains stable. \[Evidence level Ib and level III\]

In all situations, a carefully planned delivery suiting all
professionals is appropriate. Vaginal delivery is generally preferable
but, if gestation is below 32 weeks, caesarean section is more likely as
the success of induction is reduced. After 34 weeks with a cephalic
presentation, vaginal delivery should be considered. The consultant
obstetrician should discuss the mode of delivery with the mother.
Vaginal prostaglandins will increase the chance of success.
Anti-hypertensive treatment should be continued throughout assessment
and labor. \[Evidence level IV\]

**C** - Clinicians should be aware of the risk of late seizures
following delivery, and ensure that women have a careful review before
discharge from hospital.

**C** - Anti-hypertensive medication should be continued after delivery
as dictated, by the blood pressure. It may be necessary to maintain
treatment for up to 3 months, although most women can have treatment
stopped before this.

**C** - Women with persisting hypertension and proteinuria at 6 weeks
may have renal disease and should be considered for further
investigation.

Severe pre-eclampsia or eclampsia can occur in the postpartum period. 
Up to 44% of eclampsia has been reported to occur postnatally,
especially in women presenting at term. Women who develop hypertension
or symptoms of pre-eclampsia postnatally (headaches, visual
disturbances, nausea and vomiting or epigastric pain) should be referred
for a specialist opinion and investigation to exclude pre-eclampsia.
Women who deliver with severe pre-eclampsia (or eclampsia) should have
continued close observation postnatally. As eclampsia has been reported
up to 4 weeks postnatally, the optimum length of inpatient postnatal
stay is unclear but the incidence of eclampsia and severe pre-eclampsia
falls after the fourth postpartum day. The decision about discharge from
hospital needs to take account of the risk of late seizures. Most women
with severe pre-eclampsia or eclampsia will need inpatient care for 4
days or more following delivery. Careful review to ensure improving
clinical signs is needed before discharge. \[Evidence level III\]

Anti-hypertensive therapy should be continued after delivery.  Although,
initially, blood pressure may fall, it usually rises again at around 24
hours postpartum. A reduction in anti-hypertensive therapy should be
made in a stepwise fashion. There is no reason why the woman cannot go
home on treatment, to be weaned off therapy as an outpatient.  After
pre-eclampsia, blood pressure can take up to 3 months to return to
normal. During this time, blood pressure should not be allowed to exceed
160/110 mmHg. Currently, there is insufficient evidence to recommend any
particular anti-hypertensive. However, it is good practice to avoid the
use of alpha methyldopa in the postnatal period because of its adverse
effect profile, particularly depression. In breastfeeding women,
labetalol, atenolol, nifedipine and enalapril are currently in use,
either singly or in combination. \[Evidence level III\]

**Definitions**:

**Grading of Recommendations**

**Grade A** - Requires at least one randomized controlled trial as part
of a body of literature of overall good quality and consistency
addressing the specific recommendation. (Evidence levels Ia, Ib)

**Grade B** - Requires the availability of well controlled clinical
studies but no randomized clinical trials on the topic of
recommendations. (Evidence levels IIa, IIb, III)

**Grade C** - Requires evidence obtained from expert committee reports
or opinions and/or clinical experiences of respected authorities.
Indicates an absence of directly applicable clinical studies of good
quality. (Evidence level IV)

**Levels of Evidence**

**Ia**: Evidence obtained from meta-analysis of randomized controlled
trials.

**Ib**: Evidence obtained from at least one randomized controlled trial.

**IIa**: Evidence obtained from at least one well-designed controlled
study without randomization.

**IIb**:; Evidence obtained from at least one other type of
well-designed quasi-experimental study.

**III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies
and case studies.

**IV**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for most
recommendations (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate and successful treatment of severe pre-eclampsia with
    minimal adverse effects on the mother or fetus

-   Reduction in intrauterine growth restriction (IUGR)

-   Reduction in fetal prematurity

-   Reduction of post-partum eclampsia

#### POTENTIAL HARMS

-   Adverse effects of pharmacological and medical interventions to the
    mother and fetus

-   Automated methods of blood pressure measurement should be used with
    caution, as they may give inaccurate blood pressure readings in
    pre-eclampsia.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Labetalol should be avoided in women with known asthma.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These recommendations are not intended to dictate an exclusive
    course of management or treatment. They must be evaluated with
    reference to individual patient needs, resources and limitations
    unique to the institution and variations in local populations. It is
    hoped that this process of local ownership will help to incorporate
    these guidelines into routine practice. Attention is drawn to areas
    of clinical uncertainty where further research may be indicated.

-   Ultimately, as many clinical criteria are subjective, women should
    be managed according to a careful clinical assessment rather than
    relying on overly precise criteria. Each unit or region may wish to
    produce a locally adapted approach to implementation of the
    guideline addressing blood pressure monitoring, including the use of
    mean arterial pressure, thresholds for the use of magnesium sulphate
    and preferred first- and second-line anti hypertensive agents.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Tuffnell DJ, Shennan AH, Waugh JJ, Walker JJ. The management of severe
pre-eclampsia/eclampsia. London (UK): Royal College of Obstetricians and
Gynaecologists; 2006 Mar. 11 p. (Guideline; no. 10(A)). \[52
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

Royal College of Obstetricians and Gynaecologists - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Royal College of Obstetricians and Gynaecologists

#### GUIDELINE COMMITTEE

Guidelines and Audit Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Professor Deirdre J Murphy MRCOG (Chair); Caroline
Bearfield, Guidelines Research Fellow; Ms Toni Belfield, Consumers\'
Representative; Professor P R Braude FRCOG, Chairman, Scientific
Advisory Committee; Mrs C Dhillon, Head of Clinical Governance and
Standards Dept.; Dr Martin Dougherty, A. Director NCC-WCH; Miss L M M
Duley FRCOG, Chairman, Patient Information Subgroup;  Mr Alan S Evans
FRCOG; Dr Mehmet R Gazvani MRCOG; Dr Rhona G Hughes FRCOG; Mr Anthony J
Kelly MRCOG; Dr Gwyneth Lewis FRCOG, Department of Health; Dr Mary A C
Macintosh MRCOG, CEMACH; Dr Tahir A Mahmood FRCOG; Mrs Caroline E
Overton MRCOG, Reproductive medicine; Dr David Parkin FRCOG, Oncology;
Ms Wendy Riches, NICE; Mr Mark C Slack MRCOG, Urogynaecology; Mr Stephen
A Walkinshaw FRCOG, Maternal and Fetal Medicine; Dr Eleni Mavrides,
Trainees Representative

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Guideline authors are required to complete a \"declaration of
interests\'\" form.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Royal College of Obstetricians and Gynaecologists (RCOG) Web
site](http://www.rcog.org.uk/resources/Public/pdf/management_pre_eclampsia_mar06.pdf).

Print copies: Available from the Royal College of Obstetricians and
Gynaecologists (RCOG) Bookshop, 27 Sussex Place, Regent\'s Park, London
NW1 4RG; Telephone: +44 020 7772 6276; Fax, +44 020 7772 5991; e-mail:
<bookshop@rcog.org.uk>. A listing and order form are available from the
[RCOG Web site](http://www.rcogbookshop.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Guidance for the development of RCOG green-top guidelines. Clinical
    Governance Advice No 1. 2000 Jan. Available from the [Royal College
    of Obstetricians and Gynaecologists (RCOG) Web
    site](http://www.rcog.org.uk/index.asp?PageID=480).

-   Searching for evidence. Clinical Governance Advice No 3. 2001 Oct.
    Available from the [Royal College of Obstetricians and
    Gynaecologists (RCOG) Web
    site](http://www.rcog.org.uk/index.asp?PageID=481).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on July 6, 2006. The information
was verified by the guideline developer on August 16, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008