Al HaYaT MedicosPre-eclampsia is a pregnancy-specific condition with new high blood pressure after 20 weeks of pregnancy and signs of organ involvement. It is a leading cause of maternal and perinatal death worldwide, including in Pakistan. Eclampsia means seizures in a woman with pre-eclampsia. Both are emergencies.
Definitions (ISSHP)
Pre-eclampsia is new hypertension (140/90 mmHg or higher) after 20 weeks of pregnancy, plus at least one of:
- Proteinuria: for example a urine protein:creatinine ratio of 30 mg/mmol or more.
- Maternal organ dysfunction:
- acute kidney injury
- liver involvement (raised transaminases, right upper quadrant or epigastric pain)
- neurological features (severe headache, visual disturbance, seizures)
- haematological problems (low platelets, haemolysis)
- Uteroplacental dysfunction: fetal growth restriction.
Risk factors
High risk (NICE):
- hypertensive disease in a previous pregnancy
- chronic hypertension
- chronic kidney disease
- autoimmune disease such as SLE or antiphospholipid syndrome
- type 1 or type 2 diabetes
Moderate risk:
- first pregnancy
- age 40 or older
- pregnancy interval of more than 10 years
- BMI 35 or more
- family history of pre-eclampsia
- multiple pregnancy
Prevention
Women with one high-risk factor, or two or more moderate-risk factors, are advised to take low-dose aspirin (75–150 mg daily) from 12 weeks until birth (NICE). Calcium supplementation is recommended by WHO where dietary calcium intake is low.
Symptoms and signs of severe disease
- Severe headache.
- Visual problems (blurring, flashing lights).
- Epigastric or right upper quadrant pain.
- Vomiting.
- Sudden swelling of the face, hands or feet.
- Brisk reflexes and clonus.
- Blood pressure of 160/110 mmHg or higher.
- Reduced urine output.
- Breathlessness (pulmonary oedema).
Investigations
- Blood pressure monitoring.
- Urine: protein:creatinine ratio.
- Blood tests:
- full blood count (platelets)
- kidney function
- liver function
- clotting if platelets are low
- Placental growth factor (PlGF)-based testing, where available, helps rule pre-eclampsia in or out.
- Fetal assessment: growth scans, umbilical artery Doppler and CTG.
Management principles
- Antihypertensives: labetalol first-line (avoid in asthma), with nifedipine or methyldopa as alternatives, to keep blood pressure around 135/85 mmHg. Severe hypertension needs urgent treatment, for example IV labetalol, oral nifedipine or IV hydralazine, according to protocol.
- Magnesium sulfate to prevent and treat eclamptic seizures in severe pre-eclampsia. Monitor reflexes, breathing rate and urine output for magnesium toxicity; the antidote is calcium gluconate.
- Careful fluid balance. Fluid restriction is often used, because of the risk of pulmonary oedema.
- Delivery is the definitive treatment. Timing depends on gestation and on maternal and fetal condition. Give corticosteroids for fetal lung maturity if preterm delivery is likely.
- After delivery: continue monitoring. Eclampsia and severe hypertension can occur postpartum.
Eclampsia
- Call for help.
- Protect the airway.
- Place the woman in the left lateral position.
- Give magnesium sulfate (loading dose, then maintenance).
- Control blood pressure.
- Plan delivery once she is stable.
HELLP syndrome
A severe variant:
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
It can occur even with mild hypertension and needs urgent specialist care and delivery.
Exam pearls
- Magnesium sulfate is the drug of choice for eclampsia. Diazepam and phenytoin are inferior.
- Loss of reflexes is an early sign of magnesium toxicity; stop the infusion.
- The only cure is delivery of the placenta.
For more, see our Obstetrics & Gynaecology Companion and Exam Night Notes: Gynae & Obs.
Test yourself
5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.
Drug of choice to prevent and treat eclamptic seizures:
- Phenytoin
- Phenobarbital
- Diazepam
- Magnesium sulfate
- Levetiracetam
Show answer
Answer: D. Magnesium sulfate
Magnesium sulfate is superior to diazepam and phenytoin.Early clinical sign of magnesium toxicity:
- Hypertension
- Loss of deep tendon reflexes
- Seizures
- Hyperreflexia
- Tachycardia
Show answer
Answer: B. Loss of deep tendon reflexes
Loss of reflexes precedes respiratory depression; stop the infusion and give calcium gluconate if needed.Low-dose aspirin for high-risk women should start from:
- After delivery
- 12 weeks until birth
- The first day of the last period
- 36 weeks
- Only in labour
Show answer
Answer: B. 12 weeks until birth
NICE: aspirin 75–150 mg daily from 12 weeks until birth for women at high risk.First-line oral antihypertensive in pre-eclampsia (if no asthma):
- Labetalol
- Losartan
- Spironolactone
- Atenolol
- Ramipril
Show answer
Answer: A. Labetalol
Labetalol is first-line; nifedipine and methyldopa are alternatives.HELLP syndrome stands for:
- Hepatitis, Encephalopathy, Liver failure, Pain
- None of these
- Hypertension, Eclampsia, Low Lymphocytes, Proteinuria
- High Enzymes, Low Pressure
- Haemolysis, Elevated Liver enzymes, Low Platelets
Show answer
Answer: E. Haemolysis, Elevated Liver enzymes, Low Platelets
HELLP: Haemolysis, Elevated Liver enzymes and Low Platelets — needs urgent specialist care.
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Disclaimer
For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.
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