Pre-eclampsia

Definition

• Hypertension developing after 20 weeks gestation defined as BP >140/90 mmHg on at least two occasions, 4 hours apart

• Accompanied by one or more features: proteinuria (urine PCR >30 mg/mmol), renal impairment (elevated creatinine, oliguria), liver dysfunction (RUQ/epigastric pain, elevated LFTs), neurological symptoms (vision changes, headache, hyperreflexia with clonus, confusion, seizures) or haematological abnormalities (thrombocytopenia <100 x 10⁹/L, haemolysis, elevated LDH) indicating HELLP syndrome

History

• Vision changes such as blurred vision or scotomas

• Severe headache, confusion and episodes of altered mental status

• RUQ or epigastric pain and vomiting

• Oliguria and signs of fluid overload including dyspnoea or pulmonary oedema

• Rapidly worsening lower limb swelling

• Decreased fetal movements, which warrant further evaluation

• Presence of risk factors including obesity, diabetes, pre-existing hypertension or autoimmune disorders

Examination

• Altered mental state in severe cases

• Peripheral oedema, though non-diagnostic

• Hyperreflexia with or without clonus, suggestive of severe pre-eclampsia

• Pulmonary crackles indicating possible pulmonary oedema

• RUQ or epigastric tenderness as a sign of liver involvement or HELLP syndrome

• Assessment of visual acuity to detect blurring or scotomas

• Evaluation of fundal height and fetal heart rate to assess for intrauterine growth restriction and placental insufficiency

Diagnosis

• Blood tests: full blood count for thrombocytopenia (<100 x 10⁹/L), UEC for elevated creatinine and oliguria, liver function tests for elevated transaminases, LDH for evidence of haemolysis, and coagulation studies if DIC is suspected

• Urine analysis: dipstick proteinuria confirmed by urine protein:creatinine ratio >30 mg/mmol

• Fetal ultrasound: to assess fetal growth, amniotic fluid volume and exclude placental abruption

• Umbilical artery Doppler studies if fetal growth restriction is suspected

• Consider evaluation of underlying risk factors such as obesity, renal disease and autoimmune conditions

Management

• Urgent referral to a pregnancy assessment centre or hospital for suspected severe pre-eclampsia

• Continuous monitoring of BP, urine output, reflexes and fetal well-being, recognising that BP severity does not reliably predict eclamptic risk

• Admission for close observation if severe features are present

• Definitive treatment is delivery; if gestational age is ≥37 weeks, proceed with immediate delivery

• If preterm (<37 weeks), balance maternal and fetal risks with administration of corticosteroids for fetal lung maturity and careful expectant management

• Acute management of severe hypertension (BP ≥160/110 mmHg) with IV labetalol as first-line treatment; alternatives include IV hydralazine or PO nifedipine

• Magnesium sulfate is indicated for seizure prophylaxis in severe pre-eclampsia or eclampsia

• Provide supportive care with appropriate fluid management and oxygen therapy as needed

Maternal Monitoring

• Regular BP assessments to detect deterioration

• Twice-weekly blood tests for platelet count, liver function, renal function and coagulation studies as indicated

• Routine urine protein monitoring is not essential once diagnosis is established

Fetal Monitoring

• Serial ultrasound assessments for fetal growth and amniotic fluid volume

• Umbilical artery Doppler studies to evaluate placental perfusion

• Cardiotocography to monitor fetal heart rate patterns and overall well-being

Indications for Delivery

• Gestational age of 37 weeks or more warrants immediate delivery

• Maternal organ dysfunction including severe headache, RUQ/epigastric pain, visual disturbances, pulmonary oedema or eclampsia

• Fetal complications such as placental abruption or severe fetal growth restriction

• Delivery remains the definitive treatment for pre-eclampsia

Notes

• Pre-eclampsia is associated with an increased risk of future cardiovascular disease, necessitating long-term follow-up

• Key risk factors include obesity, advanced maternal age, pre-existing hypertension, diabetes and autoimmune disorders

• Early recognition and prompt management are essential to prevent progression to eclampsia and reduce maternal and fetal morbidity

• Multidisciplinary team involvement, including obstetric, anaesthetic and neonatal support, optimises outcomes in severe cases

• Patient education regarding symptom recognition and the importance of seeking urgent care is crucial in managing pre-eclampsia