Pre-Eclampsia and Eclampsia

Hypertension occurs in ~8% of pregnancies. Key categories:

• Gestational hypertension: new BP ≥ 140/90 mmHg after 20 weeks’ gestation, no proteinuria, normal labs.
• Pre-eclampsia: gestational hypertension + evidence of organ involvement, classically proteinuria (>300 mg/24 h) but may also be thrombocytopenia, renal or liver dysfunction, pulmonary oedema, or neurological symptoms.
• Severe features: BP ≥ 160/110 mmHg and/or significant organ dysfunction (severe headache, visual disturbance, epigastric/RUQ pain, oliguria, pulmonary oedema, low platelets, elevated LFTs).
• Eclampsia: generalised tonic–clonic seizures in a woman with pre-eclampsia (antepartum, intrapartum or postpartum).
• Chronic hypertension: known before pregnancy or noted before 20 weeks or persisting > 6 weeks postpartum; may have superimposed pre-eclampsia.

• Pre-eclampsia (without severe features):
  • BP ≥ 140/90 mmHg after 20 weeks on at least two readings.
  • Proteinuria or other evidence of organ involvement may be minimal.
  • Often asymptomatic or mild symptoms (mild headache, oedema).
• Pre-eclampsia with severe features:
  • BP ≥ 160/110 mmHg.
  • Severe or persistent headache, visual disturbances (“flashing lights”, blurring), hyperreflexia or clonus.
  • Epigastric or right upper quadrant pain (capsular stretch from liver involvement).
  • Oliguria, rising creatinine, pulmonary oedema, low platelets, rising LFTs.
• Eclampsia: generalised tonic–clonic seizure (before, during or after delivery), often preceded by severe headache, visual symptoms or agitation.

1. Assess ABC, place in left lateral position; give high-flow oxygen if unwell; attach monitoring (BP, pulse, SpO₂).
2. Check gestational age and obstetric history; confirm pregnancy or recent delivery (up to 6 weeks postpartum).
3. Measure BP correctly; repeat to confirm. Check urine (dipstick protein if lab unavailable).
4. Take bloods: FBC, platelets, U&E/creatinine, LFTs, coagulation profile; consider magnesium level if on MgSO₄.
5. If seizure or very high BP:
   • Protect airway, give oxygen, manage seizure (MgSO₄ – see below).
   • Start rapid-acting antihypertensive if BP ≥ 160/110 mmHg.
6. Call obstetrics/anaesthetics early – definitive treatment is delivery of the fetus and placenta at an appropriate facility.
7. Consider urgent transfer to higher level of care/ICU if available and safe.

• Vital signs including BP trend; strict input/output charting (urine catheter if severe).
• Urine dipstick for protein; 24-hour protein or protein–creatinine ratio if available (not ED-urgent but note if done).
• Bloods:
  • FBC & platelets (look for anaemia, thrombocytopenia, HELLP).
  • U&E/creatinine (renal involvement).
  • LFTs (AST/ALT, LDH – liver involvement/HELLP).
  • Coagulation profile if severe disease, HELLP, or abruption suspected.
• Consider CT head/MRI if atypical features, focal neurology or poor recovery after seizure to exclude haemorrhage or thrombosis (once stable and in consultation with obstetrics/neurology).

Goal in ED: rapidly reduce dangerously high BP (≥ 160 systolic or ≥ 110 diastolic) to safer levels (e.g. < 150/100) without dropping perfusion abruptly.

• Labetalol (IV)
  • Common first-line agent (if no asthma, heart block, or severe bradycardia).
  • Example regimen: 20 mg IV bolus over 2 minutes; if insufficient, repeat with 40 mg then 80 mg at 10–20 minute intervals as needed, up to a protocol-defined maximum.
• Hydralazine (IV)
  • Alternative or used where labetalol unavailable/contraindicated.
  • Example: 5–10 mg IV slowly; repeat every 20–30 minutes as needed, guided by BP and fetal status.
• Nifedipine (oral)
  • Short-acting oral nifedipine (e.g. 10 mg) may be used where IV access or IV agents are not immediately available; monitor BP closely.
• Always follow your local obstetric/anaesthetic protocol for exact doses and targets.

Magnesium sulfate (MgSO₄) is the drug of choice to prevent and treat eclamptic seizures.

Initial Seizure Management

• Position patient in left lateral position; protect airway and prevent injury.
• Give oxygen; suction as needed; prepare for intubation if prolonged or recurrent seizures, or low GCS.

Magnesium Sulfate Regimen (example)

• Loading dose: 4–6 g IV over 15–20 minutes.
• Maintenance: 2–3 g/hour IV infusion, usually for at least 24 hours after last seizure or delivery (follow local protocol).
• Monitor:
  • Respiratory rate, oxygen saturation.
  • Patellar reflexes.
  • Urine output (> 25–30 mL/hour).
• Signs of magnesium toxicity: loss of reflexes, respiratory depression, bradycardia.
• Antidote for toxicity: 10 mL of 10% calcium gluconate IV given slowly (as per local protocol) and stop infusion.

Benzodiazepines may be used if seizures persist while arranging MgSO₄, but magnesium remains the primary agent.

• Fluids: use cautiously – pre-eclamptic patients are intravascularly depleted but leaky; at risk of pulmonary oedema.
• Avoid routine diuretics; reserve for pulmonary oedema under specialist guidance.
• Typical approach: controlled IV fluids (e.g. ~80–100 mL/hour) with strict input/output charting – follow local protocol.
• Consider ICU/HDU admission for severe disease, eclampsia, HELLP, or organ failure.

• Definitive treatment of pre-eclampsia/eclampsia is delivery of the fetus and placenta at an appropriate facility.
• Timing and mode of delivery depend on gestational age, maternal and fetal condition – decided by obstetric team.
• ED role:
  • Resuscitate and stabilise (BP control, MgSO₄, airway/fluids).
  • Initiate investigations to identify severity and complications.
  • Communicate clearly with obstetrics/anaesthetics/ICU and prepare for transfer if needed.
• Remember postpartum eclampsia can occur up to 6 weeks after delivery – treat the same way (MgSO₄ + BP control + obstetric review).

• Record:
  • Gestational age, parity, key antenatal history.
  • Serial BP readings, symptoms (headache, visual change, RUQ pain, oedema, seizures).
  • Medications given (antihypertensives, MgSO₄: dose and time), fluids, and investigation results.
• Provide a structured handover to obstetric/ICU teams, including trends and response to treatment.