PRE ECLAMPSIA

Pre-eclampsia is a hypertensive condition of pregnancy usually diagnosed after 20 weeks of gestation and can
present as late as 4-6 weeks postpartum.

It is characterised with hypertension, proteinuria with or without oedema and, may result into maternal fits if not
managed appropriately.

It may also be superimposed on chronic hypertension.

It is classified as mild to severe pre-eclampsia.

TYPE OF ECLAMPSIA DESCRIPTION
Mild to moderate
pre-eclampsia
A diastolic BP of 90-109 mmHg and/
or systolic BP of 140-159 mmHg,
with ≥1+ proteinuria; and no organ
dysfunction
Severe preeclampsia acute severe hypertension (160/110
mmHg) and ≥1+ proteinuria OR any
degree of hypertension with evidence
of organ dysfunction (e.g., renal
dysfunction, raised liver enzymes,
thrombocytopaenia)

Clinical features of severe pre-eclampsia

  • Headache, blurring of vision of new onset
  • Epigastric or right upper quadrant pain, vomiting
  • Dyspnoea, weakness or general malaise
  • Oedema (swelling of hands, face, legs and other parts of the body), excessive weight gain
  • Systolic BP >160 mmHg and Diastolic BP >110 mmHg
  • Urine protein ++, may be oliguria
  • Pre-elampsia related hypertension usually resolves spontaneously after delivery and almost always within 12
    weeks from delivery.

Differential diagnosis

  • Other causes of oedema and hypertension, e.g. renal disease)

Investigations

  • Urine: for protein
  • Blood for:
    • LFT & RFT
    • Serum creatinine
    • Clotting time if platelet count is less than 100 X 109
    • Fibrinogen levels
  • Ultrasound Scan for foetal Estimated Gestational Age and viability

MANAGEMENT

Any case of pre-eclampsia has to be referred to hospital, lower facilities can give emergency care (Magnesium
sulphate, antihypertensive as available).

Goals of treatment are to:

  • Prevent convulsions
  • Control blood pressure
  • Deliver the baby if indicated

General measures

  • Bed rest, preferably in hospital
  • Lifestyle adjustment and diet
  • Monitor BP, urine output, renal and liver function tests, platelet count, foetal condition
  • Mother may be hypovolaemic; careful (slow) infusion of IV fluids may be necessary
  • Consider delivery if risks to mother outweigh risks of prematurity to baby

Mild to moderate pre-eclampsia

  • Based on BP response
  • Methyldopa, oral, 250 mg every 8 hours as a starting dose, increase to 500 mg 6 hourly
    according to response, Max dose 2 g daily
    AND/OR
  • Nifedipine 20-40 mg every 12 hours

Severe pre-eclampsia (hypertensive emergency)

To prevent convulsions

  • Give IV fluids (Normal saline) very slowly (1 L in 6-8 hours max)
  • Give IV loading dose of magnesium sulphate injection (4 g of MgSO4)
    • Draw 8 mL of a 50% MgSO4 and add 12 mL of water for injection or Normal saline: this is equal
      to 4 g of 20% MgSO4
    • Give the solution as a slow IV bolus over 20 minutes (the 20-20-20 rule)
  • Then give 5 g MgSO4 (10 mL of MgSO4 50%, undiluted) in each buttock deep IM (total 10 g)
    with 1 mL of 2% lignocaine in the same syringe
  • If unable to give IV loading dose, give only the 10 g deep IM

Antihypertensives
If BP is >95 mmHg diastolic or >160 mmHg systolic

  • Give hydralazine 5 mg IV bolus every 30 minutes until diastolic is BP is down to <100 mmHg
    • Alternative if hydralazine not available: Nifedipine 20-40 mg orally every 12 hours until
      delivery
    • Or Labetalol 20 mg IV over 2 minutes, double the dose every 30 minutes until diastolic is <100
      mmHg (total dose not to exceed 160 mg/hour)
  • Maintenance antihypertensive therapy is necessary after controlling the BP. Maintain
    the patient on Nifedipine 20 mg 12 hourly until delivery
  • Monitor BP every 15 minutes until stable (when systolic BP <160 and Diastolic <100 mmHg

Deliver baby

  • Women with severe pre-eclampsia should be delivered urgently (vaginally or C/S) regardless of
    gestational age in the following situations:

    • Non-reassuring foetal heart
    • Ruptured membranes
    • Uncontrolled BP
    • Oligohydramnious
    • Features of IUGR
    • Oliguria of <500 mL/24 hours
    • Pulmonary Oedema
    • Headache that is persistent and severe

After delivery

  • Monitor BP every 15 minutes for 2 hours
  • Continue to monitor vital signs (BP, urine protein, etc) very carefully for at least 48 hours
  • Continue antihypertensive to mantain diastolic BP less than 90 mmHg
  • Send home when BP is stable and no urine protein
  • Continue antihypertensive according to clinical monitoring
    • Hypertension usually resolves with the birth of the baby but may persist (e.g. in case of
      undiagnosed pre existent hypertension)
Notes
  • Do not use ergot-containing medicines
  • Do not use diuretics or ACE inhibitors