• New onset hypertension after 20 weeks of gestation (systolic blood pressure > 140 and/or diastolic blood pressure > 90)

And either

• Proteinuria (urine protein:creatinine ratio ≥30mg/mmol)

Or

• Other features of pre-eclampsia¹:
  • AKI (creatinine ≥ 90)
  • Liver dysfunction (ALT>40)/epigastric/RUQ pain
  • New severe persistent headache without an alternative diagnosis
  • Persistent visual disturbance
  • Haematological complications (platelets <150/DIC/haemolysis)
  • Neurological complications (clonus/stroke/seizures(eclampsia))
  • Pulmonary oedema
  • Uteroplacental dysfunction (fetal growth restriction/placental abruption/intrauterine death)

Onset is usually after 20 weeks of gestation, but it can also occur up to a few weeks postpartum.

Eclampsia- This is pre-eclampsia that has progressed to seizures

Risk Factors:

Clinical features of pre-eclampsia:

• Asymptomatic hypertension (picked up on screening or incidentally when presenting with another issue)
• Headache (usually frontal)
• RUQ or epigastric pain (also a symptom of HELLP syndrome)
• Nausea and vomiting
• Oedema (common but not specific). Especially if rapidly increasing and involving face and hands.
• Visual disturbance (flashing lights in the visual fields or scotomata)
• Shortness of breath (uncommon but can occur due to pulmonary oedema)
• Hyper-reflexia and/or clonus

HELLP syndrome is a variant of severe pre-eclampsia characterised by haemolysis, elevated liver enzymes and low platelets.⁴

Symptoms and signs are similar to those of pre-eclampsia but also include jaundice and bleeding.

Management of Pre-eclampsia:

• Contact obstetrics early
• Manage the patient in an area with close monitoring if pre-eclampsia with severe features
• BP management:
  • Labetalol first line unless unsuitable or contraindicated³ (e.g. asthma)
  • Nifedipine MR second line
  • Methyldopa third line (not used postpartum due to risk of depression)
• Careful fluid balance monitoring
  • Fluid restriction to reduce the risk of pulmonary oedema
  • Monitor urine output if severe
• Consider IV magnesium sulphate for eclampsia prophylaxis if severe features of pre-eclampsia

Definitive management:

Definitive management of pre-eclampsia is ultimately delivery of the fetus.   Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.

ED Management of Eclampsia:

• Ask for help early from ITU and obstetric teams
• ABC approach, manage in left lateral position
• Airway and breathing assessment with high flow oxygen
• If inadequate ventilation, consider early intubation (laryngeal oedema in pre-eclampsia and increased risk of aspiration in pregnancy)
• Magnesium sulphate IV is treatment of choice for seizures – 4g loading dose over 5-10 mins then 1g/hr infusion for 24 hours
• Further 2g boluses of magnesium sulphate can be given if further seizures occur after initial loading.³
• Patients will need to be managed in HDU/ITU to stabilise blood pressure prior to delivery

Full NICE guidance is available here