Pre-eclampsia, Gestational Hypertension

🚨 Eclampsia – Emergency Priorities

🫁 ABC → oxygen, IV access, monitor vitals

💉 Magnesium Sulfate → 4–6 g IV loading (20 min), then 1–2 g/h for 24–48 h

💊 Control BP → IV labetalol or hydralazine (target 140–150 / 90–100 mmHg)

👶 Prepare for delivery → definitive cure; give corticosteroids if 24–34 weeks and time allows

📞 Call senior obstetric, anaesthetic & neonatal team → manage in HDU/ICU setting

Hypertensive disorders complicate 7–10% of pregnancies and remain a leading cause of maternal and perinatal morbidity and mortality worldwide. Pre-eclampsia is defined as new-onset hypertension with proteinuria (or maternal organ dysfunction) after 20 weeks gestation. It arises from abnormal placentation and endothelial dysfunction, leading to systemic vasoconstriction, increased vascular permeability, and end-organ hypoperfusion. Eclampsia represents the most severe end of the spectrum, with seizures complicating pre-eclampsia.

🧬 Pathophysiology

• Abnormal trophoblast invasion → impaired spiral artery remodelling → high-resistance uteroplacental circulation.
• Placental ischaemia triggers maternal endothelial dysfunction → vasospasm, hypertension, and capillary leak.
• ↑ Anti-angiogenic factors (sFlt-1) and ↓ pro-angiogenic (VEGF, PlGF) worsen endothelial injury.
• Results in maternal HTN, proteinuria, and end-organ damage (renal, hepatic, neurological, haematological).
• Fetal consequences: growth restriction, hypoxia, oligohydramnios, stillbirth.

⚠️ Immediate delivery is required in resistant severe hypertension or persistent cerebral symptoms despite magnesium sulfate - irrespective of gestational age. 🍼 ~5% of preeclampsia cases present postpartum.

⚠️ Risk Factors

• First pregnancy, age <20 or >40
• Multiple pregnancy
• Pre-existing HTN, renal disease, diabetes, autoimmune disease (SLE, APS)
• Family history or previous pre-eclampsia
• Obesity, thrombophilia

🤰 Preeclampsia

• Onset after 20 weeks → resolves ≤12 weeks postpartum.
• Diagnostic criteria: BP ≥140/90 + proteinuria ≥300 mg/24h OR evidence of maternal organ dysfunction.
• Severe features: SBP ≥160 or DBP ≥110, significant proteinuria, neurological/visual disturbance, hepatic/renal dysfunction, thrombocytopenia, fetal compromise.

⚡ Eclampsia

• Generalised seizures in association with pre-eclampsia, unexplained by other causes.
• Most cases occur after 28 weeks, but can also occur postpartum.

🩸 HELLP Syndrome

• Haemolysis, Elevated LFTs, Low Platelets.
• Represents a severe variant of pre-eclampsia; high risk of DIC, hepatic rupture, and maternal death.

🩺 Clinical Features

• Severe headache, sudden oedema (face/hands/feet)
• Visual disturbance, epigastric/RUQ pain, vomiting
• Neurological: hyperreflexia, clonus, papilloedema, seizures
• Signs of end-organ damage: oliguria, thrombocytopenia (<100), ↑ LFTs (>70 IU/L)

⚠️ Complications

• Eclamptic seizures, intracranial haemorrhage, stroke
• Renal failure, hepatic rupture, placental abruption
• Preterm birth, IUGR, maternal or fetal death

🧪 Investigations

• Bloods: FBC, U&E, LFTs, urate, creatinine, coagulation if platelets <100
• Urine: dipstick ± 24h collection, spot protein:creatinine ratio
• Imaging: CT head (if focal neuro features, exclude bleed/stroke)
• Maternal monitoring: strict fluid balance, MEOWS chart
• Fetal assessment: CTG, growth scans, AFI, umbilical/MCA Dopplers

💊 Management of Hypertension

• Labetalol: IV 20–40 mg, repeat q15 min (max 220 mg)
• Hydralazine: IV 5–10 mg slow bolus
• Nifedipine: Oral 10 mg (if IV access delayed)
• Target BP: 140–150 / 90–100 mmHg

💉 Seizure Prophylaxis/Treatment

• Magnesium sulfate: 4–6 g IV over 20 min, then 1–2 g/h for 24–48 h
• Monitor reflexes, respiration, and urine output
• Calcium gluconate is the antidote for magnesium toxicity

👩‍👦 Maternal & Fetal Care

• Delivery is the definitive cure
• Corticosteroids for fetal lung maturity if 24–34 weeks and time allows
• Monitor closely postpartum - pre-eclampsia may worsen after birth
• High-dependency/ICU management if severe disease

📊 Summary Table

📚 References

• Eclampsia: Overview
• RQIA – Severe Pre-eclampsia & Eclampsia
• NICE NG133: Hypertension in Pregnancy