⚠️  Pre-eclampsia and Eclampsia

Course Overview

Pre-eclampsia is a pregnancy-specific multisystem disorder characterized by widespread endothelial dysfunction and vasospasm, typically occurring after 20 weeks of gestation, but it can also present up to 4–6 weeks postpartum.

When seizures develop in this context, it is classified as eclampsia, an obstetric emergency requiring immediate intervention. Early recognition and systematic management are essential to prevent maternal and fetal morbidity and mortality.

Learning Objectives

By the end of this module, learners should be able to:

1. Describe the pathophysiology and types of pre-eclampsia.

2. Recognize risk factors, clinical features, and complications.

3. Perform appropriate investigations for diagnosis and monitoring.

4. Manage hypertension and prevent or treat convulsions.

5. Understand intrapartum and postpartum care in pre-eclamptic/eclamptic patients.

6. Outline neonatal care considerations for infants born to affected mothers.

 Classification

Pre-eclampsia can be classified as:

1. Mild Pre-eclampsia

   • BP ≥140/90 mmHg

   • Proteinuria ≥30 mg/mol or ≥300 mg/24h

   • No severe organ involvement

2. Severe Pre-eclampsia

   • BP ≥160/110 mmHg

   • Proteinuria ≥3+

   • May include neurological symptoms, pulmonary edema, or impaired hepatic/renal function

3. Eclampsia

   • Pre-eclampsia with generalized tonic-clonic seizures

   • Obstetric emergency

 Investigations

Essential investigations for diagnosis and monitoring:

• Blood pressure: systolic and diastolic measurements

• Urinalysis: proteinuria assessment

• Full blood count (FBC): platelet count

• Renal function tests: serum creatinine, electrolytes

• Liver function tests: AST, ALT for hepatic involvement

• Other tests: uric acid, clotting profile if indicated

• Fetal monitoring: ultrasound for growth, amniotic fluid, and Doppler studies

 Clinical Features

Key features include:

• New-onset cerebral or visual disturbances

• Persistent upper quadrant or epigastric pain

• Pulmonary edema in severe cases

• Hyperreflexia and tendon reflex abnormalities

• Convulsions indicate progression to eclampsia

• Signs of end-organ involvement (renal, hepatic, hematologic)

 Management Principles

The four pillars of management are:

1. Prevention and control of convulsions

2. Control of hypertension

3. Maintenance of fluid balance

4. Delivery of the baby at the appropriate time

A. Management of Hypertension

• Hydralazine IV: 5 mg bolus over 15 min; repeat every 20–30 min if DBP >110 mmHg

• Labetalol IV: 20–40 mg every 10–15 min (max 300 mg; avoid in asthma/heart failure)

• Methyldopa or oral labetalol for maintenance

B. Prevention of Convulsions

• Magnesium sulfate (MgSO₄):

  • Loading: 4 g IV over 20 min

  • IM: 5 g in each buttock with 1 mL 2% lignocaine

  • Maintenance: 5 g IM every 4 hours in alternate buttocks until 24 hours post-delivery or last seizure

• Monitor before repeat doses:

  • Respiratory rate ≥16/min

  • Patellar reflexes present

  • Urine output ≥30 mL/hour

• Antidote: Calcium gluconate available in case of magnesium toxicity

C. Management of Convulsions

• Call for help and follow ABC protocol

• Protect patient from injury (left lateral position, padded bed or floor)

• Monitor fluid balance and urine output

• Control hypertension as above

• Administer MgSO₄ as indicated

D. Fluid Management

• Avoid fluid overload; maximum 2.5 L/24 hours

• If urine output <30 mL/hour, give 1 L 0.9% NS over 30 minutes (fluid challenge)

• Monitor response; refer to specialist if oliguria persists

E. Intrapartum Care

• High-risk monitoring: BP every 30 min, fetal heart rate every 15 min or with contractions

• Catheterize patient; monitor fluid input/output

• Provide adequate analgesia

• Shorten second stage of labor: consider assisted vaginal delivery (vacuum or forceps)

• Avoid ergometrine; use oxytocin 10 IU IM at delivery of the anterior shoulder

• Cesarean delivery if fetal distress or obstetric indications

F. Postpartum Care

• Monitor mother for at least 48 hours in high-dependency unit or SOU

• Maintain BP control

• Continue MgSO₄ as indicated

• Monitor for late-onset complications (renal failure, eclampsia)

G. Neonatal Care

• Infants may be compromised; ensure:

  • Thermal protection (keeping warm)

  • Oxygen support or ambu bag resuscitation as needed

  • Suctioning to clear airway

  • Monitoring for hypoglycemia, prematurity, or growth restriction

Key Summary Points

• Pre-eclampsia is endothelial dysfunction in pregnancy, post-20 weeks gestation

• Eclampsia = pre-eclampsia with seizures; obstetric emergency

• Manage hypertension, prevent seizures, ensure fluid balance, and deliver baby appropriately

• MgSO₄ is the drug of choice for seizure prevention and control

• Intrapartum and postpartum monitoring is critical

• Neonates may require immediate resuscitation

Recommended References

• Williams Obstetrics, 27th Edition, Cunningham FG et al.

• WHO Recommendations for the Prevention and Treatment of Pre-eclampsia and Eclampsia, 2022

• American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 222: Hypertension in Pregnancy, 2020

• Ministry of Health Zambia: National Guidelines for Management of Hypertensive Disorders in Pregnancy