Pre-eclampsia, severe features and eclampsia — Rapid

Synopsis

Identify placental and multisystem disease promptly, distinguish severe hypertension from other severe features, and stabilise eclampsia before coordinating definitive obstetric management.

Pre-eclampsia is new hypertension after 20 weeks with proteinuria, maternal organ dysfunction or uteroplacental dysfunction; proteinuria is not obligatory.
Quantify protein with urine PCR at least 30 mg/mmol or ACR at least 8 mg/mmol, interpreting uncertain results alongside the whole assessment.
Give magnesium sulfate 4 g intravenously over 5–15 minutes, then 1 g/hour for 24 hours; after eclampsia continue for 24 hours after the last fit.
Recurrent eclamptic seizures require an additional 2–4 g intravenous magnesium sulfate over 5–15 minutes and immediate senior reassessment.
Treat severe pressure immediately with labetalol, oral nifedipine or intravenous hydralazine in a monitored maternity setting.
Limit routine maintenance fluid in severe pre-eclampsia to 80 mL/hour unless other losses justify more; account for all drug infusions.
Before 37 weeks balance maternal and fetal indications for birth; from 37 weeks initiate birth within 24–48 hours.
Continue postnatal surveillance because symptoms and laboratory injury may persist or first appear after delivery.

Key red flags

A seizure, reduced consciousness, persistent visual disturbance or severe unremitting headache requires emergency obstetric and anaesthetic assessment.

Systolic pressure of at least 160 or diastolic pressure of at least 110 mmHg demands urgent treatment and close reassessment.

Hypoxia, pulmonary oedema, oliguria, worsening hepatic pain, haemolysis or falling platelets may necessitate critical care and expedited birth.

Investigation priorities

Blood pressure and focused maternal examinationFirst step

Establish severity and detect neurological, respiratory or circulatory compromise.

Management branches

RecognitionEscalate suspected multisystem disease

Hypertension after mid-pregnancy accompanies concerning symptoms, proteinuria or organ abnormalities.

Arrange obstetric assessment, obtain blood and urine investigations and assess fetal wellbeing while identifying severe features.
Admit when maternal or fetal concerns warrant it and agree the required monitoring and critical-care involvement.
Use validated prediction tools or PlGF testing only within their intended populations and as additions to clinical judgement.

Key medicines

Magnesium sulfate for eclampsiaGive 4 g intravenously over 5–15 minutes, followed by 1 g/hour for 24 hours; after an eclamptic seizure maintain infusion for 24 hours after the last fit. For recurrence give another 2–4 g intravenously over 5–15 minutes.Monitor breathing, tendon reflexes and urine output; renal dysfunction increases accumulation. Stop for suspected toxicity, support ventilation and ensure injectable calcium gluconate is immediately available.

Labetalol intravenous infusionA licensed pregnancy infusion regimen begins at 20 mg/hour intravenously and may double every 30 minutes according to response up to 160 mg/hour, with continuous senior-supervised titration and transition to oral treatment once stable.Use an infusion pump and close blood-pressure and pulse monitoring; asthma, bradycardia, heart block and decompensated failure alter the choice.

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