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Obstetrics

Pre-eclampsia

A multi-system disorder specific to pregnancy, diagnosed after 20 weeks gestation, characterized by new-onset hypertension AND proteinuria OR hypertension AND evidence of end-organ dysfunction. Classified as mild-moderate or severe.

Also known as: PET, Toxaemia (outdated)

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Referral and warning signs

When to refer

Refer ALL suspected Pre-eclampsia to hospital (HC4/H/RR). Urgent referral for severe features or BP >=160/110.

Red flags

  • BP >= 160/110 mmHg
  • Severe headache
  • Visual disturbances
  • Epigastric/RUQ pain
  • Oliguria
  • Pulmonary oedema / Dyspnoea
  • Seizures (Eclampsia)
  • Signs of HELLP

Signs and symptoms

  • Key Diagnostic Signs: Hypertension (BP >=140/90 after 20wks), Proteinuria (>=1+ dipstick).
  • Signs/Symptoms of Severe PE / End-Organ Dysfunction: Severe Hypertension (BP >=160/110), Headache (severe, persistent), Visual disturbances, Epigastric/RUQ pain, Nausea/Vomiting, Oliguria, Pulmonary oedema (dyspnoea), HELLP signs (jaundice, bruising), IUGR, Hyperreflexia/Clonus.
  • Oedema (less specific).

Risk factors

  • Previous pre-eclampsia.
  • Chronic hypertension.
  • Pre-existing diabetes.
  • CKD.
  • Autoimmune diseases (SLE, APS).
  • Nulliparity.
  • Age >40.
  • Obesity.
  • Multiple gestation.
  • Family history.
  • Molar pregnancy.

Diagnosis

Clinical assessment

Diagnosis based on BP + Proteinuria after 20 weeks OR BP + End-organ dysfunction signs. Assess severity.

Investigations

  • Accurate BP measurement.
  • Urine dipstick for protein (+/- quantification).
  • Blood tests (Severe PE/Suspected end-organ damage): FBC (platelets, haemolysis), LFTs, RFTs, Uric acid.
  • Ultrasound (fetal growth/fluid).

Diagnostic criteria

New onset HTN (>=140/90 after 20wks) PLUS Proteinuria (>=1+) OR HTN PLUS End-organ dysfunction.

Management

Non-pharmacological management

  • Close monitoring (maternal/fetal).
  • Hospital admission (esp. severe PE).
  • Bed rest (limited evidence).
  • Fluid management (careful balance).

Pharmacological treatment

  • Delivery is definitive cure. Timing depends on severity/gestation.
  • Mild-Moderate PE (BP 140-159/90-109, Prot >=1+, No severe features): Monitor closely (outpatient/inpatient). Antihypertensives if BP persistently >=150/100 (Methyldopa or Nifedipine SR). Aim delivery ~37 weeks.
  • Severe PE (BP >=160/110 OR PE with severe features): HOSPITALIZE. Prevent Eclampsia (Magnesium Sulphate - IV loading + IV/IM maintenance, monitor toxicity). Control Severe HTN (Target <160/110; IV Labetalol/Hydralazine or Oral Nifedipine). Plan for Delivery (stabilize first, then deliver regardless of gestation).
  • Postpartum: Continue BP monitoring. Continue MgSO4 for 24h.

Monitoring

Frequent BP. Urine output. Reflexes/RR (MgSO4). Symptoms. FHR/CTG. Labs (Severe PE).

Complications

  • Eclampsia.
  • HELLP Syndrome.
  • Placental abruption.
  • AKI.
  • Pulmonary oedema.
  • Stroke.
  • DIC.
  • Maternal death.
  • IUGR.
  • Preterm birth.
  • Stillbirth/Neonatal death.

Prevention

  • Low-dose Aspirin from 12 weeks for high-risk.
  • Calcium supplementation if low intake.
  • Early identification/management.

Patient education

  • Explanation of condition.
  • Monitoring importance.
  • Warning symptoms.
  • Medications (antihypertensives, MgSO4).
  • Need for delivery.
  • Postpartum monitoring.
  • Future pregnancy risk.

Uganda-specific notes

Major cause of maternal mortality. Early detection vital. MgSO4 essential drug. Lab monitoring access may be limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.3.7

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