Severe Pre-Eclampsia and Imminent Eclampsia

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Introduction

Severe pre-eclampsia/imminent eclampsia is an obstetric emergency and must be treated urgently.

Treatment is the same as that of eclampsia (see below).

These cases are best managed in hospital under the supervision of an obstetrician.

While blood pressure reduction is essential, lowering the blood pressure below 140/90mmHg may cause foetal distress and should be avoided.

Hypertension monitoring must be carried out every 15-30 minutes until the BP is reduced and the patient is stable.

Thereafter monitoring can be done by 2-4 hourly. Daily weighing of the patient is essential.

Symptoms of Severe pre-eclampsia

The following are the symptoms of Severe pre-eclampsia and imminent eclampsia:

  1. Frontal headaches
  2. Vomiting
  3. Visual disturbances such as double vision (diplopia), blurred vision, flashes of light
  4. Epigastric pain
  5. Decrease in urine production (oliguria)

Signs of Severe pre-eclampsia

  1. Elevated blood pressure
  2. Liver tenderness
  3. Urine production of < 30 ml/hour or < 400 ml/24 hours
  4. Increased tendon reflexes Presence of ankle clonus (occasionally)

Investigations

  • FBC
  • Blood clotting profile (bedside clotting time, prothrombin time, INR, APTT)
  • Serum uric acid
  • BUE and Creatinine
  • Urinalysis and culture
  • Liver function tests
  • Random blood glucose
  • Daily assessment of urine proteins
  • Ultrasound scan for close foetal growth monitoring

Treatment for Severe pre-eclampsia and imminent eclampsia

Treatment objectives

The treatment objectives of Severe pre-eclampsia and imminent eclampsia are:

  1. To reduce the blood pressure, but not lower than 140/90 mmHg
  2. To prevent the mother from suffering from complications of the hypertension such as a stroke
  3. To prevent fits/eclampsia
  4. To stabilise the patient and deliver her if eclampsia is imminent

Non pharmacological treatment

  • Early delivery of mother if eclampsia is imminent
  • If the patient is not symptomatic and the pregnancy is less than 34 weeks allow pregnancy to continue if the foetal condition would allow
  • If the pregnancy is 34 weeks or more consider delivery after stabilisation

Pharmacological treatment

A. BP management in severe pre-eclampsia and imminent eclampsia

Evidence Rating: [C]

Hydralazine, IV,

  • 5-10 mg slowly over 20-30 minutes

Or

Nifedipine, sublingual,

  • 10 mg stat.

Or

Labetalol, IV,

  • 20 mg stat. over at least 1 minute
  • Repeat at 10-minute intervals if the BP remains > 160/110 mm Hg as follows:
    • 40 mg; 80 mg; 80 mg boluses to a cumulative dose of 220 mg
  • When the BP < 160/110 mmHg commence an infusion of 40 mg per hour.
  • Double the infusion rate at 30-minute intervals until satisfactory response or a dose of 160 mg per hour is attained.

Then

Nifedipine retard, oral,

  • 20-40 mg daily

Or

Methyldopa, oral,

  • 250-500 mg 8-12 hourly

B. Management or prevention of seizures in severe pre-eclampsia and imminent eclampsia

Magnesium sulphate, IV,

  • 20 ml of the 20% solution (4 g)

And

Magnesium sulphate, IM,

  • 10 ml of the 50% solution, (5 g) into each buttock (total of 10 g)

Referral Criteria

Refer all cases of severe pre-eclampsia and imminent eclampsia promptly to a hospital or obstetrician after initiation of treatment.

When the “obstetrician” considers that the foetus is immature, the patient should be transferred to a hospital capable of looking after the immature baby.

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