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Pre-eclampsia & Eclampsia

Pre-eclampsia is hypertension (≥140/90) after 20 weeks with proteinuria or end-organ dysfunction. Severe features: BP ≥160/110, headache, visual disturbance, RUQ pain, HELLP. Eclampsia is a convulsive complication. Magnesium sulphate is first-line…

NICE NG133 Hypertension in Pregnancy

The pathway

1 · Confirm diagnosis

BP ≥140/90 on two occasions 4h apart, or ≥160/110 once, after 20 weeks
PLUS proteinuria (PCR >30mg/mmol) or end-organ involvement

2 · Antihypertensive treatment

Severe hypertension (≥160/110): IV labetalol infusion — 200mg in 200ml (1mg/ml), start 20mg/hr = 20ml/hr, double every 30 min to a usual max 160mg/hr. Target <150/100
Oral nifedipine modified-release 10–20mg
Avoid ACEi/ARB — teratogenic

3 · Magnesium sulphate

For eclampsia or severe pre-eclampsia: 4g IV loading dose over 5–15 min, then 1g/hr infusion
Monitor urine output, reflexes and RR — patellar reflexes are lost before toxicity
Antidote: calcium gluconate 10ml of 10% IV

4 · Fluid balance

Restrict IV fluids to 80ml/hr — pulmonary oedema risk
Catheterise, hourly urine output
Target >25ml/hr

5 · Monitor for HELLP

FBC — platelets <100 is severe
LFTs — AST/ALT >2× normal
Haemolysis: bilirubin, blood film
Platelet transfusion if <50 and bleeding

6 · Delivery decision

≥37 weeks: deliver
34–37 weeks: senior decision based on severity
<34 weeks: corticosteroids (betamethasone 12mg IM × 2 doses 24h apart) before delivery if time permits

Drugs

Drug	Dose	Route	Notes
Labetalol	200mg in 200ml (1mg/ml) — start 20mg/hr	IV infusion	20mg/hr is 20ml/hr at this concentration. Double every 30 min if needed — 40, 80, then 160mg/hr usual maximum. Oral labetalol 200mg TDS as maintenance.
Nifedipine MR	10–20mg	PO	Modified-release only. Avoid immediate-release in pregnancy.
Magnesium sulphate	4g loading, 1g/hr	IV	Monitor Mg levels if renal impairment. Antidote: calcium gluconate 10ml 10% IV.
Betamethasone	12mg	IM	Two doses 24h apart if <36 weeks and delivery imminent. Fetal lung maturation.

When to escalate

Eclamptic seizure — IV MgSO4 4g bolus immediately, left lateral position, O2, call obstetrics,Uncontrolled BP ≥160/110 despite treatment — IV labetalol, consider hydralazine, obstetrics,HELLP syndrome — HDU, haematology, consider early delivery,Pulmonary oedema — ITU, strict fluid restriction, CPAP

Reference: NICE NG133 Hypertension in Pregnancy 2019 / RCOG Green-top 10A & 10B

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