Management

ED Management of Pre-eclampsia:

• Contact obstetrics early
• Severe hypertension in pregnancy SBP 160 or DBP 110 requires urgent antihypertensive therapy in a monitored setting
• BP management:
  • Labetalol first line unless unsuitable or contraindicated³ (e.g. asthma)
  • Nifedipine MR second line
  • Methyldopa third line (not used postpartum due to risk of depression)
• Careful fluid balance monitoring
  • Fluid restriction to reduce the risk of pulmonary oedema
  • Monitor urine output if severe
• Consider IV magnesium sulphate for eclampsia prophylaxis if severe features of pre-eclampsia

Definitive management:

Definitive management of pre-eclampsia is ultimately delivery of the fetus.   Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.

Learning bite 

For management of severe hypertension in pregnancy, follow local guidelines. An oral antihypertensive may be given initially (nifedipine MR 10mg or labetalol 200mg) followed by IV labetalol or IV hydralazine if adequate BP control is not achieved.¹

ED Management of Eclampsia:

• Ask for help early from ITU and obstetric teams
• ABC approach, manage in left lateral position
• Airway and breathing assessment with high flow oxygen
• If inadequate ventilation, consider early intubation (laryngeal oedema in pre-eclampsia and increased risk of aspiration in pregnancy)
• Magnesium sulphate IV is treatment of choice for seizures 4g loading dose over 5-10 mins then 1g/hr infusion for 24 hours
• Further 2g boluses of magnesium sulphate can be given if further seizures occur after initial loading.³
• Patients will need to be managed in HDU/ITU to stabilise blood pressure prior to delivery

Pitfall

If a patient is presumed to have eclampsia but is not responding to repeated boluses of magnesium sulphate, commence an anti-epileptic and consider alternative diagnoses. If not known to have epilepsy and no strong evidence that seizure is eclamptic, will need neuroimaging with CT head and/or MRV to look for other diagnoses including venous sinus thrombosis.

Learning bite 

Eclampsia should be considered in all women presenting with a seizure after 20 weeks gestation or in the postpartum period. Unless a seizure can be clearly attributed to epilepsy, magnesium sulphate should be commenced.