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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