A primigravida at 35 weeks of pregnancy is admitted with a BP of 180/110 mm Hg and diplopia. What is the name of this condition? How will you stabilize her? What may be the complications of such a case? How can you predict this disease? (1+5+4+5=15)
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I now have comprehensive information from authoritative obstetric and nephrology textbooks to answer all four parts. Let me compile the complete answer.
Severe Pre-eclampsia with Impending Eclampsia
1. Name of the Condition (1 mark)
This is Severe Pre-eclampsia with Features of Impending Eclampsia.
- Severe pre-eclampsia is defined by BP ≥ 160/110 mm Hg after 20 weeks of gestation
- Diplopia (double vision) is a prodromal neurological symptom indicating impending eclampsia — it signals hypertensive encephalopathy and cortical visual disturbance
- The classical triad of impending eclampsia includes: severe headache, visual disturbances (blurring/diplopia/amaurosis), and epigastric pain
2. Stabilization (5 marks)
Management follows the Parkland Protocol for severe pre-eclampsia/eclampsia. The four pillars are:
A. Seizure Prophylaxis / Control — Magnesium Sulfate (MgSO₄)
| Step | Dose |
|---|---|
| Loading dose | 4–6 g IV over 15–20 minutes |
| Maintenance | 2 g/hour IV infusion |
- MgSO₄ is the drug of choice — it is the most effective anticonvulsant, maintains uterine and fetal blood flow, and has a wide safety margin
- Monitor continuously for signs of hypermagnesaemia: loss of deep tendon reflexes (at ~10 mg/dL), respiratory depression (at ~12 mg/dL)
- Antidote: 1 g IV calcium gluconate (given slowly) reverses toxicity immediately
- If seizures persist despite therapeutic MgSO₄: add diazepam or phenytoin as second-line
B. Antihypertensive Therapy (once seizure control is established)
Target: Bring diastolic BP to 90–105 mm Hg (avoid sharp drops → uteroplacental insufficiency)
| Drug | Dose |
|---|---|
| Labetalol | 20 mg IV bolus, repeat q10 min PRN up to 300 mg total |
| Hydralazine | 5–10 mg IV push, repeat every 2–4 hours |
| Nifedipine (oral) | 10–20 mg orally, can be used if IV access not immediately available |
ACE inhibitors and ARBs are absolutely contraindicated in pregnancy (fetal renal dysplasia, oligohydramnios).
C. Monitoring — Assess End-Organ Involvement
Baseline investigations mandatory:
- CBC + platelets (thrombocytopenia → HELLP)
- LFTs (hepatitis, hepatic rupture risk)
- Serum creatinine, BUN (renal involvement)
- Urine output — maintain ≥ 25 mL/hour
- LDH + peripheral smear (haemolysis in HELLP)
- Fetal heart rate monitoring + biophysical profile
D. Fluid Management
- Restrict IV fluids — pre-eclampsia patients are at high risk for pulmonary oedema due to low oncotic pressure and capillary leak
- Avoid diuretics and hyperosmotic agents
- CT head if: reduced consciousness, persistent seizures, or lateralising neurological signs
E. Delivery
- Definitive treatment is delivery of the placenta; plan timing based on gestational age, fetal maturity (35 weeks here = consider delivery after stabilisation)
- At 35 weeks, risk of prematurity is low — proceed to delivery after maternal stabilisation
3. Complications (4 marks)
Maternal Complications
| System | Complication |
|---|---|
| Neurological | Eclamptic seizures, hypertensive encephalopathy, intracerebral oedema/haemorrhage, cortical blindness |
| Haematological | HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets), DIC |
| Hepatic | Hepatitis, periportal necrosis, subcapsular haematoma, hepatic rupture (life-threatening) |
| Renal | Acute kidney injury, acute tubular necrosis (can cause oliguria/anuria) |
| Pulmonary | Pulmonary oedema (from capillary leak + low oncotic pressure) |
| Cardiovascular | Hypertensive crisis, future risk of chronic hypertension, ischaemic heart disease |
| Death | Maternal mortality historically 5–10%; caused mainly by eclampsia, hepatic rupture, abruption |
HELLP syndrome is a particularly severe variant:
- Microangiopathic haemolytic anaemia (schistocytes, ↑LDH, ↑bilirubin, ↓haptoglobin)
- AST > 70 U/L
- Platelets < 100 × 10⁹/L
- Perinatal mortality: 7–34%
Fetal/Neonatal Complications
| Complication | Details |
|---|---|
| IUGR (Intrauterine Growth Restriction) | Placental insufficiency, most common with severe/early-onset disease |
| Placental abruption | 1–4% incidence; can cause sudden fetal demise |
| Preterm birth | Iatrogenic (indicated delivery) or spontaneous |
| Neonatal death | Twofold increased risk |
| Stillbirth | Relative risk 2.7× compared to normotensive controls |
4. Prediction of Pre-eclampsia (5 marks)
Prediction uses a combined first-trimester screening approach (around 11–13+6 weeks):
A. Maternal Risk Factors
- Nulliparity (primigravida — as in this case)
- Age < 20 or > 40 years
- BMI > 35 kg/m²
- Personal/family history of pre-eclampsia
- Multiple gestation
- Chronic hypertension, diabetes, CKD, antiphospholipid antibody syndrome
- New paternity (immunological factor)
B. Biophysical Markers
- Uterine artery Doppler (uterine artery pulsatility index, UtA-PI): Elevated PI indicates impaired trophoblastic invasion of spiral arteries; predicts early-onset pre-eclampsia
- Mean arterial pressure (MAP): Elevated MAP in first trimester is predictive
C. Biochemical Biomarkers
| Marker | Finding in Pre-eclampsia |
|---|---|
| PAPP-A (Pregnancy-Associated Plasma Protein-A) | ↓ Low levels |
| PlGF (Placental Growth Factor) | ↓ Markedly reduced (< 100 pg/mL before 35 weeks has 98% NPV for ruling out delivery due to PE within 2 weeks) |
| sFlt-1 (Soluble fms-like tyrosine kinase-1) | ↑ Elevated — anti-angiogenic factor |
| sFlt-1:PlGF ratio | Ratio < 38 has 99% NPV for ruling out PE within 1 week and 95% NPV for next 4 weeks |
| sEng (Soluble endoglin) | ↑ Elevated; augments sFlt-1 effects |
D. Combined Screening Performance
Using all modalities together — maternal characteristics + PAPP-A/PlGF + UtA-PI + MAP — the detection rate for early-onset pre-eclampsia (delivery < 34 weeks) reaches:
- Maternal characteristics alone: 50%
-
- Biochemical markers: 75%
-
- Biophysical markers: 90%
-
- Both biochemical & biophysical: 95%
E. Prevention in High-Risk Women
- Low-dose aspirin (75–150 mg/day), started between 12–16 weeks and continued until delivery, reduces the risk of pre-eclampsia in high-risk women by ~50% for early-onset disease (ASPRE trial)
- The sFlt-1 screening strategy was used to identify high-risk women in the ASPRE RCT with a 77% detection rate
Sources: Rosen's Emergency Medicine, 9th ed. • Comprehensive Clinical Nephrology, 7th ed. • Creasy & Resnik's Maternal-Fetal Medicine • National Kidney Foundation Primer on Kidney Diseases, 8th ed.
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