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Preeclampsia and eclampsia have long been documented in history, previously referred to as toxemia of pregnancy. Unfortunately, these conditions continue to be not well understood.  Early-onset and late- onset are both known to be caused by a placental disorder; however, a maternal genetic predisposition to metabolic and cardiovascular disease has been noted in late-onset. The International Society for the Study of Hypertension in Pregnancy (ISHHP) considers hypertension in pregnancy to consist of a systolic blood pressure greater than 140 mmHg and a diastolic blood pressure greater than 90 mmHg. Additionally, the ISHHP recognizes late-onset as occurring at 34 weeks gestation or later. Other clinical manifestations can range in severity. Left untreated these disorders can result in maternal death and/or fetal demise (3). 

This course will discuss the signs and symptoms of preeclampsia and eclampsia, as well as their diagnoses, and treatments. Upon competition of this course, the nurse should feel knowledgeable and comfortable providing patient education regarding the “red flags,” current treatments, when to notify a provider, and when to seek emergent care. 

Overview 

Many people have never heard the term “pre-eclampsia” until either they or a loved one became pregnant. Unfortunately, this pregnancy complication affects mothers and babies around the world and can even be fatal if not treated adequately or promptly.  

Pre-eclampsia and eclampsia hypertension disorders affect 4-8% of all pregnancies and are responsible for approximately 6% of maternal deaths in the United States (9,10, 11). To be categorized as pre-eclampsia, hypertension must be present after the 20th week of gestation, on two separate occasions at least four hours apart in a previously normotensive mother (9). This hypertension is either accompanied by proteinuria and edema, or target organ damage will be observed in the absence of proteinuria. To be categorized as eclampsia, new-onset tonic-clonic seizures must also be present (9).  

HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a life-threatening complication of these disorders. Other maternal complications can include cerebral hemorrhage, disseminated intravascular coagulation (DIC), hepatic failure, and acute kidney injury (AKI) (9, 10). For the fetus, complications may include abruptio placentae (placental abruption), intrauterine growth restriction (IGR), premature delivery, and intrauterine death (9, 10). Although treatments are available, the only cure for pre-eclampsia and eclampsia is the delivery of both the fetus and the placenta (9,10).  

Nurses must be able to recognize the signs and symptoms of pre-eclampsia and eclampsia and educate patients regarding what to look for and when to seek emergent care. This course aims to inform nurses about the signs and symptoms of pre-eclampsia and eclampsia, as well as diagnoses and treatments, further enabling them to provide appropriate education to patients and community members.  

Introduction  

Pre-eclampsia and eclampsia have long been documented throughout human history, previously referred to as toxemia of pregnancy. Unfortunately, these conditions continue to be not well understood.  

Pre-eclampsia is now understood to be an endothelial dysfunction in pregnant women, which causes an increased risk of future cardiovascular disease, venous thromboembolism, and stroke (9).  

Early-onset and late-onset pre-eclampsia are both known to be caused by a placental disorder; however, a maternal genetic predisposition to metabolic and cardiovascular disease has been noted in late-onset (12).  

The American College of Obstetricians and Gynecologists considers hypertension in pregnancy to consist of a systolic blood pressure greater than 140 mmHg or a diastolic blood pressure greater than 90 mmHg, and higher in cases of pre-eclampsia with severe features (9). Other clinical manifestations can range in severity. When other features are present, the diagnosis changes from gestational hypertension to pre-eclampsia (3,6, 9). Left untreated, these disorders can result in maternal death and fetal demise (3). This course will discuss the signs and symptoms, diagnosis, and treatment of pre-eclampsia and eclampsia. 

Upon completing this course, the nurse should feel knowledgeable and comfortable providing patient education regarding the “red flags” and current treatment of eclampsia and pre-eclampsia, as well as when to notify the provider and seek emergent care.  

Epidemiology  

As discussed above, pre-eclampsia is a prevalent pregnancy complication, occurring in 5-14% of worldwide pregnancies each year (9). In developing countries, this disease affects up to 18% of pregnancies, with hypertensive disorders being the second cause of both stillbirths and neonatal fatalities in these nations (9). In the United States, about 2-6% of otherwise healthy, nulliparous women experience pre-eclampsia; of these, only 10% of pregnancies occur at less than 34 weeks’ gestation (9).  

Generally, pre-eclampsia only advances to eclampsia in about 1 in every 200 cases (0.5%) when a magnesium sulfate prophylaxis is not given (9).  

Etiology and Pathogenesis 

Pre-eclampsia is a placental disease that is still actively studied today. Major risk factors that have been identified include a history of pre-eclampsia, chronic hypertension, gestational diabetes, antiphospholipid antibody syndrome (APS), and obesity. 

Other risk factors of pre-eclampsia in women include (9): 

• Dyslipidemia 

• Endothelial dysfunction 

• Hyperglycemia and insulin resistance 

• Metabolic syndrome 

 Other identified risk factors include advanced maternal age (AMA), nulliparity, chronic kidney disease (CKD), systemic lupus erythematosus (lupus), multifetal gestations, obstructive sleep apnea, low serum calcium levels, and more (9)Genetic research is ongoing to identify maternal predispositions (6).  

The clinical definition of pre-eclampsia includes having two elevated blood pressure (BP) readings in a previously normotensive mother and proteinuria, or severe features, listed below (8).  

Diagnostic Criteria for Pre-eclampsia:  

• Hypertension: Systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, on two occasions, 4 hours apart in the previously normotensive patient. Proteinuria: Serum protein levels ≥300mg/24-hour urine collection or protein/creatinine ratio  ≥0.3 or urine dipstick (point-of-care) reading =1+  

• The above criteria are needed to diagnose pre-eclampsia; however, other components can be associated, putting the mother’s and baby’s lives at greater risk: Pre-eclampsia with Severe Features (9): Systolic blood pressure ≥160 mm Hg or diastolic BP ≥110 mm Hg, on two occasions, 4 hours apart, on bed rest. 

• Thrombocytopenia: Platelet count < 100,000/ μL 

• Elevated serum creatinine: 1.1 mg/dL or doubling of creatinine in the absence of other renal disease 

• Pulmonary edema New-onset cerebral or visual symptoms

Patient Teaching – “Red Flags”  

Pre-eclampsia can be tricky for patients to recognize, as it can develop without any symptoms, or symptoms can be mistaken as common pregnancy problems. Patients need to know how to monitor their blood pressure at home. Teach patients to watch for the following signs and symptoms of pre-eclampsia and when to seek immediate care (9): 

• Severe headaches  

• Vision changes, including blindness or blurred vision 

• Altered mental status 

• Right-sided abdominal or epigastric pain refractory to other treatments 

• Nausea or vomiting  

• Decreased urine output 

• Shortness of breath  

• Sudden swelling of the face, hands, or feet 

• Severe weakness or malaise (may be a sign of hemolytic anemia) 

• Clonus (may indicate increased risk of convulsions) 

 Patients should notify their provider if they experience these “red flag” symptoms. Patients should visit the emergency department with any severe headaches, vision changes, severe abdominal pain, or shortness of breath. 

Complications  

Complications of pre-eclampsia and eclampsia can be severe or even fatal for both the mother and baby. Early recognition and treatment are imperative for the best outcomes. Possible maternal complications include (8,9): 

• Eclamptic (tonic-clonic) seizures 

• Stroke  

• Cortical blindness or retinal detachment 

• Liver dysfunction or rupture  

• Acute renal insufficiency  

• Myocardial infarction (MI) 

• Pulmonary edema 

•  Disseminated intravascular coagulation (DIC)  

•  Placental abruption, Hemolysis, elevated liver enzymes, low platelet count  (HELLP) syndrome  

Possible fetal complications include: 

•  Growth restriction 
•  Stillbirth  ​
• Complications related to premature delivery

Treatment  

Treatment goals for pre-eclampsia and eclampsia are to control blood pressure, prevent seizures, and deliver promptly. Starting a daily aspirin close to the end of the first trimester is recommended for patients with a history of pre-eclampsia with severe features (8,9). Labetalol, nifedipine, and hydralazine are anti-hypertensives commonly used to control blood pressure (9). If these first-line therapies are ineffective, a continuous infusion of either nicardipine or esmolol is recommended (9). Magnesium sulfate has proven to be the most efficacious treatment for eclampsia and recurrent eclamptic seizure prevention and requires close monitoring for toxicity (2,9). Additionally, the mother must continue to be closely monitored during the postpartum period, as eclamptic seizures can occur up to six weeks after delivery (7). 

Signs & Symptoms of Magnesium Sulfate Toxicity

Nurses should be aware that although magnesium sulfate is the preferred first-line treatment for controlling the progression from pre-eclampsia to eclampsia, there are still some risks with this course of action (2,9). Thus, the nurse should know how to identify potential magnesium sulfate toxicity in the patient quickly.

Signs & Symptoms of Magnesium Sulfate Toxicity (2)

Early signs: 

• Nausea/vomiting/diarrhea 

• Muscle weakness 

• Hypotension  

• ECG changes (prolonged PR intervals, widened QRS complex) 

• Late signs: 

• Progressive, worsening muscle weakness  

• Loss of deep tendon reflexes (DTRs) 

• Signs of abnormal cardiac conductivity (SA/AV node block) 

• Respiratory paralysis 

• Cardiac arrest and respiratory arrest 

Clinicians must recognize signs and symptoms of magnesium sulfate toxicity as soon as possible since the conduction can turn fatal reasonably quickly. Modern management and treatment of any patient receiving a magnesium infusion include (2,9): 

• Constantly assessing the ABCs: airway, breathing, and circulation, as well as mental status 

• Constantly assessing patellar reflexes 

• Discontinuing the injection as soon as signs are recognized 

• Reducing the magnesium levels in the body:  

• With IV diuretics for patients with normal kidney function 

• With dialysis for patients with impaired kidney function  

Delivery Recommendations

Since the only true cure for pre-eclampsia is delivering the baby, the following are timing recommendations for delivery (1,9): 

• 37 weeks gestation if no severe features present  

• As early as 34 weeks gestation with severe features 

• Immediately, if blood pressure remains uncontrolled with treatment, laboratory values continue to worsen, or there is fetal compromise.   

Other delivery criteria during pre-eclampsia include but are not limited to, ruptured membranes, uncontrolled blood pressure, RUQ tenderness, development of HELLP syndrome, placental abruption, unexplained coagulopathy, oliguria (<500mL/24 hours), oligohydramnios (with amniotic fluid index of <5 cm), pulmonary edema, persistent and severe headache, and more (9). 

Ongoing Research Studies 

here is a plethora of ongoing research related to pre-eclampsia. Some topics currently being investigated include identifying genetic predispositions for pre-eclampsia, the future risk for the maternal development of heart disease, and the effects of COVID-19 (5). The Pre-eclampsia Registry is a valuable source for researchers that includes IRB-approved clinical studies with data related to the following (5):  

• Self-reported medical, pregnancy, and family history  

• Abstracted medical records 

• Long-term follow-up data for both the participant and her children 

• DNA samples  

• Genetic variants and whole exome sequencing data  

Conclusion

Pre-eclampsia is a potentially devastating but treatable condition that affects many mothers and their babies worldwide. It is a leading cause of both maternal and fetal mortality, and the symptoms can persist for weeks after birth. The causes of pre-eclampsia and eclampsia are still studied today, and there is much ongoing research available. As healthcare providers and educators, nurses must recognize the signs and symptoms of pre-eclampsia and eclampsia, know how to diagnose and treat them and determine when emergent care is warranted quickly. 

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