Pre-eclampsia & HELLP Syndrome — Advanced Nursing Guide

Diagnostic Criteria

Core Definition

BP ≥140/90 mmHg on two occasions ≥4 hours apart after 20 weeks gestation, PLUS at least one of: proteinuria, or a severe feature in the absence of proteinuria.

Proteinuria Thresholds

Dipstick: ≥2+ (300 mg/L) on two occasions
Spot PCR (protein:creatinine ratio): ≥30 mg/mmol
24-hour urine: ≥300 mg/24h
Automated dipstick: ≥1+ significant if PCR not available

Diagnosis Without Proteinuria (ISSHP 2018)

Thrombocytopaenia: platelets <100 × 10⁹/L
Renal insufficiency: creatinine >90 μmol/L or doubling
Impaired liver function: transaminases ≥2× upper limit
Pulmonary oedema (new onset)
New-onset headache unresponsive to analgesia
Visual disturbances (scotomata, photopsia, blurring)

Severe Features Checklist

Any ONE of the following = severe pre-eclampsia

⚠ BP ≥160/110 mmHg

Persistent severe headache (unresponsive to analgesia)

Visual disturbances — blurring, scotomata, diplopia

Epigastric or RUQ pain (hepatic capsule stretch)

Platelets <100 × 10⁹/L

Creatinine >90 μmol/L (or doubling without renal disease)

Pulmonary oedema (dyspnoea, SpO2 <94%)

AST/ALT ≥2× upper limit of normal

ISSHP 2018 Classification

Category	Definition
Pre-existing (Chronic) HTN	Known BP ≥140/90 before 20 weeks or pre-pregnancy
Gestational HTN	New BP ≥140/90 after 20 weeks, no proteinuria/features
Pre-eclampsia	New BP ≥140/90 + proteinuria or severe feature
Superimposed PET	Chronic HTN + new proteinuria or severe feature after 20 wks
White Coat HTN	Office ≥140/90 but ambulatory <135/85

Early-Onset vs Late-Onset PET

Early-Onset (<34 weeks)

Placental origin (shallow trophoblast invasion)
Abnormal uterine artery Dopplers
Associated with FGR, oligohydramnios
Higher maternal/neonatal morbidity
Often requires preterm delivery
High recurrence risk

Late-Onset (≥34 weeks)

Maternal constitutional factors
Often normal Dopplers
Less severe placental insufficiency
Lower risk of FGR
More amenable to delivery at term
Still risk of severe complications

Superimposed PET: Look for worsening BP, new proteinuria, falling platelets, or rising creatinine in a woman with known chronic hypertension. Carries higher risk than either condition alone.

BP Monitoring Protocol

Standard 4-Hourly Protocol

Minimum 4-hourly if BP <160/110 and stable
Increase to hourly if BP ≥150/100
Continuous monitoring if BP ≥160/110 or deteriorating
Use validated automated device or auscultation
Correct cuff size: use large cuff if arm circumference >33 cm
Patient rested ≥5 minutes, seated or left lateral
Record both arms initially; use higher reading arm

MEOWS Trigger Thresholds (Red Flags)

Systolic ≥160 mmHg ● RED

Diastolic ≥110 mmHg ● RED

Systolic ≥140 / Diastolic ≥90 ● AMBER

HR >120 or <40 bpm ● AMBER

SpO2 <94% ● RED

UO <0.5 mL/kg/hr for >2 hours ● RED

Sudden deterioration consciousness ● RED

Urinary Protein Assessment

Method	Significant	Notes
Dipstick	≥2+	Screening only; false positives common
Spot PCR	≥30 mg/mmol	Preferred rapid test; correlates with 24h
24h urine	≥300 mg/24h	Gold standard; impractical in acute setting

Deep Tendon Reflexes (DTR)

Assess patellar and biceps reflexes each shift
Normal: ++ (brisk but not excessive)
Hyperreflexia: +++ — escalate; consider MgSO4
Clonus: ≥3 beats — urgent; sign of CNS irritability
Absent reflexes on MgSO4 — STOP infusion, check Mg level

Fluid Balance

Strict hourly urine output via IDC
Target UO: ≥0.5 mL/kg/hr (≥30 mL/hr)
Total fluid intake: generally restricted to 80–100 mL/hr IV + oral
Cumulative balance: aim neutral to mildly negative postpartum
Pulmonary oedema risk high — avoid fluid overload
Weigh patient daily if feasible

Fetal Wellbeing Monitoring

CTG (Cardiotocography)

Commence on admission; minimum 20 minutes
Continuous CTG if: oxytocin, severe HTN, signs of abruption
Reassess frequency per clinical condition
Interpret using FIGO/NICE criteria

Doppler Velocimetry

Umbilical artery Doppler: assesses uteroplacental resistance
Absent/reversed end-diastolic flow = severe FGR risk
Middle cerebral artery (MCA) Doppler: fetal anaemia/redistribution
Ductus venosus abnormality: imminent fetal compromise

Biophysical Profile (BPP)

Score 0–10: fetal breathing, movement, tone, AFV, CTG
Score <6/10: consider delivery after steroids if <34 weeks
AFI <5 cm: oligohydramnios — escalate

Signs of Deterioration

Immediate Escalation Triggers

BP ≥160/110 mmHg despite treatment
Sudden severe headache or neck stiffness
Visual loss, diplopia, or flashing lights
New or worsening epigastric/RUQ pain
Tonic-clonic seizure (eclampsia)
Sudden collapse or altered consciousness
Pulmonary oedema: dyspnoea, pink frothy sputum
Oliguria <30 mL/hr for 2 consecutive hours
Sudden fall in platelet count

Haematological / Biochemical Monitoring

FBC, U&E, LFTs, coagulation: baseline then 12–24 hourly (or per condition)
Uric acid: elevated correlates with severity
LDH: elevated in haemolysis (HELLP)
Peripheral blood film if haemolysis suspected
Group & screen + crossmatch if surgical risk

Acute Severe Hypertension Management

Target: Reduce BP to <160/110 mmHg within 30–60 minutes. Do NOT reduce too rapidly — aim 140–150 / 90–100 mmHg. Overshoot risks uteroplacental insufficiency.

IV Labetalol (First-line)

Initial dose: 20 mg IV over 2 minutes
If inadequate response at 10 min: 40 mg IV
Then 80 mg IV every 10 min (max 300 mg total)
Infusion: 1–2 mg/min if boluses inadequate
Avoid in: asthma, bradycardia, heart block, acute heart failure

Oral Nifedipine MR (First-line, if IV not available)

Immediate-release: 10–20 mg oral, repeat at 30 min if needed
Max dose: 30 mg acute; 60 mg/day maintenance
Avoid sublingual (precipitous BP drop)
Caution with MgSO4 — enhanced hypotension risk

IV Hydralazine (Second-line)

5 mg IV bolus over 1–2 minutes
Repeat 5–10 mg every 20 min (max 20 mg total)
Onset 10–20 min; duration 2–4 hours
Side effects: reflex tachycardia, headache, flushing
Pre-load with 500 mL crystalloid to reduce hypotension risk

Magnesium Sulphate (MgSO4)

Indications: Seizure prophylaxis in severe PET; treatment of eclampsia. NOT an antihypertensive.

Loading Dose (Seizure Prophylaxis)

4 g MgSO4 (50% solution) = 8 mL diluted to 100 mL in 0.9% NaCl
Infuse IV over 15–20 minutes
Initiate immediately on diagnosis of severe PET

Maintenance Dose

1 g/hr IV infusion (50% MgSO4 in 0.9% NaCl)
Continue for 24 hours postpartum (or 24h from last seizure)
Adjust if renal impairment (reduce to 0.5 g/hr if UO <25 mL/hr)

Toxicity Monitoring (Every Hour)

Deep tendon reflexes: Loss of DTR occurs at serum Mg 3.5–5 mmol/L
Respiratory rate: Stop if RR <12/min
Urine output: Stop if UO <25 mL/hr
Serum Mg if available: therapeutic 2–3.5 mmol/L; toxic >5 mmol/L
ANTIDOTE: Calcium gluconate 1 g (10 mL of 10%) IV over 10 min

CALL FOR HELP — activate emergency response, obstetric team, anaesthetics
Protect airway — lateral tilt, suction if needed, O2 via face mask 10–15 L/min
Do NOT restrain limbs during seizure; time the fit
Obtain IV access ×2 large bore cannula
MgSO4 4 g IV over 5–10 min (loading dose for eclampsia)
If seizure persists >5 min: second bolus 2 g MgSO4 IV or IV diazepam 10 mg
Commence MgSO4 maintenance 1 g/hr for 24 hours
Treat severe BP: IV labetalol or hydralazine
Urgent FHR assessment; plan expedited delivery
Bloods: FBC, U&E, LFT, clotting, crossmatch
Document seizure duration, time MgSO4 given, fetal response

Antihypertensive Comparison Table

Drug	Route	Dose	Onset	Cautions
Labetalol	IV bolus/infusion	20–80 mg bolus; max 300 mg	5–10 min	Avoid: asthma, bradycardia, heart block
Nifedipine MR	Oral	10–20 mg; max 60 mg/day	15–30 min	Caution with MgSO4; avoid sublingual
Hydralazine	IV bolus	5 mg bolus; max 20 mg	10–20 min	Reflex tachycardia; pre-load with fluids
Methyldopa	Oral	250–500 mg TDS (max 3 g/day)	2–4 hrs	Maintenance only; not acute; sedating
Amlodipine	Oral	5–10 mg once daily	Hours	Postpartum/maintenance; well tolerated

CONTRAINDICATED in pregnancy: ACE inhibitors (captopril, enalapril), ARBs (losartan, valsartan) — teratogenic/fetotoxic. Diuretics generally avoided unless pulmonary oedema.

HELLP Syndrome

Diagnostic Criteria (Sibai Criteria)

H — Haemolysis: Peripheral smear (schistocytes/burr cells), LDH ≥600 U/L, bilirubin ≥20.5 μmol/L

EL — Elevated Liver Enzymes: AST ≥70 U/L, ALT elevated (≥2× ULN)

LP — Low Platelets: <100 × 10⁹/L (Class I: <50; Class II: 50–100; Class III: 100–150)

Mississippi Classification

Class	Platelets	AST/ALT	LDH
Class I (Severe)	<50 × 10⁹/L	≥70 U/L	≥600 U/L
Class II (Moderate)	50–100 × 10⁹/L	≥70 U/L	≥600 U/L
Class III (Mild)	100–150 × 10⁹/L	≥40 U/L	≥600 U/L

Complete HELLP = all three criteria. Partial HELLP = 1–2 criteria only (higher risk of misdiagnosis).

DIC Risk & Transfusion

DIC Warning Signs

Rapid fall in platelet count
Prolonged PT/APTT, low fibrinogen (<2 g/L)
Elevated fibrin degradation products (D-dimer)
Abnormal bleeding from IV sites or gums
Petechiae or ecchymosis

Transfusion Thresholds

Component	Threshold	Target
Platelets (surgical)	<50 × 10⁹/L	≥50
Platelets (regional anaesthesia)	<80 × 10⁹/L	≥80
FFP	PT/APTT >1.5× normal	10–15 mL/kg
Cryoprecipitate	Fibrinogen <1.5 g/L	Fibrinogen >2 g/L

Corticosteroids in HELLP

Dexamethasone 10 mg IV q12h or betamethasone 12 mg IM q24h
Primarily for fetal lung maturity (<34 weeks)
Platelet augmentation effect: transient, 24–48h post-dose
Evidence for improved maternal outcome remains limited

Hepatic Rupture Warning Signs

Life-threatening emergency — rare but fatal

Severe RUQ or epigastric pain radiating to shoulder
Sudden hypotension and tachycardia (haemoperitoneum)
Increasing abdominal girth
Rapidly rising LFTs and falling Hb
Haematoma on USS/CT liver

Immediate actions: Call surgical team; IV access ×2; crossmatch 6 units; avoid abdominal palpation; prepare for emergency laparotomy or angio-embolisation.

Post-partum HELLP

Up to 30% of HELLP cases are diagnosed postpartum (24–48h after delivery). Onset may be sudden with no antenatal history. Always monitor BP and labs for minimum 72 hours postpartum in at-risk women.

Labs typically worsen for 24–48h postpartum before improving
Platelet nadir usually at 24–48 hours postpartum
Resolution expected by 72–96 hours
If not resolving by 96h: consider TTP/HUS differential
Continue MgSO4 for 24h after last seizure or delivery
Strict fluid balance; watch for third-space fluid mobilisation
Brisk diuresis (3–5 L/day) is a good prognostic sign

Timing of Delivery

Gestation	Severity	Recommendation
Any gestation	Eclampsia, severe HELLP, pulmonary oedema, DIC	Expedite delivery
<34 weeks	Severe PET, stable	Steroids + MgSO4 + consider 48h if stable
34–37 weeks	Severe PET	Deliver; weigh risks vs benefits of delay
≥37 weeks	Any PET	Deliver; no benefit to prolonging pregnancy

Anaesthesia Considerations

Regional (spinal/epidural) preferred if platelets ≥80 × 10⁹/L
Epidural preferred in severe PET — allows incremental dosing
General anaesthesia: risk of hypertensive crisis at intubation
If GA: pre-treat with antihypertensive before laryngoscopy
Avoid intubation if airway oedema suspected
RSI with modified-dose thiopentone or propofol + suxamethonium

PPH Risk & Management

Elevated PPH risk in PET/HELLP due to: Thrombocytopenia, coagulopathy (DIC), uterine atony (prolonged labour, MgSO4 use), operative delivery, placental abruption

Pre-delivery Preparation

Group & screen / crossmatch 4 units pRBC
Check coagulation: PT, APTT, fibrinogen
IV access ×2 (at least 16G)
Active management of 3rd stage (oxytocin 10 IU IM or IV infusion)
Avoid ergometrine in hypertensive patients
Carbetocin: alternative if available; lower risk of HTN

If PPH Occurs

Bimanual compression + uterine massage
Oxytocin infusion 40 IU in 500 mL over 4h
Tranexamic acid 1 g IV within 3 hours of birth
Correct coagulopathy concurrently
Escalate: balloons, B-Lynch suture, hysterectomy if uncontrolled

Postpartum BP Monitoring

Key fact: BP can worsen in the first 3–5 days postpartum due to fluid mobilisation from third-space. New-onset PET can occur up to 4–6 weeks postpartum.

4-hourly BP for minimum 72h postpartum
Daily BP monitoring until 2 weeks if hypertension persists
Maintain antihypertensives if BP ≥150/100 postpartum
Target postpartum BP: <140/90 mmHg
NSAIDs: use cautiously — may raise BP; avoid if renal impairment

Breastfeeding-Compatible Antihypertensives

Safe: Labetalol, nifedipine, amlodipine, enalapril (postpartum), captopril (postpartum)

Use with caution: Methyldopa (sedation in infant), atenolol

Avoid: ARBs (losartan) — insufficient safety data in breastfeeding

Postpartum Care

☐ Continue MgSO4 for 24h postpartum (or 24h from last seizure)
☐ 4-hourly BP, HR, SpO2 monitoring minimum 72h
☐ Strict fluid balance — watch for third-space remobilisation
☐ Monitor DTR hourly if on MgSO4
☐ FBC, LFT, U&E 12–24 hourly until trending down
☐ Urine output ≥0.5 mL/kg/hr
☐ Thromboprophylaxis (LMWH when platelets ≥50 ×10⁹/L)
☐ Neonatal review by paediatrician (prematurity, FGR, MgSO4 effects)
☐ Breastfeeding support and safe medication counselling
☐ BP check at 6-week postnatal visit
☐ Counselling on future pregnancy risk and pre-conception care

Future Pregnancy Risk Counselling

Recurrence risk: ~15–20% (early-onset PET: up to 25–35%)
Low-dose aspirin (75–150 mg) from 12 weeks reduces recurrence risk by ~15%
Risk of chronic hypertension, cardiovascular disease, CKD
Encourage weight optimisation, smoking cessation
Screen for underlying thrombophilia, renal disease
Refer to maternal-fetal medicine for pre-pregnancy counselling

GCC-Specific Considerations

Higher Prevalence Factors: Pre-eclampsia incidence is elevated in Gulf populations — Saudi Arabia, UAE, Qatar, Kuwait, Oman, Bahrain — due to a convergence of risk factors.

Key Risk Factor Drivers in the Gulf

Consanguinity: High rates of first-cousin marriage increase genetic susceptibility to hypertensive disorders of pregnancy

Late Booking: Women presenting after 20 weeks miss early screening and intervention; vitamin D deficiency prevalent

Grand Multiparity: Parity ≥5 associated with increased uterovascular disease and PET risk

Antenatal Attendance: Irregular or no antenatal care; cultural barriers; expat population gaps

Obesity & T2DM: Gulf has one of the world's highest rates of obesity and diabetes — both independent PET risk factors

Multiple Pregnancy: Increasing use of ART (IVF) with higher multiple pregnancy rates

GCC Exam High-Yield Points

DHA / DOH / HAAD (UAE)

MgSO4 toxicity antidote: Calcium gluconate 1 g IV (10 mL of 10%) over 10 min
First sign of Mg toxicity: loss of patellar reflexes
Respiratory arrest risk: serum Mg >7.5 mmol/L
Magnesium cardiac arrest: serum Mg >15 mmol/L
Therapeutic range: 2–3.5 mmol/L

SCFHS (Saudi Arabia)

Eclampsia management priority: ABC then MgSO4
Aspirin prophylaxis dose: 75–150 mg/day from 12 weeks
Delivery timing in severe PET ≥37 weeks: expedite delivery
Labetalol contraindication: asthma, heart block
Regional anaesthesia threshold: platelets ≥80 × 10⁹/L

QCHP (Qatar)

Eclampsia: protect airway + MgSO4 4g IV loading then 1g/hr
Recurrent seizure on MgSO4: additional 2g MgSO4 or diazepam
Avoid IV fluids >80–100 mL/hr total to prevent pulmonary oedema
Postpartum BP peaks: days 3–5 after delivery

Exam Practice Questions

Q1. A patient on MgSO4 infusion has absent patellar reflexes, RR 10/min. What is the FIRST action?

Show Answer

STOP the MgSO4 infusion immediately. Then administer calcium gluconate 1 g IV (10 mL of 10% solution) over 10 min. Maintain airway; give O2. Monitor and contact MO/obstetric team.

Q2. A primigravida at 32 weeks presents BP 165/112, headache, epigastric pain, platelets 88 × 10⁹/L. What is the diagnosis?

Show Answer

Severe Pre-eclampsia with features of possible HELLP Class II. Requires immediate: IV antihypertensive, MgSO4 loading, corticosteroids for fetal lung maturity, senior review, delivery planning.

Q3. What is the minimum platelet count for performing spinal anaesthesia safely in a PET patient?

Show Answer

≥80 × 10⁹/L is the accepted threshold for regional anaesthesia (spinal or epidural) in most GCC and international guidelines.

Q4. Which oral antihypertensive is CONTRAINDICATED in pregnancy but can be safely used postpartum (including breastfeeding)?

Show Answer

Enalapril (ACE inhibitor) — contraindicated in pregnancy (fetotoxic) but considered compatible with breastfeeding postpartum. ARBs remain to be avoided throughout breastfeeding.

Severity Assessment Tool

For clinical decision support only — does not replace clinical judgement.

Systolic BP (mmHg)

Diastolic BP (mmHg)

Platelet Count (×10⁹/L)

Creatinine (μmol/L)

Symptoms Present

Severe headache Visual disturbance Epigastric/RUQ pain Facial/pulmonary oedema Seizure occurred