What are the management steps for a suspected patient with pre-eclampsia in United Kingdom (UK) primary care?

From the Guidelines

In primary care in the UK, a patient with suspected pre-eclampsia requires urgent referral to secondary care for specialist assessment, as recommended by the most recent guidelines 1. If you suspect pre-eclampsia (based on hypertension ≥140/90 mmHg plus proteinuria and/or symptoms like headache, visual disturbances, epigastric pain), check blood pressure, test urine for protein, and arrange immediate same-day assessment at the maternity unit. While awaiting transfer, monitor vital signs and fetal wellbeing if equipment is available. Do not initiate antihypertensive treatment in primary care unless blood pressure exceeds 160/110 mmHg, in which case oral labetalol (200-400mg) or nifedipine (10mg) may be given as a temporizing measure, as suggested by the ISSHP classification, diagnosis, and management recommendations for international practice 1. Do not give diuretics or ACE inhibitors. Ensure the patient is positioned on her left side during transfer to improve uteroplacental perfusion. Pre-eclampsia can rapidly progress to eclampsia (seizures) or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), so prompt specialist care is essential. The definitive treatment is delivery of the baby and placenta, which only specialists can arrange with appropriate maternal and neonatal support.

Some key points to consider in the management of pre-eclampsia include:

• Automated blood pressure measurement with devices validated for pregnancy and pre-eclampsia 1
• Use of dipstick proteinuria testing for screening followed by quantitative testing by urinary protein-to-creatinine ratio or 24-hour urine collection 1
• Treatment of severe hypertension with intravenous labetalol, oral nifedipine, or intravenous hydralazine 1
• Magnesium sulfate for eclampsia treatment and prevention among women with severe pre-eclampsia 1
• Delivery at term for pre-eclampsia, with consideration of earlier delivery in cases of severe disease or fetal growth restriction 1

It is essential to prioritize the patient's safety and well-being, and to seek specialist advice and guidance in the management of pre-eclampsia, as the condition can be unpredictable and potentially life-threatening.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Suspected Patient with Pre-Eclampsia in UK Primary Care

• The primary objective of managing pre-eclampsia is the safety of the mother 2.
• Women with mild disease developing at 37 weeks' gestation or longer have a pregnancy outcome similar to that found in normotensive pregnancy, and should undergo induction of labor for delivery 2.
• Induction of labor and/or delivery is also recommended for those at or beyond 34 weeks' gestation in the presence of severe preeclampsia, labor or rupture of membranes, or non-reassuring tests of fetal well-being 2.

Management of Pre-Eclampsia

• The American College of Obstetricians and Gynecologists recommends magnesium sulfate as the gold standard for the management of pre-eclampsia, but it has a short action time that does not provide stable maintenance of blood pressure 3.
• Labetalol is currently recommended as first-line treatment by the national UK guidance 3.
• A study comparing outcomes following intravenous magnesium, intravenous labetalol, and oral nifedipine in pregnant women with pre-eclampsia found that labetalol provides proper reduction of blood pressure, but has the risk of undesirable maternal and neonatal adverse effects 3.
• Another study found that both oral nifedipine and intravenous labetalol are effective for safely reducing blood pressure to target levels in patients with severe pre-eclampsia 4.

Help-Seeking Behavior

• A qualitative study of experiences of women and their families in the UK found that women need individualized information on signs and symptoms of pre-eclampsia to facilitate timely and appropriate help-seeking 5.
• Women often used self-monitoring of their blood pressure to negotiate for help 5.

Effectiveness of Antihypertensive Drugs

• A randomized control trial comparing the effectiveness of nifedipine, labetalol, and hydralazine as emergency antihypertension in severe preeclampsia found that nifedipine is the most effective drug to reduce blood pressure when single dose administration is used, but requires more doses to further reduce blood pressure 6.
• Hydralazine is the most effective when the drug administration is maxed up to three doses within 60 minutes with 20 minutes interval 6.