What questions should be asked of a pregnant patient suspected of having pre‑eclampsia?

Essential Questions for Suspected Pre-eclampsia Assessment

When evaluating a pregnant patient for suspected pre-eclampsia after 20 weeks' gestation, systematically ask about five critical symptom categories: headache, visual disturbances, epigastric pain/vomiting, reduced fetal movements, and any history of hypertension or proteinuria. 1

Core Symptom Assessment

Neurological Symptoms (Most Critical)

Ask specifically about:

• Headache - Present in 80% of eclamptic patients and an independent risk factor for eclampsia 1, 2
• Visual disturbances - Occurs in 45% of eclamptic cases, including:
  • Blurred vision
  • Flashing lights
  • Scotomata (blind spots)
  • Temporary vision loss 1, 2

Critical caveat: 20% of women with eclampsia report NO neurological symptoms before seizure, so absence of these symptoms does not rule out pre-eclampsia 2. Even when blood pressure is only mildly elevated (diastolic ≤100 mmHg), 34% of eclamptic women fall into this category 1.

Gastrointestinal Symptoms

• Epigastric pain (right upper quadrant pain)
• Vomiting or persistent nausea

These are independent risk factors for serious morbidity in severe pre-eclampsia and warrant same-day hospital assessment even without hypertension 1.

Fetal Well-being

• Reduced fetal movements - Can be the first clinical indication of pre-eclampsia 1
• Perception of decreased fetal activity compared to usual pattern

Risk Factor History

High-Priority Risk Factors (Require Early Specialist Referral)

Ask about:

• Previous pre-eclampsia (7.19-fold increased risk) 1
• Multiple pregnancy (2.93-fold risk) 1
• Pre-existing hypertension or booking diastolic BP ≥90 mmHg 1
• Pre-existing renal disease or proteinuria at booking 1
• Pre-existing diabetes (3.56-fold risk) 1
• Antiphospholipid antibodies (9.72-fold risk - highest risk factor) 1

Moderate Risk Factors

• First pregnancy (nulliparity: 2.91-fold risk) 1
• Age ≥40 years (1.68-1.96-fold risk) 1
• BMI ≥35 at booking 1
• Family history of pre-eclampsia in mother or sister (2.90-fold risk) 1
• ≥10 years since last pregnancy 1
• Booking diastolic BP ≥80 mmHg (even if <90) 1

Timing and Progression Questions

Ask about:

• Gestational age - Pre-eclampsia before 32 weeks has the most serious outcomes, with 50% chance of progression to severe disease 1
• Onset timing of any symptoms
• Progression of symptoms - Pre-eclampsia can progress to life-threatening status in an average of two weeks from diagnosis 1

Structured Assessment Algorithm

For any positive symptom response:

1. Headache or visual disturbances alone (no hypertension/proteinuria):

   • Follow local investigation protocols
   • Consider reducing interval before next assessment 1

2. Epigastric pain (regardless of BP or proteinuria):

   • Refer for same-day hospital assessment 1

3. Reduced fetal movements:

   • Follow local protocols for fetal assessment
   • Perform full pre-eclampsia assessment (BP + proteinuria) 1

Common Pitfalls to Avoid

• Do not rely on edema or weight gain - These are not predictive of pre-eclampsia 1
• Do not dismiss mild hypertension - Eclampsia can occur with diastolic BP ≤100 mmHg in 34% of cases 1
• Do not wait for proteinuria - Symptoms alone warrant investigation even without documented proteinuria 1
• Do not assume safety between visits - Educate patients that pre-eclampsia can develop between scheduled assessments and provide 24/7 contact information 1

The evidence strongly supports that headache and epigastric pain are the most clinically significant symptoms requiring immediate action, as they independently predict progression to eclampsia and severe maternal morbidity 1. However, the absence of symptoms does not exclude pre-eclampsia, making objective measurements (blood pressure and proteinuria) essential at every assessment 1.