Headache or raised blood pressure after 20 weeks
Obstetrics
Clinic, triage or the ward
The first question
Is this preeclampsia, and how severe?
Two patients: the gestational age and the maternal stability first, then the fetal status.
- 01
Confirm the pressure
Correct cuff, seated, repeated after 15 minutes; 160/110 or more is severe and treated within the hour.
- 02
Ask the preeclampsia questions
Headache, visual disturbance, epigastric pain, dyspnoea, swelling of face and hands, reduced movements.
- 03
Test
Urine protein-to-creatinine ratio, CBC, creatinine, liver enzymes, LDH; fetal growth and monitoring.
- 04
Classify and act
Gestational hypertension, preeclampsia, or preeclampsia with adverse conditions or severe complications; treat the pressure, give magnesium where indicated, plan delivery by gestation and severity.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Headache character and response to analgesia
- Visual symptoms: scotomata, blurring, photophobia
- Epigastric or right upper quadrant pain
- Nausea, vomiting
- Swelling: sudden, face and hands
- Reduced fetal movements
- Booking blood pressure, prior preeclampsia, chronic hypertension, aspirin use
Examination that discriminates
- Blood pressure, repeated
- Reflexes and clonus
- Epigastric tenderness
- Oedema (unreliable) and fundal height
- Fundoscopy if visual symptoms
- Neurological examination if the headache is atypical
Investigations
- Urine protein-to-creatinine ratio or 24-hour protein
- CBC with platelets, creatinine, urate, AST and ALT, LDH, bilirubin
- Fetal monitoring, growth scan, umbilical artery Doppler
- Neuroimaging for thunderclap onset, focal signs or seizure with atypical features
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Preeclampsia | New hypertension with proteinuria, organ involvement or fetal effects | Normal pressure and tests | urgent |
| Preeclampsia with severe features (eclampsia, HELLP) | Severe pressure, symptoms, platelets under 100, rising enzymes, creatinine, seizure | Mild pressure, no symptoms, normal bloods | emergent |
| Gestational hypertension | New hypertension without the features | Any feature of preeclampsia | urgent |
| Chronic hypertension | Hypertension before 20 weeks or before pregnancy | Normal pressure early | routine |
| Tension-type or migraine headache | Typical history, normal pressure and tests | Any preeclampsia feature | routine |
| Cerebral venous thrombosis, stroke, PRES | Thunderclap onset, focal signs, seizure, altered consciousness, persisting visual loss | A headache that behaves like the patient's usual headaches | emergent |
Pitfalls this pathway refuses
- Comparing with population norms rather than the booking pressure
- Requiring proteinuria before calling it preeclampsia (SOGC does not)
- Dropping a severe pressure too far, too fast
- Forgetting that preeclampsia and eclampsia occur postpartum