Pre-eclampsia and eclampsia — the Pakistan pathway
The national obstetric guideline, reduced to what you do in the next hour: recognise it, load the magnesium, control the pressure, limit the fluid — and give the magnesium before she is transferred, not after.
The line to remember."Offer Magnesium sulfate for seizure prophylaxis before referral/in utero transfer to tertiary care hospital."
If you take one thing from this page, take the word "before". A woman with severe pre-eclampsia who is loaded with magnesium and then moved is a different patient from one who is moved and then loaded. The drug is cheap, it is on the shelf in most district hospitals, and the evidence for it is among the strongest in obstetrics.
Every recommendation here carries a divergence badge.Same as international guidelinePakistan-adaptedLocal data onlyNational guideline outdated
Most of the clinical detail matches international practice — the divergences that matter here are about measurement and screening in a country that does not have the equipment those guidelines assume, and about calcium in a population with low dietary intake.
Decision-support only. Doses are transcribed from the SOGP 2022 guideline and must be checked against it and against your hospital protocol before use. This page does not replace obstetric judgement, and nothing here should delay getting senior help.
🔬 Beta — pending obstetric sign-off. Built on the SOGP Hypertensive Disorders in Pregnancy Guidelines 2022 (Pak Armed Forces Med J 2022;72(3)). Awaiting review by an obstetrician; the reviewer who signs off the rest of this section is a urology trainee, and this page is outside that scope. Verify every dose before acting.
Step 1 · Is this pre-eclampsia?
SOGP Hypertensive Disorders in Pregnancy Guidelines 2022
National guideline outdated The national obstetric guideline, written by obstetricians from health care settings across Pakistan, peer reviewed internationally, endorsed by the Pakistan Society of Internal Medicine and the Hypertension League of Pakistan, and pilot tested before release. The guideline states it will be reviewed after two years. That review was due in 2024 and no newer edition could be found in August 2026, so check for an update before relying on anything time-sensitive here.
What counts as hypertension, and what makes it pre-eclampsia Same as international guideline
Hypertension in pregnancy. Systolic 140 mmHg or more, or diastolic 90 mmHg or more, on at least two occasions at least four hours apart in a previously normotensive woman — or systolic 160 or more, or diastolic 110 or more, reconfirmed within 15 minutes.
Pre-eclampsia. New-onset hypertension after 20 weeks with one or more of: proteinuria (spot protein/creatinine above 30 mg/mmol, or above 300 mg in 24 hours, or 2+ on dipstick); maternal end-organ dysfunction; or uteroplacental dysfunction, meaning fetal growth restriction.
Liver transaminases at least twice normal, or severe persistent right-upper-quadrant or epigastric pain unresponsive to medication
Pulmonary oedema
Persistent neurological signs — altered mental status, hyperreflexia, clonus, severe headache — or visual symptoms
Proteinuria is not essential for the diagnosis of pre-eclampsia.
The rest of the classification
Gestational hypertension
New-onset hypertension after 20 weeks without proteinuria or end-organ damage, resolving within 3 months postpartum. Half of women with early-onset gestational hypertension go on to develop pre-eclampsia.
Chronic hypertension
Diagnosed before pregnancy or before 20 weeks, or first found in pregnancy and persisting at least 12 weeks after delivery.
Superimposed pre-eclampsia
In chronic hypertension: a sudden rise in previously controlled BP or escalation of treatment, or new or suddenly increased proteinuria.
Eclampsia
Generalised seizures in a woman with pre-eclampsia that cannot be attributed to another cause.
HELLP syndrome
Haemolysis, elevated liver enzymes, low platelets — considered a variant of pre-eclampsia.
How to measure it, in the country we actually work in Pakistan-adapted
SOGP-HDP group recognizes that in many areas of the country only aneroid devices are available and despite their inaccuracy aneroid devices will need to be used. Regardless of the method used, we recommend a minimum of two BP measurements to diagnose hypertension.
International guidance assumes a validated automated or mercury device. This guideline says out loud that much of Pakistan has aneroid devices, does not pretend otherwise, and compensates by requiring two readings rather than one. That is what an adapted recommendation looks like when it is written honestly.
Step 2 · Screening and prevention
SOGP 2022 — sections 5 and 6
First-trimester screening — and the method the guideline rules out Pakistan-adapted
Where the tools exist. Universal screening at 11–14 weeks using maternal characteristics, mean arterial pressure and uterine artery pulsatility index, entered into the free FMF web calculator. The risk cut-off is 1 in 100.
Where they do not. In low-resource settings, screen with at least two parameters — maternal factors plus mean arterial pressure.
What the guideline rules out."Maternal risk factors alone should not be used for first trimester PE screening as this would lower the performance of the screening."
This is the sharpest divergence in the section, because the risk-factor checklist is exactly how most doctors here are taught to triage, and it is what several international guidelines rest on. The guideline's position is that a checklist alone underperforms, and that adding a mean arterial pressure — which needs nothing but the cuff already in your hand — materially improves it. Adding placental growth factor where available improves it further.
For mid-trimester, uterine artery Doppler at 22–24 weeks predicts pre-eclampsia or growth restriction with about 60% accuracy. There is no fully reliable mid-trimester test.
Two cheap tablets, started early enough Pakistan-adapted
Aspirin 150 mg at bedtime
Start before 16 weeks and continue to 36 weeks. The bedtime timing is specified, not incidental.
Calcium 1 g daily
From the 16th week.
Educate every at-risk woman
She needs to know the red-flag symptoms herself, because she will notice them before anyone else does.
The limit of prophylaxis. Prevention works on preterm pre-eclampsia. It does not prevent pre-eclampsia at term.
The calcium recommendation is the locally specific half of this pair. Calcium supplementation is a population-with-low-dietary-calcium recommendation rather than a universal one, which is why it appears here and not in every international guideline.
Maternal history that raises the risk
Maternal age under 18 or over 40
Nulliparity
Inter-pregnancy interval over 10 years or under 2 years
Pre-eclampsia in a first-degree relative
Multiple or multifetal pregnancy
Previous pre-eclampsia or gestational hypertension
Pre-existing vascular or kidney disease
Step 3 · How bad is it, and where does she go?
SOGP 2022 — red flags, severity and triage
Red flags — what makes this an emergency Same as international guideline
Symptoms to ask about — and to teach her
Persistent headache
Epigastric pain, or right-upper-quadrant pain with nausea and vomiting
Vomiting
Blurring of vision, visual disturbance or blindness
Swelling of face, hands or body, or rapid weight gain
Reduced fetal movements
Abdominal pain with vaginal bleeding
Chest pain or breathlessness
Red flag signs
Proteinuria
Acute kidney injury — creatinine 90 µmol/L (1 mg/dL) or more
Liver involvement — ALT or AST above 40 IU/L, with or without right-upper-quadrant or epigastric pain
Signs of impending pulmonary oedema, or falling oxygen saturation
Triage
Asymptomatic, mild features
May be managed as an outpatient — but individualise it against her ability to attend, and her financial and social constraints. The guideline says this explicitly, because a plan she cannot follow is not a plan.
Symptomatic pre-eclampsia, or concern for the fetus
Admit to the antenatal ward for observation and monitoring.
Severe pre-eclampsia or impending eclampsia
Admit to obstetric critical care or HDU for stabilisation and early delivery.
Red flag signs, and you are in a district or secondary hospital
Refer or arrange in-utero transfer to tertiary care — and give magnesium sulphate before she goes.
Step 4 · Controlling the blood pressure
SOGP 2022 — tables VI, VII and VIII
Controlling the blood pressure Same as international guideline
Pre-eclampsia without severe features — start an antihypertensive if BP is above 140/90 on two occasions six hours apart.
Gestational hypertension — aim for a target below 135/85.
Severe hypertension, 160/110 or above — treat promptly. This is the number that causes cerebral haemorrhage and eclampsia.
Do not drop the pressure too far: over-correction reduces placental perfusion and compromises the fetus. The hydralazine table aims for systolic 140–160 and diastolic 90–100.
Order of preference. First-line labetalol, then nifedipine, then methyldopa.
Oral maintenance doses
Drug
Dose
Labetalol
100–2400 mg daily
Nifedipine
10 mg three times daily, increasing to 20 mg three to four times daily; maximum 120 mg/day. Extended release 30–90 mg once daily, maximum 120 mg/day
Methyldopa
250–750 mg eight-hourly
Intravenous labetalol
One ampoule is 20 mL = 100 mg, so 2 mL = 10 mg.
Give 10–20 mg IV, then 20–80 mg every 20–30 minutes, to a maximum of 300 mg.
Infusion: add 200 mg (40 mL) to 60 mL of 0.9% sodium chloride to make 100 mL — that is 2 mg/mL. Run at 1–2 mg/min and label the bag.
Intravenous hydralazine
Dilute 20 mg (1 ampoule) in 20 mL water for injection.
Give 5 mg (5 mL) as an IV bolus. Record BP every 10 minutes and run continuous CTG.
If severe hypertension persists after 20 minutes, give a second 5 mg bolus; after a further 20 minutes, a third.
If it persists after three boluses, start an infusion: 80 mg (4 ampoules) in 90 mL of 0.9% saline, at 5 mg/hour (30 mL/hour), increasing by 10 mL every 30 minutes to a maximum of 90 mL/hour (15 mg/hour).
Aim for systolic 140–160 and diastolic 90–100 — not lower.
What to stop, and what never to start
ACE inhibitors, angiotensin receptor blockers, renin inhibitors and mineralocorticoid receptor antagonists are teratogenic — stop them and switch before or as soon as pregnancy is confirmed.
Thiazide diuretics should not be used: they restrict the plasma volume expansion of normal pregnancy.
Step 5 · Magnesium sulphate
SOGP 2022 — tables IX and X
Magnesium sulphate — the drug that prevents the death Pakistan-adapted
When. Seizure prophylaxis where there are signs and symptoms of impending eclampsia, and — the line to remember — before referral or in-utero transfer to tertiary care.
Loading dose
4 g intravenously, slowly, over 20 minutes. Using a 20 mL syringe, draw 4 g of 50% magnesium sulphate (8 mL) and add 12 mL of sterile water or saline to make a 20% solution.
Maintenance
1–2 g per hour by infusion pump. Add 4 g of magnesium sulphate to 200 mL of normal saline and run at 1 g per hour, that is 50 mL/hour, until 24 hours after delivery or 24 hours since the last fit.
Toxicity — what to watch for
Respiratory rate below 10/min, or oxygen saturation below 92%
Muscle paralysis
Absent reflexes
Urine output below 30 mL/hour
If you suspect it. If toxicity is suspected: stop the infusion, take a sample for a magnesium level, and give calcium gluconate 10 mL in 100 mL of normal saline intravenously over 10–20 minutes.
Measuring serum magnesium is not necessary unless there are signs of toxicity. The therapeutic range in adults is 5–8 mg/dL.
If you have no infusion pump. Both the maintenance regimen and the hydralazine infusion in this guideline assume an infusion pump, and the fluid section asks for pumps or dial flows too. Many facilities in Pakistan do not have one. The guideline publishes no intramuscular alternative, so this page does not invent one — if you have no pump, follow your hospital protocol for magnesium administration and escalate early, because the loading dose and the transfer still matter more than anything else you will do that hour.
Step 6 · Fluids, steroids and when to deliver
SOGP 2022 — sections 13.8 to 13.10
Fluids kill here — the 80 mL rule Same as international guideline
In severe pre-eclampsia, limit intravenous fluid to 80 mL/hour unless there is a specific indication otherwise.
Fluid overload can lead to maternal death. Measure intake and output accurately.
Give fluids by infusion pump or dial flow.
Auscultate the lungs regularly in anyone on IV fluids, to catch pulmonary oedema early.
Do not use diuretics in the absence of pulmonary oedema.
Measure urine output hourly with an indwelling catheter.
Do not use volume expansion unless hydralazine is being given.
Offer mechanical thromboprophylaxis with compression stockings.
When to deliver Same as international guideline
Situation
What the guideline says
Well-controlled gestational or uncomplicated chronic hypertension
Deliver at 38–39 weeks.
Pre-eclampsia without severe features, 34 to 36+6 weeks
Prolonging the pregnancy is considered for fetal benefit, as long as maternal assessment stays satisfactory and there is no clinical or laboratory evidence of maternal compromise.
Pre-eclampsia at 37 weeks or more
Deliver. Birth should be initiated within 24–48 hours of hospitalisation.
Severe features at any gestation
Consider early delivery irrespective of gestation for uncontrolled hypertension despite optimal treatment, BP above 160/110, HELLP, deteriorating blood tests, saturation below 90%, abruption, impending eclampsia or abnormal velocimetry.
Under 26 weeks — pre-viable
Delivery is advised to avoid serious maternal morbidity and mortality, after counselling and informed consent.
Under 34 weeks with planned delivery
Ensure NICU services in the hospital, or arrange in-utero transfer after discussion with a neonatologist.
Steroids. Antenatal corticosteroids for fetal lung maturity between 28+0 and 34+0 weeks, and up to 38+0 weeks before elective caesarean. Do not give multiple courses.
Neuroprotection. Magnesium sulphate for fetal neuroprotection if delivery is expected within 24 hours below 32 weeks.
Step 7 · After delivery
SOGP 2022 — sections 13.12 and 13.13
The 48 hours after delivery are not the end of it Same as international guideline
Women with pre-eclampsia should stay in hospital 48 to 72 hours because of a 40% risk of postnatal eclampsia.
Check blood pressure four-hourly during the hospital stay, and keep asking about red-flag symptoms.
Start an antihypertensive if BP is above 150/100 in a woman who was not on one antenatally.
If she was already on one, continue it while BP is above 150/100 and consider reducing the dose below 140/90.
If BP stays below 130/80 across a 72-hour stay, no antihypertensive is needed.
Enalapril may be offered postnatally with monitoring of renal function and potassium. Nifedipine, atenolol, labetalol and metoprolol are safe postnatally.
If one drug does not control it, combine nifedipine and labetalol.
Repeat blood tests 48–72 hours after delivery. If normal, do not repeat; if abnormal, repeat as clinically indicated.
Breastfeeding: antihypertensives pass into breast milk at very low levels and are unlikely to have clinical effects, but avoid diuretics and angiotensin receptor blockers.
Discharge criteria — all three
No symptoms of pre-eclampsia
Blood pressure, with or without treatment, below 150/100
Blood results stable or improving
Follow-up. Daily home BP monitoring, at a nearby health facility or by a health worker if she has no device. Self-monitoring for headache, visual disturbance, nausea, vomiting, epigastric pain, faintness or convulsions. Report back if BP rises above 150/100. Postnatal visits locally for six weeks; if BP has not settled by three months, back to tertiary care to investigate other causes.
The conversation before she leaves. Recurrence of pre-eclampsia in a future pregnancy is 16–23%. After gestational hypertension, the risk of gestational hypertension again is 16–47% and of pre-eclampsia 2–7%. Future cardiovascular risk is increased roughly 1.5 to 3 times, and women who develop preterm pre-eclampsia lose about ten years of life expectancy on average. That conversation is part of the discharge, not an optional extra.
Common questions
When do I give magnesium sulphate — before or after transferring her?
Before. The SOGP guideline says to offer magnesium sulphate for seizure prophylaxis before referral or in-utero transfer to a tertiary care hospital. Loading dose is 4 g intravenously over 20 minutes.
What is the magnesium sulphate regimen?
Loading: 4 g IV slowly over 20 minutes — draw 8 mL of 50% magnesium sulphate into a 20 mL syringe and add 12 mL of sterile water or saline to make a 20% solution. Maintenance: 4 g in 200 mL normal saline at 1 g per hour (50 mL/hour) by infusion pump, continued until 24 hours after delivery or 24 hours since the last fit.
How do I recognise magnesium toxicity?
Respiratory rate below 10 per minute or oxygen saturation below 92%, muscle paralysis, absent reflexes, or urine output below 30 mL/hour. Stop the infusion, send a magnesium level, and give calcium gluconate 10 mL in 100 mL normal saline IV over 10 to 20 minutes. Routine magnesium levels are not needed unless toxicity is suspected.
Which antihypertensive first in pregnancy?
Labetalol, then nifedipine, then methyldopa. For severe hypertension use IV labetalol or oral nifedipine; IV hydralazine is given as 5 mg boluses every 20 minutes up to three doses before starting an infusion. Aim for systolic 140–160 and diastolic 90–100 — dropping the pressure further compromises placental perfusion.
Is proteinuria needed to diagnose pre-eclampsia?
No. New-onset hypertension after 20 weeks with maternal end-organ dysfunction or uteroplacental dysfunction — fetal growth restriction — is pre-eclampsia whether or not there is protein in the urine.
How much IV fluid can she have?
In severe pre-eclampsia, limit intravenous fluid to 80 mL/hour unless there is a specific indication. Fluid overload can kill. Measure urine output hourly with a catheter, auscultate the lungs regularly, and do not use diuretics unless there is pulmonary oedema.
What prophylaxis prevents pre-eclampsia in Pakistan?
Aspirin 150 mg at bedtime started before 16 weeks and continued to 36 weeks, plus calcium 1 gram daily from the 16th week. The calcium is the locally specific half — it is a recommendation for populations with low dietary calcium intake. Prophylaxis prevents preterm pre-eclampsia, not pre-eclampsia at term.
Can I screen for pre-eclampsia using risk factors alone?
The guideline says no — maternal risk factors alone should not be used for first-trimester screening because it lowers the performance of the screening. In low-resource settings, use at least two parameters: maternal factors plus mean arterial pressure, which needs nothing but the cuff you already have.
How long should she stay in hospital after delivery?
48 to 72 hours, because the risk of postnatal eclampsia is 40%. Check blood pressure four-hourly, keep asking about red-flag symptoms, and start an antihypertensive if BP is above 150/100.
Sources
Society of Obstetricians and Gynaecologists Pakistan (SOGP) — Hypertensive Disorders in Pregnancy Guidelines 2022. Pakistan Armed Forces Medical Journal 2022;72(3). Open access. The source of every definition, threshold, drug dose, magnesium regimen, fluid limit, delivery timing and postnatal instruction on this page. Written by obstetricians from health care settings nationwide, peer reviewed internationally, endorsed by the Pakistan Society of Internal Medicine and the Hypertension League of Pakistan, and pilot tested.
CURRENCY NOTE: the guideline states it will be reviewed after two years, which put the review due in 2024. No newer edition was findable in August 2026. Check for an update before relying on time-sensitive detail.
The magnesium sulphate maintenance regimen and the hydralazine infusion are written for an infusion pump, and the fluid section asks for pumps or dial flows. The guideline publishes no intramuscular alternative and neither does this page.
Related on this site: the hypertension pathway covers non-pregnant adults on the Pakistan Hypertension League's 4th National Guidelines, including the staged national targets and the CKD-EPI Pak equation.