Intended for healthcare professionals

Practice Easily Missed?


BMJ 2012; 345 doi: (Published 19 July 2012) Cite this as: BMJ 2012;345:e4437
  1. David Williams, consultant obstetric physician1,
  2. Naomi Craft, general practitioner2
  1. 1University College London Hospital, London WC1E 6AU, UK
  2. 253 New Cavendish Street, London W1G 9TQ
  1. Correspondence to: D Williams d.j.williams{at}

A 36 year old primigravida woman attended for antenatal care at 10 weeks’ gestation with a blood pressure 120/80 mm Hg and no proteinuria. At 28 weeks, she presented to her general practitioner with urinary frequency and mild dysuria. Urine analysis showed 3+ proteinuria, and her blood pressure was 144/90 mm Hg. The fundal height measured 3 cm less than expected for this gestation. A midstream urine sample was sent for culture and a review arranged for a week later. At 29 weeks, her blood pressure was 175/115 mm Hg, proteinuria was 3+, and no urinary infection had been isolated. She was urgently admitted to hospital, but on arrival no fetal heartbeat could be detected. Labour was induced and a growth restricted, stillborn infant was delivered. Maternal hypertension persisted postpartum.

What is pre-eclampsia?

Pre-eclampsia is defined by the gestational onset of hypertension and proteinuria.1 It is, however, a multisystem disorder that can affect all maternal organs.1 2 Delivery of the fetus and placenta remains the only cure, but preterm delivery may adversely affect neonatal outcome, with complications resulting from prematurity and low birth weight.3 Pre-eclampsia evolves into eclampsia when maternal seizures develop. Eclampsia is rare in well resourced countries—just 1% of all women with pre-eclampsia develop eclampsia.4 A severe form of pre-eclampsia characterised by microangiopathic haemolytic anaemia is often termed the HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome.2

How common is pre-eclampsia?

Pre-eclampsia predominantly affects women in their first pregnancy (2-8% of first pregnancies)5 and has a variable incidence across nations, being most common in Latin America and the Caribbean.6 In the United Kingdom, about one in 200 pregnancies is affected by severe pre-eclampsia (about 3500 cases a year).7

Why is pre-eclampsia missed?

Pre-eclampsia is usually asymptomatic until it is in an advanced state,2 8 9 10 and so it …

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