Pre-eclampsia and Eclampsia in Pregnancy: A Critical Narrative Review of Mechanistic Heterogeneity, Prediction, Prevention and Management Across Resource Settings
Jacques Forwah Ndeh *
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Edung Emem Samuel
Emergency Department, Basildon and Thurock University Hospital London NHS Trust Foundation, Basildon, United Kingdom.
Islamiyat Ajibola Lawal
Department of O&G, Manchester University Foundation NHS Trust, Blackburn, United Kingdom.
Ihunda Chizi-Orusa
Department of Ageing and Medicine, NHS - Royal Surrey NHS Foundation Trust Guildford, England, United Kingdom.
Olabimpe Oluwabusayo Oyinlove
Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Ido-Ekiti State, Nigeria.
Medinat Abubakar
Department of Obstetrics & Gynaecology, Daisy Hill Hospital, Newry, Northern Islan, United Kingdom.
Scholarstica Ugonwa Ukakogu
Department of Obstetrics and Gynaecology, Molab Hospital, Ilorin, Nigeria.
C. Peter, Ezinwa
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State, Nigeria.
Abiodun Abisola Ogunyanwo
Department of Emergency Medicine, NHS, Bedford, United Kingdom.
Mary Ajayi
Department of Obstetrics and Gynaecology, University of Medical Sciences Teaching Hospitals Complex, Ondo, Nigeria.
Jacob Joseph Saaku
Department of General Practice, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.
Anas Adamu Aliyu
Department of Obstetrics and Gynaecology, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom.
Ogunlesi, Oluwayemisi Adeola
Department of Paediatrics, Evercare Hospital, Lagos, Nigeria.
Bello Omotayo Ebun
Department of Community Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria.
Ogheneothuke Prosper Otiara
Department Family Medicine, Eku Baptist Government Hospital, Eku, Delta State, Nigeria.
Chibuokem Chisom Chine
Department of Obstetrics and Gynecology, Betsi Cadwaladr University Health Board, Bangor, Wales, United Kingdom.
Patience Oofun Omale
Department of Prevention Care and Treatment, Institute of Human Virology, Abuja, Nigeria.
Chimmuanya Chuka-Okoli
Department of Obstetrics and Gynecology, Gbagada GH, Lagos, Nigeria.
Nnodi, Aleruchi Chioma
Department of Internal Medicine, University of Port Harcourt, Port Harcourt, Nigeria and Department of Emergency Medicine, University of Bradford, Bradford, West Yorkshire, United Kingdom.
Imeobong Imeh Umoh
Department of Emergency Medicine, University of Sunderland, Sunderland, United Kingdom.
Prince-Nnabugwu Ruth Amarachukwu
Department of Emergency Medicine, National Hospital, Abuja, Nigeria.
Afusat Sobowale-Adams
Department of Emergency Medicine, University of Leicester, Leicester, United Kingdom.
Adija Hassanah Osumah
Department of General Practice, Hamfar Hospital, Agege, Lagos, Nigeria.
Benjamin Essien
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Bassey Okon Bassey
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Otti Chidiedere Joel
Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Utuku-Oxxllx, Enugu State, Nigeria.
Ewa Anthony Obi
Department of Family Medicine, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Idiege Idiege Omang
Department of Surgery, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Akaba Kingsley Onoridea
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Nnaji Chimuanya Joseph
Department of Surgery, Nnandi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria.
Immaculate Ihuoma Ekeagba
WORCACCCE UNION GROUP Integrated Healthcare Sciences, Technological Development and Training and Innovative Research Foundation (WUGIHSTTAIRF), P.O Box 45 Bamenda, North West Region, Cameroon.
Abeshi Sylvester Etenikang
Department of Obstetrics and Gynecology, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
*Author to whom correspondence should be addressed.
Abstract
Background: Pre-eclampsia and eclampsia remain among the leading causes of maternal death and severe maternal and perinatal morbidity worldwide. Mortality is concentrated in low-resource settings, while the diagnostic boundaries of the syndrome, its presumed mechanisms and the evidence for preventive and therapeutic strategies have changed considerably during the past decade.
Aims and Scope: This critical narrative review appraises evidence on classification and burden, pathophysiological heterogeneity, the cerebral basis of eclampsia, risk prediction and diagnosis, prevention, acute management, health-system delivery, and postpartum and lifelong consequences. Its central question is how far current certainty extends across disease subtypes and resource settings.
Methods: Literature published between 1 January 1990 and 16 August 2026 was identified through structured searches of bibliographic databases, authoritative guideline sources and citation tracking. Studies were appraised qualitatively for design, internal validity, consistency, precision and transferability, and the evidence was synthesised thematically.
Findings: The strongest evidence supports magnesium sulphate for the prevention and treatment of eclamptic seizures, low-dose aspirin started early in pregnancy in women identified as being at high risk of preterm pre-eclampsia, prompt treatment of severe hypertension, and planned delivery at term. Planned delivery in late preterm disease reduces maternal morbidity at the cost of short-term neonatal morbidity in high-income settings. Angiogenic imbalance is the best-characterised mediator of the maternal syndrome and supports reliable short-term rule-out testing, yet benefits for hard perinatal outcomes have not been demonstrated consistently. Recent synthesis restricted to trustworthy trials has substantially weakened confidence in calcium supplementation. Term and postpartum disease, eclampsia without antecedent warning signs, and the causal contribution of the maternal cardiovascular system remain incompletely explained. Much residual mortality reflects failures to deliver proven care rather than an absence of efficacious interventions.
Implications: Priorities include phenotype-specific trials, outcome-based evaluation of biomarkers, implementation research in high-burden settings and structured postpartum cardiovascular follow-up.
Conclusion: Pre-eclampsia is better understood as a family of placental and maternal cardiovascular pathways converging on a shared maternal syndrome. Further progress depends on matching interventions to these pathways and on delivering effective care equitably.
Keywords: Hypertensive disorders of pregnancy, angiogenic imbalance, placental growth factor, low-dose aspirin, magnesium sulphate, posterior reversible encephalopathy syndrome, maternal mortality, cardiovascular risk