Preeclampsia / Eclampsia

Key considerations: Eclampsia (seizures), HELLP syndrome, Placental abruption

Cannot miss

history: Gestational age; Headache, visual changes, RUQ pain; Prior preeclampsia history; Medical history (chronic HTN, renal disease, autoimmune); exam: Serial BPs; Reflexes (hyperreflexia with clonus); Fundal height; Edema (though nonspecific); Mental status; labs: CBC with platelets; LFTs (AST, ALT, LDH); Creatinine; Uric acid; Urine protein/creatinine ratio or 24h urine; Coagulation studies (PT, PTT, fibrinogen if HELLP); Peripheral smear if thrombocytopenia (schistocytes → HELLP); imaging: Fetal monitoring (NST/BPP); Ultrasound for fetal growth, amniotic fluid, placental assessment; bedside: Continuous fetal monitoring; Foley catheter for I/O monitoring

immediate: MgSO4 for seizure prophylaxis: 4-6g IV load over 15-20 min, then 1-2g/hr maintenance; Antihypertensives for severe-range BPs: labetalol 20mg IV or hydralazine 5-10mg IV or nifedipine 10mg PO; Goal: SBP <160, DBP <110 within 30-60 minutes; general: Continuous fetal monitoring; Strict I/O; Serial labs q6-12h; MgSO4 monitoring: reflexes, RR, urine output (hold if RR<12, reflexes absent, UO<30mL/hr); specific: diagnosis: Preeclampsia without Severe Features; steps: If <37 weeks: close outpatient monitoring, serial labs; Delivery at 37 weeks; Antihypertensives for SBP ≥140 or DBP ≥90; diagnosis: Preeclampsia with Severe Features; steps: Admit, MgSO4, antihypertensives; If ≥34 weeks: deliver; If <34 weeks: betamethasone, attempt to deliver in 48h after steroid course; If <24 weeks: counseling, consider termination; diagnosis: Eclampsia; steps: MgSO4 4-6g IV bolus (if not already on it), then 1-2g/hr; Lateral decubitus position; Secure airway; Deliver after maternal stabilization; Do NOT use phenytoin or benzodiazepines as first-line; diagnosis: HELLP; steps: Delivery regardless of gestational age; MgSO4; Transfuse platelets if <50k and delivery imminent; Consider dexamethasone 10mg IV q12h (controversial)

admit: All preeclampsia with severe features; HELLP; Eclampsia; discharge: Preeclampsia without severe features if <37 weeks with close outpatient monitoring and reliable follow-up; consults: MFM (Maternal-Fetal Medicine); Anesthesia (neuraxial anesthesia planning); Neonatology if preterm

MgSO4 is the ONLY proven seizure prophylaxis in preeclampsia — NOT phenytoin, NOT benzos
MgSO4 toxicity: loss of reflexes (8-12 mEq/L) → respiratory depression (12-15) → cardiac arrest (>15). Antidote: calcium gluconate 1g IV
Preeclampsia can occur up to 6 WEEKS postpartum — maintain clinical vigilance
HELLP: Hemolysis (LDH >600, schistocytes), Elevated Liver enzymes (AST/ALT >70), Low Platelets (<100k)

ACOG Practice Bulletin No. 222, 2020; Magpie Trial, Lancet 2002. Last reviewed: 2024-11-01