New-onset hypertension + proteinuria or end-organ dysfunction after 20 weeks gestation; eclampsia adds seizures.
Also known as: preeclampsia, eclampsia, HELLP syndrome, gestational hypertension, hypertensive disorders of pregnancy
Overview
Hypertensive disorder of pregnancy characterized by new-onset hypertension (≥140/90 on two occasions ≥4 hours apart) after 20 weeks gestation with either proteinuria (≥300 mg/24 h, protein:creatinine ratio ≥0.3, or dipstick 2+) or new-onset end-organ dysfunction. Severe features warrant urgent management. Eclampsia is preeclampsia with new-onset tonic-clonic seizures. HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant.
Epidemiology
Affects ~5-8% of pregnancies in the US; major contributor to maternal and perinatal morbidity and mortality. Higher rates in nulliparous, advanced maternal age, multifetal, and historically marginalized populations.
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Question 1ReproductiveMedium
A 32-year-old woman at 36 weeks gestation has a blood pressure of 156/102 mm Hg confirmed on two readings 4 hours apart, 3+ proteinuria on dipstick, a serum creatinine of 1.3 mg/dL, and a new persistent headache. Which of the following is the most likely diagnosis?
After 20 weeks gestation this patient has new hypertension (156/102 mm Hg on two readings) plus 3+ proteinuria, establishing preeclampsia.
Severe features are present: a serum creatinine of 1.3 mg/dL indicates renal insufficiency (>1.1 mg/dL) and the new persistent headache is a cerebral symptom — either one alone upgrades the diagnosis to severe features. Note that 156/102 mm Hg is below the severe-range threshold (>=160/110), so the severity here derives from the renal insufficiency and headache, not the blood pressure itself.
Management is magnesium sulfate for seizure prophylaxis, IV labetalol or hydralazine for sustained severe-range pressures, and delivery as the definitive treatment.
Why the others are wrong
Chronic hypertension — defined by elevated blood pressure before 20 weeks or pre-pregnancy; it does not produce new proteinuria, renal insufficiency, or headache at 36 weeks. Sets the anchoring trap of fixating on the blood pressure alone.
Gestational hypertension — new hypertension after 20 weeks but WITHOUT proteinuria or end-organ involvement; the 3+ proteinuria and creatinine of 1.3 mg/dL exclude it. Sets the premature-closure trap of stopping at the mildest diagnosis.
HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome — requires laboratory evidence of hemolysis, transaminitis, and thrombocytopenia, none of which is reported here. Sets the buzzword trap of jumping to the most dramatic preeclampsia variant without its defining labs.
Preeclampsia without severe features — tempting because 156/102 mm Hg is below the severe-range threshold of 160/110, but severity can come from end-organ findings alone; the creatinine of 1.3 mg/dL and the new persistent headache each qualify as severe features. Sets the trap of grading severity by blood pressure alone.
Question 2ReproductiveEasy
A 24-year-old at 38 weeks has BP 164/112 on two readings 15 minutes apart, 2+ proteinuria, and a severe persistent headache for 3 hours. Platelet count is 140K. Which of the following is the most appropriate management?
AExpectant management with close fetal monitoring
BIV phenytoin, IV antihypertensives, and prompt delivery
CIV magnesium, IV antihypertensives, and prompt delivery
DOral labetalol with inpatient observation and daily labs
EAntenatal corticosteroids with delivery deferred 48 hours
Reveal answer & full explanation
Correct answer: C — IV magnesium, IV antihypertensives, and prompt delivery
AExpectant management with close fetal monitoring
BIV phenytoin, IV antihypertensives, and prompt delivery
CIV magnesium, IV antihypertensives, and prompt delivery✓
DOral labetalol with inpatient observation and daily labs
EAntenatal corticosteroids with delivery deferred 48 hours
Why IV magnesium, IV antihypertensives, and prompt delivery is correct
This is preeclampsia with severe features: the BP of 164/112, confirmed 15 minutes apart, is in the severe range (≥160/110), and the new severe persistent headache is a cerebral severe feature in its own right.
IV magnesium sulfate (MgSO4) is given for seizure prophylaxis: 4 g loading dose then 1–2 g/hour maintenance.
Confirmed severe-range BP calls for acute antihypertensive therapy (IV labetalol, IV hydralazine, or oral immediate-release nifedipine), given as soon as possible and ideally within 30–60 minutes to reduce the risk of maternal stroke.
Delivery is the definitive treatment; at ≥34 weeks with severe features, delivery is recommended once the mother is stabilized, so at 38 weeks proceed without delay.
Before 34 weeks, a persistent headache refractory to treatment is one of the conditions that rule out expectant management.
Why the others are wrong
Antenatal corticosteroids with delivery deferred 48 hours — Corticosteroids to accelerate fetal lung maturity are only needed if <34 weeks; at 38 weeks fetal lung maturity is established and delaying delivery with severe features is dangerous.
Oral labetalol with inpatient observation and daily labs — Admission and oral blood pressure control omit the two interventions this diagnosis requires: magnesium sulfate for seizure prophylaxis and delivery, which is the only definitive treatment at 38 weeks with a severe feature.
Expectant management with close fetal monitoring — Expectant management may be considered for preeclampsia without severe features between 34–37 weeks, but is not appropriate with severe features at 38 weeks.
IV phenytoin, IV antihypertensives, and prompt delivery — phenytoin is a familiar antiseizure drug and the antihypertensive and delivery components are right, but magnesium sulfate is the recommended agent for seizure prophylaxis in preeclampsia with severe features and was more effective than phenytoin at preventing eclampsia in direct comparison.
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Preeclampsia: BP ≥140/90 on two occasions ≥4 hours apart after 20 weeks PLUS either proteinuria (≥300 mg/24h, P:Cr ≥0.3, or dipstick 2+) OR one of: platelets <100,000, creatinine >1.1 or doubling, AST/ALT >2x ULN, pulmonary edema, or new-onset cerebral/visual symptoms. Severe features: BP ≥160/110, platelets <100,000, AST/ALT >2x ULN, creatinine >1.1 or doubling, pulmonary edema, cerebral/visual symptoms, severe persistent RUQ/epigastric pain. (Proteinuria is NOT required for severe features classification, and its absence does not exclude diagnosis if end-organ dysfunction is present.)
Labs
Urinalysis with protein quantitation (24-h urine protein, P:Cr ratio, or dipstick)
CBC (thrombocytopenia in HELLP, hemoconcentration)
BMP (elevated creatinine in severe disease)
LFTs (AST/ALT >2x ULN = severe feature; HELLP)
LDH and peripheral smear (hemolysis: elevated LDH, schistocytes)
Uric acid (rises early in preeclampsia)
Coagulation studies if HELLP or severe
sFlt-1/PlGF ratio (in some centers — prognostic, ratio <38 has high NPV)
Diagnostic criteria for preeclampsia and severe features (ACOG).
Treatment
First-line
Definitive treatment is delivery of the placenta — timing depends on gestational age, severity, and fetal status
Preeclampsia without severe features ≥37 weeks: delivery
Preeclampsia with severe features ≥34 weeks: delivery; <34 weeks individualized with antenatal corticosteroids and close monitoring at tertiary center; deliver after maternal stabilization at any gestational age for uncontrolled severe-range BP, persistent headache or visual/cerebral symptoms, eclampsia, pulmonary edema, HELLP, worsening renal function, suspected abruption, or abnormal fetal testing (give steroids if <34 weeks when time allows, but do not delay for deterioration)
Severe HTN (≥160/110): rapid BP control with IV labetalol, IV hydralazine, OR oral immediate-release nifedipine (initial agents)
Magnesium sulfate for seizure prophylaxis — preeclampsia with severe features, eclampsia, or HELLP: loading 4-6 g IV over 15-20 min, then 1-2 g/h infusion; continue 24 h postpartum
Antihypertensive maintenance for chronic management: labetalol, nifedipine ER, methyldopa (less commonly used now)
Avoid ACEi/ARB and atenolol in pregnancy
Eclampsia
ABCs, left lateral decubitus position, oxygen, IV access
Magnesium sulfate IV — first-line for treatment AND prevention of recurrent seizures (4-6 g loading then 1-2 g/h; redose 2-4 g if seizure recurs)
Rapid BP control
Delivery once stabilized (regardless of gestational age)
Continue magnesium ≥24 h postpartum
Recurrent seizures despite magnesium: lorazepam or sodium amytal; consider CT head
HELLP syndrome
Magnesium sulfate for seizure prophylaxis
Antihypertensive control
Delivery once maternal stabilized (regardless of gestational age unless <34 wk and patient stable for corticosteroid window)
Antenatal corticosteroids if <34 weeks
Platelet transfusion if <20,000 or <40,000 with bleeding or planned C-section
Magnesium sulfate × 24-48 h postpartum
Prevention
Low-dose aspirin 81-162 mg daily starting at 12-16 weeks for women at high risk (prior preeclampsia, chronic HTN, diabetes, CKD, autoimmune disease, multifetal) or with ≥2 moderate risk factors
Calcium supplementation in low-intake populations
Weight management before pregnancy
Complications
Maternal: stroke (especially with uncontrolled severe HTN), pulmonary edema, acute kidney injury, hepatic rupture (HELLP), DIC, placental abruption, eclamptic seizures, death
Postpartum: continued or new-onset preeclampsia/eclampsia possible up to 6 weeks postpartum
PANCE pearls
Magnesium sulfate is the drug of choice for seizure prevention and treatment in preeclampsia/eclampsia — NOT benzodiazepines or phenytoin first-line.
Monitor magnesium toxicity: loss of deep tendon reflexes (first), respiratory depression, cardiac arrest; treat with calcium gluconate 1 g IV.
Postpartum preeclampsia/eclampsia is well-recognized and can occur up to 6 weeks after delivery — counsel patients about warning symptoms.
Avoid ACE inhibitors and ARBs in pregnancy (renal anomalies, oligohydramnios, fetal demise) — switch to labetalol, nifedipine, or methyldopa.
Low-dose aspirin starting at 12-16 weeks reduces preeclampsia incidence in high-risk women by ~15% (RR 0.85) and also lowers preterm birth, fetal growth restriction, and perinatal mortality (USPSTF 2021, Grade B).
Preeclampsia is a marker for future cardiovascular disease — counsel about long-term risk modification.
Treat severe HTN within 30-60 minutes of confirmation to reduce stroke risk.
References
ACOG PB 222 — ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia
ACOG CO 743 — ACOG Committee Opinion 743: Low-Dose Aspirin Use During Pregnancy
USPSTF 2021 — Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: USPSTF Recommendation Statement (JAMA 2021)
Magpie Trial — Magnesium Sulfate vs Placebo for Women with Preeclampsia (Magpie Trial Collaborative, Lancet 2002)
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