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.
Question 2ReproductiveEasy
A 24-year-old at 38 weeks has BP 156/104 on two readings, 2+ proteinuria, and a severe persistent headache for 3 hours. Platelet count is 140K. Which of the following is the most appropriate management?
AAntenatal corticosteroids with delivery deferred 48 hours
BOral labetalol with inpatient observation and daily labs
CIV magnesium, IV antihypertensives, and prompt delivery
DExpectant management with close fetal monitoring
Reveal answer & full explanation
Correct answer: C — IV magnesium, IV antihypertensives, and prompt delivery
AAntenatal corticosteroids with delivery deferred 48 hours
BOral labetalol with inpatient observation and daily labs
CIV magnesium, IV antihypertensives, and prompt delivery✓
DExpectant management with close fetal monitoring
Why IV magnesium, IV antihypertensives, and prompt delivery is correct
This is preeclampsia with severe features. Although the BP (156/104) is below the severe range (≥160/110), the new-onset severe persistent headache is a cerebral severe feature that establishes the diagnosis.
IV magnesium sulfate (MgSO4) is given for seizure prophylaxis: 4 g loading dose then 1–2 g/hour maintenance.
IV antihypertensives (labetalol or hydralazine) are given if BP reaches severe range (≥160/110); here delivery and magnesium are the priority, with antihypertensives ready if BP escalates.
Delivery is the definitive treatment; at 38 weeks with severe features, proceed to delivery without delay.
Severe headache represents CNS involvement and mandates delivery regardless of gestational age.
Why the others are wrong
A) 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.
B) 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.
D) 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.
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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
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
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.