Preeclampsia and Eclampsia

Symptoms

• Often asymptomatic — detected on routine BP and urine checks
• Severe headache, visual disturbances (scotoma, blurred vision)
• Right upper quadrant or epigastric pain (hepatic capsule stretching)
• Sudden weight gain, generalized edema (especially face and hands)
• Nausea, vomiting
• Seizures (eclampsia)
• Dyspnea (pulmonary edema)

Signs / physical exam

• Hypertension (≥140/90 confirmed)
• Severe HTN ≥160/110
• Hyperreflexia, clonus
• Epigastric tenderness, RUQ tenderness
• Pulmonary edema (crackles, hypoxia)
• Altered mental status, focal neurologic findings
• Edema is not a diagnostic criterion but commonly present

Diagnostic criteria

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)

Imaging

• Fetal: ultrasound for growth, amniotic fluid, biophysical profile, umbilical artery Doppler
• Maternal: CT/MRI head if focal neurologic findings, atypical seizures, or refractory disease
• Echocardiogram if cardiac dysfunction suspected

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