Eduovisual
Pregnancy, Childbirth & Puerperium
Gestational hypertension and preeclampsia: management
— Chronic HTN: BP ≥140/90 before 20 weeks or pre-pregnancy
— Gestational HTN: new BP ≥140/90 after 20 weeks, no proteinuria, no severe features
— Preeclampsia: gestational HTN + proteinuria OR end-organ dysfunction
— Preeclampsia with severe features: BP ≥160/110, thrombocytopenia <100k, Cr >1.1 (or doubling), AST/ALT 2× normal, pulmonary edema, cerebral/visual symptoms
— Eclampsia: preeclampsia + new-onset generalized seizure
— HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets
— Chronic HTN with superimposed preeclampsia
— New BP ≥140/90 on 2 readings ≥4 hours apart (or single ≥160/110 confirmed in minutes)
— Headache, scotomata, RUQ pain, rapid edema, oliguria, brisk DTRs
— Sudden weight gain >2 lb/week in third trimester
— IUGR, oligohydramnios, abnormal umbilical artery Dopplers (placental insufficiency clue)
— High risk (any one → ASA 81 mg): prior preeclampsia, multifetal gestation, chronic HTN, T1/T2DM, renal disease, autoimmune (SLE, APLS)
— Moderate risk (≥2 → ASA 81 mg): nulliparity, obesity (BMI >30), age ≥35, family history, low SES, Black race, prior adverse pregnancy outcome
— Start 81 mg ASA daily between 12–28 weeks (ideally before 16 weeks), continue until delivery
Board pearl: Preeclampsia can present up to 6 weeks postpartum — new headache or HTN in a recently delivered patient is preeclampsia until proven otherwise.
— Asymptomatic patient at routine prenatal visit, 3rd trimester
— BP creeping up from baseline normotension
— No proteinuria, no symptoms, normal labs
— ~50% progress to preeclampsia, especially if dx <32 weeks
— Neurologic: persistent frontal/occipital headache unrelieved by acetaminophen, scotomata, blurred vision, photopsia, altered mentation
— Hepatic: RUQ or epigastric pain (Glisson capsule stretch), nausea/vomiting mimicking gastritis
— Pulmonary: dyspnea, orthopnea (pulmonary edema from capillary leak + LV dysfunction)
— Renal: oliguria, foamy urine, rapid edema (face, hands)
— Hematologic: bruising, petechiae (HELLP)
— Gestational age (drives delivery timing decisions)
— Prior pregnancies: preeclampsia, HELLP, abruption, IUGR, preterm delivery
— Chronic conditions: HTN, DM, CKD, lupus, APLS, thrombophilia
— Medications: ASA prophylaxis adherence, antihypertensives
— Substance use: cocaine/methamphetamine mimic preeclampsia
— Family history: preeclampsia in mother/sister doubles risk
— Often presents to ED with headache or seizure
— NSAIDs given for postpartum pain can worsen BP — counsel and reassess
Board pearl: "Severe features" don't require proteinuria. A patient at 34 weeks with BP 165/115, headache, and AST 90 has preeclampsia with severe features even with a negative urine dip — proceed to magnesium and delivery planning.
Step 3 management: Always ask the pregnant patient with HTN about headache, vision changes, RUQ pain, dyspnea at every encounter — these symptoms alone reclassify her disease severity.
— Seated, back supported, feet flat, arm at heart level, appropriate cuff size
— Two measurements ≥4 hours apart for diagnosis (unless severe range)
— Severe-range BP ≥160/110 confirmed within 15 minutes mandates acute treatment — do not wait 4 hours
— Use the higher arm for subsequent readings
— Facial/periorbital edema (more concerning than dependent edema, which is physiologic)
— Rapid weight gain on the chart
— Restlessness, hyperreflexia → impending eclampsia
— Brisk DTRs (3+/4+), ankle clonus → CNS irritability, eclampsia risk
— Visual fields, fundoscopy: retinal vasospasm, papilledema in severe cases
— Mental status changes → urgent CNS imaging if focal/atypical
— Pulmonary crackles, S3, JVD → pulmonary edema (severe feature)
— SpO2 <94% on room air is abnormal in pregnancy
— RUQ/epigastric tenderness → hepatic capsule distension, HELLP, subcapsular hematoma
— Fundal height: assess for IUGR (lag >3 cm from GA)
— Tetanic uterus, vaginal bleeding → consider abruption (preeclampsia is a major risk factor)
— Leopold maneuvers, fetal heart tones
— NST (reactive vs nonreactive), biophysical profile
— Decreased fetal movement is a red flag
— Preeclampsia is a state of intravascular volume depletion despite total body fluid overload — be cautious with IV fluids (max ~80 mL/hr) to avoid pulmonary edema
— Avoid invasive lines unless refractory; arterial line only if persistently severe-range BP on multiple agents
Key distinction: Dependent edema in a pregnant patient is normal. Facial, periorbital, or hand edema with sudden weight gain is suggestive of preeclampsia.
CCS pearl: On any pregnant patient with elevated BP, order in this sequence: repeat BP, urine protein/creatinine ratio, CBC, CMP (LFTs, Cr), uric acid, LDH, NST, OB consult. Don't forget magnesium level if already on Mg infusion.
— Proteinuria: ≥300 mg/24h urine, urine P:Cr ratio ≥0.3, or dipstick ≥2+ (only if quantitative unavailable)
— Thrombocytopenia: platelets <100,000
— Renal insufficiency: Cr >1.1 mg/dL or doubling of baseline
— Hepatic: transaminases ≥2× ULN, or severe RUQ/epigastric pain unresponsive to meds
— Pulmonary edema
— New-onset headache unresponsive to acetaminophen or visual symptoms
— CBC with platelets, peripheral smear if HELLP suspected (schistocytes)
— CMP: Cr, AST, ALT, bilirubin, LDH
— Uric acid (rises in preeclampsia; supportive, not diagnostic)
— Urine: dipstick → confirm with spot P:Cr ratio (24h collection rarely needed acutely)
— Type & screen, coags (PT/PTT, fibrinogen) if delivery imminent or HELLP
— Hemolysis: LDH >600, total bili >1.2, schistocytes, low haptoglobin
— EL: AST/ALT >2× ULN
— LP: platelets <100k
— NST at presentation; reactive = reassuring
— BPP if NST nonreactive
— Growth ultrasound every 3–4 weeks (IUGR is common)
— Umbilical artery Doppler for IUGR fetuses (absent/reversed end-diastolic flow → urgent delivery consideration)
— Amniotic fluid index (oligohydramnios suggests placental insufficiency)
— Routine 24-hour urine when spot P:Cr is feasible
— Renal biopsy (almost never needed acutely)
— sFlt-1/PlGF ratio — emerging but not standard US care yet
Step 3 management: A 32-week patient with BP 150/95 and headache — order CBC, CMP, uric acid, urine P:Cr, LDH, NST within the first hour. Severe-range BP gets antihypertensive while labs are pending.
Board pearl: Proteinuria is no longer required to diagnose preeclampsia if severe features or end-organ damage are present.
— Atypical seizure (focal, prolonged, postpartum without prior preeclampsia)
— Persistent neurologic deficit
— Suspected PRES (posterior reversible encephalopathy syndrome) — MRI shows posterior white matter edema
— Suspected intracranial hemorrhage (leading cause of preeclampsia mortality)
— Differentiate from cerebral venous sinus thrombosis, ischemic stroke
— Severe RUQ pain, hemodynamic instability, dropping Hgb → subcapsular hepatic hematoma or rupture (HELLP complication, surgical emergency)
— Pulmonary edema with cardiac symptoms → assess for peripartum cardiomyopathy
— Severe HTN with LV dysfunction
— Fibrinogen, D-dimer if DIC suspected (HELLP, abruption)
— Fibrinogen <300 in pregnancy is abnormal; <200 suggests consumption
— sFlt-1:PlGF ratio: ratio <38 has high NPV for preeclampsia within 1 week; FDA-cleared in US in 2023 for risk stratification in hospitalized patients between 23–35 weeks
— Useful for triage but does not replace clinical/lab criteria
— TSH, plasma metanephrines, renin/aldosterone, renal artery Doppler — usually deferred to postpartum
— Consider APLS workup if recurrent preeclampsia <34 weeks, IUGR, fetal loss
— Reclassify as chronic HTN, evaluate for secondary causes
— Echo, renal US, lipid panel, A1c, urine microalbumin
Key distinction: Eclampsia vs PRES vs stroke — all present with seizure or focal deficit. Imaging differentiates. Eclampsia seizures are typically generalized, self-limited (<1–2 min), and resolve with magnesium; focal/prolonged seizures or persistent deficits require imaging.
CCS pearl: A postpartum patient with new seizure 5 days after delivery — order MRI brain with venography (rule out CVST), CBC, CMP, magnesium level. Start magnesium empirically while imaging is obtained.
1. Severity (with or without severe features)
2. Gestational age
3. Maternal and fetal status
— <37 weeks: expectant management with twice-weekly BP checks, weekly labs, NST 1–2×/week, growth US every 3–4 weeks
— ≥37 weeks (37w0d): deliver (induction; cesarean only for obstetric indications)
— Outpatient management acceptable if reliable, no severe features, stable
— <34 weeks: admit, magnesium for seizure prophylaxis, antihypertensives for severe-range BP, antenatal corticosteroids (betamethasone) for fetal lung maturity, expectant management only at tertiary center if mother/fetus stable
— ≥34 weeks: deliver after stabilization (magnesium, BP control, steroids if 34–36+6 not previously given)
— Any GA with unstable mother/fetus: deliver regardless of GA after stabilization
— Eclampsia
— Pulmonary edema
— DIC
— Abruption
— Uncontrollable severe HTN despite multiple agents
— Nonreassuring fetal status, IUFD
— HELLP (generally deliver, though brief stabilization acceptable)
— Renal failure, hepatic hematoma/rupture, stroke
— Vaginal preferred when feasible — cesarean for obstetric indications
— Magnesium continued intrapartum and 24 hours postpartum
— ABCs, left lateral position, IV magnesium 4–6 g load over 15–20 min, then 2 g/hr
— Refractory seizures: additional Mg bolus 2 g, then benzodiazepine
— Treat severe-range BP, then deliver after stabilization
Step 3 management: A 36-week patient with BP 145/92, no symptoms, normal labs, +1 proteinuria → admit, confirm preeclampsia, induce labor. Don't expectantly manage at term.
Board pearl: Delivery is the only cure. Every management decision answers: "Can we safely continue the pregnancy, or is it time to deliver?"
— IV labetalol: 20 mg → 40 mg → 80 mg → 80 mg q10min, max 300 mg
— Avoid in asthma, heart block, decompensated HF, bradycardia
— IV hydralazine: 5–10 mg q20min, max 30 mg
— Watch for maternal hypotension and reflex tachycardia → fetal distress
— PO immediate-release nifedipine: 10 mg, may repeat q20min × 2 doses (10, 20, 20 mg)
— First-line if no IV access
— Goal: BP <160/110, but not below 130/80 (placental perfusion)
— Recheck BP every 10 min during titration, every 15 min × 1 hr after control
— Indication: all preeclampsia with severe features, eclampsia, HELLP
— Routine use in mild preeclampsia/gestational HTN is not recommended
— Dose: 4–6 g IV load over 20 min, then 1–2 g/hr infusion
— Continue 24 hours postpartum (or 24 hr after last seizure)
— Monitor: DTRs, RR, urine output, mental status
— Toxicity: loss of DTRs (>7 mEq/L), respiratory depression (>10), cardiac arrest (>12)
— Antidote: calcium gluconate 1 g IV over 3 min
— Renal dose adjustment: if Cr >1.0 or oliguria, reduce infusion to 1 g/hr and follow levels
— Labetalol 200–800 mg PO BID-TID (first-line)
— Nifedipine ER 30–90 mg daily
— Methyldopa 250–500 mg TID-QID (older, fewer side effects but weaker)
— Avoid: ACEi, ARBs, direct renin inhibitors (renal dysgenesis, oligohydramnios, neonatal AKI), atenolol (IUGR), nitroprusside (cyanide), thiazides if volume-depleted
CCS pearl: Severe BP 170/115 in a 30-week pregnant patient — order IV labetalol 20 mg, repeat BP in 10 min, start magnesium 4 g load + 2 g/hr, call OB, continuous fetal monitoring, betamethasone 12 mg IM.
— Gestational HTN or preeclampsia without severe features: 37 weeks
— Preeclampsia with severe features: 34 weeks (earlier if unstable)
— HELLP: generally at diagnosis after stabilization; brief delay for steroids if <34 weeks and stable
— Chronic HTN, well-controlled: 38–39 weeks
— Chronic HTN + superimposed preeclampsia: per preeclampsia algorithm
— Betamethasone 12 mg IM × 2 doses, 24 hours apart (or dexamethasone)
— Indicated 24w0d–33w6d if delivery anticipated within 7 days
— Late preterm steroids (34w0d–36w6d) if not previously given and delivery in 7 days
— Don't delay delivery for steroids if mother/fetus unstable
— Vaginal preferred; induction with oxytocin and cervical ripening (prostaglandins, Foley) as needed
— Cesarean for standard obstetric indications (malpresentation, nonreassuring fetal status, failed induction)
— Magnesium is continued through delivery and 24 hours postpartum
— Neuraxial (epidural/spinal) is preferred — improves BP control, reduces stroke risk
— Platelet threshold for neuraxial: generally ≥70,000 with stable trend (some institutions 50k)
— Avoid ergot alkaloids (methylergonovine) for postpartum hemorrhage — they exacerbate HTN; use oxytocin, misoprostol, carboprost (carboprost contraindicated in asthma)
— Limit IV fluids to 80 mL/hr total (high pulmonary edema risk)
— Avoid aggressive volume resuscitation for oliguria — preeclampsia oliguria is functional
— BP often peaks 3–6 days postpartum
— Continue Mg 24 hr postpartum
— NSAIDs are acceptable per ACOG (do not significantly worsen BP) — earlier guidance was overly cautious
— Lactation: labetalol, nifedipine, enalapril all compatible
Step 3 management: After delivery, transition IV antihypertensives to PO labetalol or nifedipine ER. Discharge BP goal <150/100; close follow-up at 3–7 days, 1–2 weeks, then 6 weeks.
Board pearl: Methylergonovine is contraindicated for postpartum hemorrhage in preeclampsia/HTN — choose oxytocin or carboprost.
— Baseline proteinuria complicates diagnosis — use rise from baseline (doubling of P:Cr or Cr)
— Higher risk of superimposed preeclampsia (40–50% in stage 3–5 CKD)
— Closer surveillance: monthly visits in 1st/2nd trimester, biweekly in 3rd, weekly NST from 32 weeks
— Nephrology co-management; consider early delivery for worsening renal function
— Renally excreted — toxicity risk markedly elevated
— If Cr >1.0–1.2 or oliguria: load 4 g, reduce maintenance to 1 g/hr
— Check Mg levels q4–6h (therapeutic 4.8–8.4 mg/dL or 4–7 mEq/L)
— Follow urine output, DTRs, RR closely; have calcium gluconate at bedside
— HELLP and AFLP (acute fatty liver of pregnancy) can overlap — AFLP has hypoglycemia, hyperammonemia, marked coagulopathy
— Subcapsular hematoma: limit palpation, avoid vomiting/Valsalva, urgent imaging if hemodynamic change
— Hepatic rupture is a surgical emergency (general surgery + OB + interventional radiology)
— Doubles preeclampsia risk
— ASA prophylaxis indicated
— Tighter BP control, frequent growth scans (macrosomia + IUGR both possible)
— High recurrence of preeclampsia — ASA + low-molecular-weight heparin for APLS
— Distinguish lupus nephritis flare from preeclampsia: complement levels (low in lupus), anti-dsDNA, urine sediment (active sediment in lupus)
— Cuff sizing matters — use large adult or thigh cuff
— Higher preeclampsia risk; ASA prophylaxis if other risk factors
— Moderate risk → ASA if combined with another factor
— Higher rates of chronic HTN, DM, preeclampsia
Key distinction: Lupus flare vs preeclampsia — both cause HTN, proteinuria, low platelets. Lupus has low C3/C4, active urine sediment, rising dsDNA; preeclampsia has elevated uric acid, normal complement.
CCS pearl: In a CKD stage 3 patient on magnesium, recheck Mg level at 2 hours after load and q4h thereafter; have calcium gluconate 1 g drawn up at bedside.
— Nulliparity = moderate risk factor for preeclampsia
— Consider ASA prophylaxis if any additional risk factor (obesity, family history)
— Higher rates of poor prenatal care attendance — address access barriers
— High-risk category — ASA prophylaxis indicated for all
— Earlier onset, more severe disease; deliver dichorionic twins at 38 weeks, monochorionic-diamniotic at 36 weeks, with hypertensive disorders deliver per preeclampsia rules
— Can present up to 6 weeks postpartum, peak 3–6 days
— De novo postpartum preeclampsia: ~5% of cases
— Symptoms: headache, vision changes, dyspnea, seizure
— Manage identically: labs, magnesium if severe features, antihypertensives
— Don't dismiss postpartum headache as "tension" or "spinal headache" — check BP and labs
— Education at discharge: return for HA, vision changes, RUQ pain, dyspnea, swelling
— Recurrence risk 15–20% overall, higher (40–50%) if severe/early-onset (<34 weeks) or HELLP
— ASA 81 mg starting 12–16 weeks in all subsequent pregnancies
— Pre-pregnancy counseling: optimize BP, weight, glucose
— Long-term: 2× lifetime cardiovascular disease risk — preeclampsia is a CV risk equivalent
— Strongly placental in etiology
— Higher recurrence, higher maternal/fetal morbidity
— Workup for thrombophilia/APLS if recurrent
— Both very short (<6 months) and very long (>10 years) increase preeclampsia risk
— Counsel on optimal spacing 18–24 months
Step 3 management: Postpartum patient (day 5) presents with HA and BP 168/108 — admit, labs, magnesium load and infusion ×24 hr, IV labetalol for BP. Don't send home with PO med from the ED.
Board pearl: Every patient with prior preeclampsia gets ASA 81 mg daily, started 12–16 weeks, in every subsequent pregnancy — this is a high-yield, frequently missed counseling point.
— Eclampsia: tonic-clonic seizure; can occur without prodromal severe features
— Stroke (hemorrhagic > ischemic): leading cause of preeclampsia-related death; tight BP control prevents this
— HELLP (10–20% of severe preeclampsia)
— Pulmonary edema (2–3%): from capillary leak, LV dysfunction, iatrogenic fluid overload
— Acute kidney injury: usually prerenal/ATN; rare cortical necrosis
— Hepatic subcapsular hematoma/rupture: rare but catastrophic
— DIC: from abruption, HELLP, dead fetus
— Placental abruption (1–4%, higher with severe HTN)
— Postpartum hemorrhage: thrombocytopenia, DIC contributors
— PRES and reversible cerebral vasoconstriction syndrome (RCVS)
— Cardiomyopathy / peripartum cardiomyopathy: overlap presentation
— Maternal death: preeclampsia/eclampsia is among top 5 causes of maternal mortality in US
— IUGR (placental insufficiency)
— Oligohydramnios
— Preterm delivery (iatrogenic or spontaneous)
— Nonreassuring fetal status, abruption-related hypoxia
— Stillbirth (rare with appropriate surveillance)
— Neonatal complications of prematurity: RDS, IVH, NEC
— 2–4× lifetime risk of chronic HTN
— 2× lifetime risk of ischemic heart disease, stroke, VTE
— Higher risk of T2DM, CKD, dementia
— Recognized by AHA as a female-specific CVD risk factor (2011, 2021 update)
— Counsel and screen lifelong: BP yearly, lipid panel, glucose, lifestyle counseling
— Higher BP, BMI in adolescence/adulthood (DOHaD)
— Neurodevelopmental effects largely related to prematurity rather than preeclampsia per se
Key distinction: Eclampsia vs epilepsy in pregnancy — first-ever seizure after 20 weeks in a previously well patient is eclampsia until proven otherwise; magnesium first, workup second.
Board pearl: A preeclampsia history puts a woman at high CV risk forever — at every primary care visit, document the obstetric history and screen accordingly.
— New diagnosis of preeclampsia, gestational HTN, eclampsia, HELLP
— Severe-range BP not responding to first agent
— Suspected abruption, IUFD, nonreassuring fetal monitoring
— Severe features <34 weeks (expectant management)
— Early-onset preeclampsia (<34 weeks)
— Recurrent preeclampsia
— Complex comorbidity (CKD, APLS, transplant)
— Eclampsia with prolonged postictal state or repeat seizures
— Pulmonary edema requiring noninvasive or invasive ventilation
— Stroke, intracranial hemorrhage
— Hepatic hematoma/rupture, DIC requiring massive transfusion
— Refractory HTN requiring continuous IV infusion (nicardipine, labetalol drip)
— Multiorgan failure, sepsis, hemodynamic instability
— Atypical seizure (focal, prolonged, refractory)
— Persistent neurologic deficit
— Suspected stroke, CVST, PRES with deficits
— AKI requiring dialysis
— Preeclampsia superimposed on CKD with rapid decline
— Suspected TMA (HUS/TTP) — overlapping presentation
— HELLP not improving 72 hr postpartum (consider TTP, HUS, catastrophic APLS)
— Suspected DIC requiring blood product support
— Preeclampsia with severe features <34 weeks
— NICU need (anticipated preterm delivery)
— Limited capacity for transfusion, ICU, or subspecialty support
— Unstable patient (active labor, seizing, hemorrhaging) — stabilize before transfer
— Document maternal and fetal status, accepting physician, mode of transport
CCS pearl: A 31-week patient with BP 175/115, headache, AST 120, plt 85k at a community hospital — start magnesium load + infusion, IV labetalol, betamethasone, call MFM at tertiary center, arrange neonatal transport team, document fetal status before transfer.
Step 3 management: Escalation triggers should be on every L&D admission order set — having a written threshold ("call OB attending if BP >160/110 not controlled after 2 doses of labetalol") prevents delays.
— BP ≥140/90 before 20 weeks or pre-pregnancy
— Persists >12 weeks postpartum
— Manage to BP <140/90 (CHAP trial)
— Add ASA prophylaxis at 12 weeks (high-risk category)
— New BP ≥140/90 after 20 weeks, no proteinuria, no severe features, no end-organ dysfunction
— Up to 50% progress to preeclampsia
— Resolves by 12 weeks postpartum (otherwise reclassify as chronic HTN)
— Deliver at 37 weeks
— Gestational HTN + proteinuria OR end-organ involvement (without severe-range BP or severe-feature labs)
— BP ≥160/110, OR
— Thrombocytopenia <100k, OR
— Cr >1.1 or doubling, OR
— AST/ALT 2× ULN, OR
— Pulmonary edema, OR
— Persistent headache/visual symptoms unresponsive to meds
— New-onset seizure in a patient with preeclampsia (or no prior diagnosis)
— Can occur antepartum, intrapartum, or postpartum (up to 6 weeks)
— Hemolysis (LDH >600, schistocytes, low haptoglobin)
— Elevated liver enzymes (AST/ALT ≥2× ULN)
— Low platelets (<100k)
— Considered a variant of severe preeclampsia; 15–20% have normal or only mildly elevated BP
— Class 1 (plt <50k) is most severe
— Chronic HTN patient develops new proteinuria, worsening BP, or end-organ involvement after 20 weeks
— Highest rate of complications among hypertensive disorders
Key distinction: HELLP can present without severe-range BP — diagnosis is lab-based. A pregnant patient with RUQ pain, nausea, and low platelets needs LFTs and LDH even if BP looks "okay."
Board pearl: Reclassify diagnosis at every visit — gestational HTN can become preeclampsia overnight, and preeclampsia without severe features can develop severe features in hours.
— 3rd trimester, RUQ pain, nausea, jaundice
— Hypoglycemia, marked coagulopathy, hyperammonemia, AKI
— Overlap with HELLP — Swansea criteria help
— Treatment: prompt delivery, supportive care, glucose
— Mortality higher than HELLP
— TTP: pentad (MAHA, thrombocytopenia, AKI, fever, neuro symptoms); ADAMTS13 <10%; treat with plasma exchange, caplacizumab, steroids
— aHUS: postpartum onset common; complement-mediated; eculizumab
— Differentiation from HELLP: HELLP improves with delivery within 48–72 hr; TMA does not. If labs worsen 72 hr postpartum → think TMA.
— Low C3/C4, active urine sediment, rising dsDNA
— May coexist with preeclampsia — manage both
— Paroxysmal HTN, headache, palpitations, diaphoresis
— Plasma/urine metanephrines
— Mortality high if undiagnosed; deliver via cesarean after alpha-then-beta blockade
— Tachycardia, weight loss, tremor
— TSH suppressed; treat with PTU (1st trimester) or methimazole (2nd/3rd)
— Sympathomimetic HTN, agitation, mydriasis
— UDS; supportive care, benzodiazepines; avoid beta-blocker monotherapy
— Headache with visual symptoms — but BP and labs normal
— Diagnosis of exclusion in pregnancy
— Often occurs because of preeclampsia, but can be from other hypertensive emergencies, immunosuppressants, sepsis
— Postpartum headache, seizure, focal deficit
— MR venography; anticoagulate
Key distinction: AFLP vs HELLP — both have RUQ pain and elevated LFTs. AFLP has hypoglycemia, profound coagulopathy, hyperammonemia; HELLP has hemolysis and lower platelets but normal glucose.
Step 3 management: When HELLP labs worsen 72 hours postpartum despite delivery, reconsider the diagnosis — think TTP/aHUS, send ADAMTS13, consult hematology.
— Labetalol 200 mg PO BID or nifedipine ER 30 mg daily, titrate to BP <140/90
— Avoid ACEi/ARBs if breastfeeding within first few days postpartum (small infant exposure concern), though enalapril and captopril are acceptable for chronic use in lactation
— Continue iron, prenatal vitamin as appropriate
— Acetaminophen for pain; NSAIDs are acceptable per ACOG (older guidance to avoid was overly cautious; small studies show no significant BP increase)
— Return precautions: severe headache, vision changes, RUQ pain, dyspnea, swelling, seizure, BP ≥160/110
— Home BP monitoring; teach proper technique
— Symptom diary
— BP check at 3–7 days postpartum (ACOG; remember peak BP day 3–6)
— Follow-up visit at 1–2 weeks
— Comprehensive postpartum visit by 6 weeks (or "fourth trimester" plan)
— If BP persists >12 weeks postpartum → reclassify as chronic HTN, primary care/cardiology transition
— Counsel before discharge and again at 6-week visit
— 81 mg ASA daily, start 12–16 weeks in next pregnancy, continue to delivery
— Lifestyle: DASH diet, exercise 150 min/week, weight optimization, smoking cessation
— Annual BP, lipid panel, glucose/A1c
— Document preeclampsia history in problem list — AHA recognizes it as a female-specific CVD risk enhancer
— Pooled cohort equations underestimate risk — consider preeclampsia in shared decision-making for statins, BP goals
— Estrogen-containing methods generally avoided in uncontrolled HTN; progestin-only, IUD, implant preferred
— Resume contraception before discharge or at 1–2 week visit
Step 3 management: Discharge order set should include: PO antihypertensive, BP cuff Rx, follow-up appointment scheduled within 7 days, written return precautions, ASA counseling for future pregnancy, primary care handoff.
Board pearl: AHA recognizes preeclampsia as a major CV risk factor — lifelong cardiovascular screening is part of the standard of care.
— BP q4h, daily weight, strict I/O
— Daily symptom assessment (headache, vision, RUQ, dyspnea)
— Labs: CBC, CMP, LDH every 1–3 days based on severity
— NST daily, BPP twice weekly, growth US every 2 weeks
— Daily fetal kick counts
— BP checks 2× weekly (clinic or home)
— Weekly labs (CBC, CMP, urine P:Cr)
— NST 1–2× weekly, BPP weekly
— Growth US every 3–4 weeks
— Patient education: symptom red flags
— Inpatient BP q4h until stable
— Continue antihypertensives at discharge if BP >150/100 at discharge
— Home BP twice daily for at least 2 weeks
— Follow-up: 3–7 days, 1–2 weeks, 6 weeks, then per ongoing HTN status
— Recurrence risk in future pregnancies (~15–20%)
— Preeclampsia → lifelong CV risk
— Importance of ASA in subsequent pregnancies
— Recognize postpartum red flags
— Lactation: most antihypertensives compatible
— Mental health: postpartum depression risk increased after complicated pregnancy — screen with EPDS
— Warm handoff to primary care/internist for ongoing HTN management
— Communicate diagnosis explicitly in discharge summary
— Confirm appointment is scheduled before discharge
— Telehealth BP monitoring programs improve adherence and reduce readmission
— ACOG Severe Hypertension in Pregnancy bundle — treatment of severe-range BP within 60 minutes
— Tracked as a Joint Commission perinatal quality metric
Key distinction: In-office BP alone misses postpartum hypertensive crises. Home BP monitoring with structured follow-up calls within 7 days of discharge significantly reduces postpartum readmission.
CCS pearl: On discharge of any postpartum preeclamptic patient, schedule a follow-up BP check in 3–7 days, give a BP cuff (or prescription), and document return precautions in the discharge instructions.
— Discuss expectant management vs delivery, especially at 24–34 weeks
— Counsel on maternal vs fetal risks — at extreme prematurity, mother may decline delivery despite recommendation
— Document shared decision-making, including risk of stillbirth, abruption, eclampsia, stroke
— Involve MFM, neonatology for periviable cases (22–25 weeks) — joint counseling on resuscitation
— When maternal life is endangered, delivery is indicated regardless of GA — this rarely conflicts ethically because maternal stabilization is also fetal-protective
— Periviable (22–25 weeks): joint decision-making about active neonatal resuscitation; document wishes
— Eclamptic patients post-seizure or magnesium-affected may lack capacity — surrogate decision-maker
— Acute severe HTN with altered mental status may require emergent treatment under implied consent
— Substance use in pregnancy: varies by state — counsel but reporting laws vary; harm-reduction framing
— Intimate partner violence: routine screening, especially in pregnancy
— AIM (Alliance for Innovation on Maternal Health) Severe Hypertension Bundle: treat severe-range BP within 60 min, standardized order sets, simulation training, debriefs
— Magnesium administration errors are a top medication safety issue — use smart pumps, double-check, infusion only via dedicated line
— Black women have 3× higher maternal mortality in the US, much driven by preeclampsia/HELLP and delays in recognition/treatment
— Address implicit bias, delays in pain assessment, communication gaps
— Doulas and patient navigators improve outcomes
— Postpartum readmission for HTN often follows discharge without home BP monitoring or scheduled follow-up — this is a documented gap in care
— Standardized discharge bundles reduce readmissions
— Time-stamp severe-range BP recognition and treatment
— Document failure to control after first dose and escalation
Step 3 management: When a postpartum patient with preeclampsia is discharged, schedule the 3–7 day BP check, provide a home BP monitor, and explicitly document return precautions — this single intervention bundle reduces stroke and readmission.
Board pearl: Maternal mortality disparities are a tested Step 3 concept — recognize that Black women experience 3× higher mortality and that systemic interventions (bundles, equity-focused care) are the answer.
— Diagnostic BP: ≥140/90 (gestational HTN/preeclampsia); ≥160/110 (severe range)
— Proteinuria: ≥300 mg/24h or P:Cr ≥0.3 or dipstick ≥2+
— Platelets: <100k = severe
— Cr: >1.1 or doubling = severe
— LFTs: ≥2× ULN = severe
— ASA dose: 81 mg daily, start 12–16 weeks (definitely by 28)
— Magnesium load: 4–6 g IV over 20 min, then 1–2 g/hr
— Mg toxicity antidote: calcium gluconate 1 g IV
— Delivery timing: 37 wk (mild), 34 wk (severe), at dx (HELLP after stabilization)
— Postpartum onset window: up to 6 weeks
— Recurrence risk: 15–20% (40–50% if early/severe)
— Lifetime CV risk: 2–4× chronic HTN, 2× IHD/stroke
— IV labetalol, IV hydralazine, PO IR nifedipine — all first-line
— Goal: <160/110 within 30–60 min, but not below 130/80
— ACEi, ARBs, direct renin inhibitors
— Atenolol (IUGR)
— Nitroprusside (cyanide)
— Methylergonovine in HTN/preeclampsia for PPH
— Atypical seizure → MRI brain
— Severe RUQ pain + drop in Hgb → liver imaging for hematoma
— Eclampsia seizure: generalized, <1–2 min, self-limited, resolves with Mg
— HELLP: hemolysis + low platelets + high LFTs (BP may be normal)
— AFLP: hypoglycemia + coagulopathy + hyperammonemia
— Severe-range BP → treat within 60 minutes (AIM bundle)
— Severe features → Mg sulfate
— Term + any preeclampsia → deliver
CCS pearl: Order sets to memorize: "Severe preeclampsia admission" → IV labetalol PRN, magnesium sulfate, betamethasone if <34 weeks, NST, q4h BP, daily labs, OB consult, MFM consult.
Board pearl: The single most-tested intervention: ASA 81 mg starting at 12–16 weeks in any woman with prior preeclampsia or other high-risk factors.
— 34-week G1 with BP 168/112, headache, +2 protein, plt 92k, AST 95
— Answer chain: IV labetalol → magnesium sulfate → betamethasone → plan delivery
— Trap: choosing nifedipine + magnesium together is fine (older "interaction" was overstated)
— 5 days postpartum, headache, BP 165/108, no proteinuria
— Answer: admit, magnesium, IV antihypertensive
— Trap: "discharge with PO med" — wrong; needs inpatient Mg if severe features
— Woman with prior preeclampsia at 34 weeks, now 8 weeks pregnant
— Answer: ASA 81 mg starting at 12–16 weeks
— Trap: high-dose ASA, heparin, or "no prevention needed"
— Patient on Mg infusion becomes lethargic, RR 8, areflexic
— Answer: stop Mg, give calcium gluconate 1 g IV, support airway
— Trap: naloxone, flumazenil
— RUQ pain, nausea, plt 75k, AST 180, LDH 750, BP 145/92
— Answer: HELLP — deliver after stabilization
— Trap: "wait for severe BP before diagnosing" — HELLP is lab-based
— Postpartum day 3, presents with generalized seizure
— Answer: ABCs, left lateral position, magnesium load + infusion, labs, BP control, imaging if focal/prolonged
— Trap: lorazepam first-line (Mg is first-line in eclampsia)
— 38yo with history of severe preeclampsia 5 years ago, now in primary care
— Answer: screen for HTN, lipids, glucose annually; counsel on CV risk
— Trap: "no specific follow-up needed"
— PPH in preeclamptic woman, what to avoid
— Answer: avoid methylergonovine
— Trap: oxytocin (oxytocin is fine and first-line)
— Mild preeclampsia at 37 weeks → induce labor
— Severe preeclampsia at 34 weeks → deliver
— Trap: cesarean is rarely the right answer unless obstetric indication
Step 3 management: When stem mentions BP ≥160/110 OR any severe feature, the next step is almost always (1) acute antihypertensive, (2) magnesium, (3) plan delivery — in that order.
Board pearl: When the question gives you a postpartum headache, always check BP before considering migraine, spinal headache, or sinusitis.
The core teaching point: Hypertensive disorders of pregnancy require ASA prophylaxis in high-risk women starting at 12–16 weeks, prompt treatment of severe-range BP (≥160/110) within 60 minutes, magnesium sulfate for seizure prophylaxis in severe features, and timely delivery (37 weeks for mild, 34 weeks for severe) — with lifelong cardiovascular follow-up because preeclampsia doubles future CV risk.
— Prevent: ASA 81 mg daily, start 12–16 weeks in high-risk (prior preeclampsia, chronic HTN, DM, CKD, autoimmune, multifetal) or ≥2 moderate-risk factors (nulliparity, BMI >30, age ≥35, family history, Black race, low SES)
— Diagnose: BP ≥140/90 after 20 weeks + proteinuria OR end-organ dysfunction = preeclampsia; severe = BP ≥160/110, plt <100k, Cr >1.1, AST/ALT ≥2× ULN, pulmonary edema, persistent HA/visual symptoms
— Treat acutely: IV labetalol, IV hydralazine, or PO IR nifedipine within 60 min for severe-range BP; magnesium sulfate (4–6 g load, 1–2 g/hr) for severe features or eclampsia; calcium gluconate for Mg toxicity
— Deliver: 37 weeks if mild, 34 weeks if severe features, immediately if unstable mother/fetus; vaginal preferred; continue Mg 24 hr postpartum
— Avoid: ACEi/ARBs, atenolol, methylergonovine, aggressive IV fluids
— Follow up: BP check 3–7 days postpartum, comprehensive visit by 6 weeks; reclassify as chronic HTN if BP persists >12 weeks; lifelong CV screening because preeclampsia doubles IHD/stroke risk and is recognized by AHA as a major female-specific CV risk factor
— Counsel: 15–20% recurrence (40–50% if early/severe); ASA in every future pregnancy starting 12–16 weeks; recognize postpartum red flags up to 6 weeks
Board pearl: Delivery is the only cure. Every clinical decision answers one question: "Can we safely continue this pregnancy, or is it time to deliver?" — and that answer is driven by gestational age, severity, and maternal/fetal stability.
Step 3 management: Build a discharge bundle — PO antihypertensive, home BP cuff, 3–7 day follow-up, written return precautions, ASA counseling, primary care handoff, mental health screen.