Pregnancy, Childbirth & Puerperium

Severe preeclampsia and HELLP syndrome

Clinical Overview and When to Suspect Severe Preeclampsia/HELLP

— SBP ≥160 or DBP ≥110 on two readings ≥4 h apart (or sooner if treated)

— Platelets <100,000/µL

— Creatinine >1.1 mg/dL or doubling from baseline

— AST/ALT ≥2× upper limit of normal, or severe persistent RUQ/epigastric pain

— Pulmonary edema

— New cerebral or visual symptoms (headache unresponsive to acetaminophen, scotomata, blurring)

Board pearl: Proteinuria is no longer required for diagnosis if end-organ dysfunction is present. A patient at 32 weeks with BP 165/105 and platelets 78,000 has severe preeclampsia even with negative urine dip.

Step 3 management: Suspicion alone in an outpatient with BP ≥160/110 mandates immediate L&D triage, not next-day follow-up.

Definition: Preeclampsia = new-onset hypertension (SBP ≥140 or DBP ≥90 on two occasions ≥4 h apart) after 20 weeks' gestation, plus proteinuria OR end-organ dysfunction. Can occur up to 6 weeks postpartum.

Severe features (any one upgrades to "preeclampsia with severe features"):

HELLP syndrome: Hemolysis (schistocytes, LDH ≥600, indirect bili ≥1.2), Elevated Liver enzymes (AST/ALT ≥2× ULN), Low Platelets (<100,000). May occur without significantly elevated BP in ~15% — do not anchor on hypertension.

Who to suspect: Any pregnant or postpartum patient ≥20 weeks with headache, visual changes, RUQ pain, nausea/vomiting, edema, dyspnea, or oliguria. Suspect HELLP in third trimester with malaise and "viral-like" symptoms.

Risk factors: Nulliparity, prior preeclampsia, chronic HTN, pregestational diabetes, multifetal gestation, antiphospholipid syndrome, lupus, CKD, BMI >30, age >35, IVF, family history.

Pathophysiology pearl: Abnormal placental spiral artery remodeling → placental ischemia → release of antiangiogenic factors (sFlt-1↑, PlGF↓) → systemic endothelial dysfunction.

Presentation Patterns and Key History

— Headache: Frontal, persistent, unrelieved by acetaminophen; harbinger of eclampsia

— Visual disturbance: Scotomata, photopsia, blurring, rarely cortical blindness (PRES)

— Epigastric or RUQ pain: From hepatic capsule distension by periportal hemorrhage/necrosis

— Malaise, nausea, vomiting in third trimester — frequently misdiagnosed as gastroenteritis, cholecystitis, or viral hepatitis

— RUQ pain in 65–90%; tea-colored urine if hemolysis severe

— Up to 30% present postpartum, typically within 48 h but can be up to 7 days

— Gestational age (drives delivery decisions)

— Prior pregnancies, prior preeclampsia/HELLP, time of onset

— Baseline BP, baseline proteinuria, baseline platelets/creatinine

— Aspirin prophylaxis use (81 mg daily from 12–28 weeks in high-risk)

— Symptoms of pulmonary edema (orthopnea, dyspnea)

— Decreased fetal movement

— Vaginal bleeding (concern for abruption — strongly associated with severe preeclampsia)

— Normotensive HELLP (~15%)

— Late postpartum preeclampsia (4–6 weeks out, often presenting to ED with seizure or headache)

— Superimposed preeclampsia on chronic HTN — diagnose if new proteinuria, sudden BP worsening, or new end-organ dysfunction

Key distinction: AFLP (acute fatty liver of pregnancy) vs HELLP — AFLP has hypoglycemia, profound coagulopathy with low fibrinogen, elevated ammonia, and encephalopathy; HELLP fibrinogen is usually normal until DIC develops.

Board pearl: Postpartum headache + hypertension = preeclampsia until proven otherwise; do not anchor on migraine or tension headache.

Classic severe preeclampsia triad symptoms:

HELLP-predominant presentation:

Eclampsia warning: Generalized tonic-clonic seizure in a patient with preeclampsia; can occur antepartum (~50%), intrapartum (~25%), or postpartum (~25%).

History to elicit:

Atypical patterns to recognize:

Physical Exam Findings and Hemodynamic Assessment

— Confirm two BP readings ≥4 h apart with appropriately sized cuff, seated, arm at heart level; if SBP ≥160 or DBP ≥110, reconfirm in minutes — do not wait 4 h to treat severe-range BP

— Tachycardia mild; bradycardia suggests impending eclampsia or magnesium toxicity

— SpO₂ <95% suggests pulmonary edema

— Hyperreflexia (3+/4+), sustained clonus → CNS irritability, eclampsia risk

— Altered mental status → consider PRES, ICH, or hepatic encephalopathy (AFLP)

— Funduscopic: retinal arteriolar spasm, rarely serous retinal detachment

— Bibasilar crackles, S3, JVD, pitting edema → pulmonary edema (5% of severe preeclampsia, more common postpartum)

— Hypertensive heart failure can be present with preserved or reduced EF

— RUQ/epigastric tenderness → hepatic capsule distension; rebound or expanding tenderness with hypotension = subcapsular hematoma rupture (surgical emergency)

— Fundal height, uterine tenderness, vaginal bleeding (abruption screening)

— Continuous external fetal monitoring (NST) — categorize as I/II/III

— Category III tracing (recurrent late decels, absent variability, bradycardia) → expedited delivery

— Sonographic estimated fetal weight, AFI, umbilical artery Dopplers

CCS pearl: Order the first BP recheck within 15 minutes and continuous fetal monitoring; place patient in left lateral decubitus to optimize uteroplacental perfusion.

Step 3 management: Severe-range BP (≥160/110) sustained >15 min mandates IV antihypertensive within 30–60 minutes — this is a hospital quality metric (ACOG safety bundle).

Vital signs:

General/neuro:

Cardiopulmonary:

Abdomen:

Extremities: Generalized non-dependent edema (face, hands) — supportive but not required; brisk DTRs.

Fetal:

Diagnostic Workup — Initial Labs

— CBC with peripheral smear: Platelets <100k = severe; schistocytes/helmet cells = MAHA of HELLP

— Comprehensive metabolic panel: Creatinine >1.1 or 2× baseline = severe; uric acid often elevated (supportive, not diagnostic)

— AST, ALT: ≥2× ULN = severe feature; LDH ≥600 U/L in HELLP (combined hemolysis + hepatic origin)

— Total and indirect bilirubin: ≥1.2 mg/dL supports hemolysis

— Haptoglobin: Low/undetectable supports intravascular hemolysis

— Urinalysis + urine protein: Dipstick ≥2+ suggests proteinuria; quantify with spot urine protein/creatinine ratio ≥0.3 or 24-h urine ≥300 mg

— Coagulation: PT/PTT, fibrinogen — fibrinogen <300 suspicious for DIC or AFLP; fibrinogen <200 in HELLP suggests evolving DIC or abruption

— Type and screen (anticipate delivery, possible transfusion)

— Glucose: Hypoglycemia points away from HELLP toward AFLP

— Class 1: plts ≤50k (highest morbidity)

— Class 2: plts 50–100k

— Class 3: plts 100–150k (partial HELLP)

Board pearl: Proteinuria magnitude (e.g., 5 g vs 1 g) is no longer used to define severe features — removed from ACOG criteria. Don't pick "massive proteinuria" as the severe-feature answer.

Key distinction: Uric acid is suggestive but not part of formal diagnostic criteria; do not anchor on it.

Preeclampsia labs ("preeclampsia panel"):

Tennessee HELLP criteria (complete HELLP): Platelets <100k, AST ≥70, LDH ≥600, with hemolysis evidence

Mississippi classification:

Fetal assessment: NST, biophysical profile, growth ultrasound, umbilical artery Dopplers (look for absent/reversed end-diastolic flow → severe placental insufficiency)

Additional if dyspneic: CXR for pulmonary edema, BNP, troponin if chest pain

Diagnostic Workup — Advanced or Confirmatory Studies

— FDA-approved test (2023) for hospitalized 23–35 week patients with suspected preeclampsia

— Ratio ≥40 → high risk of progression to severe preeclampsia within 2 weeks (rule-in)

— Ratio <38 → low risk (rule-out) — supports outpatient management

— Not a substitute for clinical criteria, but useful when diagnosis ambiguous (e.g., chronic HTN with proteinuria baseline)

— RUQ ultrasound: If severe RUQ pain, evaluate for subcapsular hepatic hematoma or hepatic infarction

— CT abdomen (without contrast if Cr elevated): If ultrasound nondiagnostic and hematoma suspected

— Head CT/MRI: If focal neurologic deficits, atypical seizure, persistent altered mentation → rule out ICH, cerebral venous thrombosis, PRES (posterior reversible encephalopathy syndrome — vasogenic edema in parieto-occipital lobes on FLAIR/T2)

— CXR: Dyspnea or hypoxia → pulmonary edema, effusions

— Echocardiogram: If pulmonary edema or persistent dyspnea — assess EF, diastolic function, postpartum cardiomyopathy

— Umbilical artery Doppler: absent/reversed end-diastolic flow → urgent delivery considerations

— Middle cerebral artery Doppler: "brain-sparing" pattern

— Biophysical profile ≤4/10 → delivery

— TTP/HUS: ADAMTS13 activity (<10% = TTP); persistent thrombocytopenia + hemolysis beyond 72 h postpartum

— AFLP: ammonia, glucose, fibrinogen, Swansea criteria

— Lupus flare/APS: ANA, anti-dsDNA, complement, antiphospholipid antibodies

Step 3 management: Persistent thrombocytopenia or worsening hemolysis >72 h postpartum in a patient who should be improving → pivot toward TTP, aHUS, or AFLP; consult hematology/MFM, consider plasma exchange empirically.

Board pearl: PRES is reversible with BP control and magnesium — do not miss it on imaging.

Angiogenic biomarkers (sFlt-1/PlGF ratio):

Imaging:

Fetal advanced testing:

Workup for mimics if atypical (postpartum, persistent):

Risk Stratification and First-Line Management Logic

1. Control blood pressure (prevent stroke)

2. Seizure prophylaxis with magnesium sulfate

3. Timely delivery (definitive treatment)

— Preeclampsia without severe features: Deliver at 37 0/7 weeks

— Preeclampsia with severe features: Deliver at 34 0/7 weeks if stable; immediate delivery regardless of gestational age if any of:

· Uncontrolled severe hypertension despite IV agents

· Eclampsia

· Pulmonary edema

· Abruption, DIC

· Non-reassuring fetal status / IUFD

· Subcapsular hepatic hematoma

· Renal failure progression

· Stroke

— HELLP syndrome: Generally deliver at ≥34 weeks; <34 weeks may give 48 h for steroids if maternal/fetal stable

— Only at tertiary center with MFM, NICU

— Daily labs, BP control, fetal surveillance

— Antenatal corticosteroids (betamethasone 12 mg IM × 2, 24 h apart) for fetal lung maturity

— Magnesium during steroid course, then often discontinued if stable

Step 3 management: Three orders in the first hour for severe preeclampsia: (1) IV labetalol or hydralazine for BP ≥160/110, (2) magnesium sulfate 4–6 g IV load then 1–2 g/h, (3) OB/MFM consult and admit to L&D.

Board pearl: Magnesium does not lower blood pressure meaningfully — you still need an antihypertensive.

Three pillars of management:

Delivery timing by ACOG:

Expectant management (<34 weeks, severe features, stable):

Mode of delivery: Vaginal preferred if feasible; C-section for obstetric indications. Severe preeclampsia is not itself an indication for C-section.

Fluid management: Restrict to ~80 mL/h total IV/PO — these patients are at high risk for pulmonary edema due to low oncotic pressure and capillary leak.

Pharmacotherapy — First-Line Drug Regimens

— IV labetalol: 20 mg IV → 40 mg → 80 mg → 80 mg q10 min (max 300 mg). Avoid in asthma, HR <60, decompensated HF.

— IV hydralazine: 5–10 mg IV q20 min (max 30 mg). Side effects: reflex tachycardia, maternal hypotension, headache (mimics worsening preeclampsia).

— PO immediate-release nifedipine: 10 mg PO, may repeat q20 min × 2 doses (10, 20, 20 mg). Useful when no IV access.

— Labetalol 200–800 mg PO BID-TID (max 2400 mg/day)

— Nifedipine XR 30–120 mg daily

— Methyldopa 250–500 mg PO TID-QID (slower onset; second-line, fine for breastfeeding)

— Avoid: ACEi, ARBs, direct renin inhibitors in pregnancy (teratogenic, esp. 2nd/3rd trimester). ACEi acceptable postpartum and breastfeeding-compatible (enalapril, captopril).

— Load: 4–6 g IV over 20–30 min, then 1–2 g/h infusion

— Continue through delivery and 24 h postpartum (or 24 h after last seizure in eclampsia)

— Therapeutic level 4.8–8.4 mg/dL

— Renal dosing: If Cr >1.0–1.2 or oliguria, load same but maintenance 1 g/h with q4–6 h levels

— Loss of DTRs (>8 mg/dL) → respiratory depression (>12) → cardiac arrest (>25)

— Antidote: calcium gluconate 1 g IV over 5–10 min

CCS pearl: Order DTRs, respiratory rate, and urine output q1h while on magnesium; have calcium gluconate at bedside.

Board pearl: If a seizure occurs on magnesium, give additional 2 g IV bolus — don't switch agents first.

Acute severe BP control (goal: SBP <160, DBP <110 within 30–60 min; avoid <130/80 to preserve placental flow):

Maintenance oral BP control (antepartum and postpartum):

Seizure prophylaxis — magnesium sulfate:

Magnesium toxicity progression:

Antenatal corticosteroids: Betamethasone 12 mg IM × 2 (24 h apart) for 24–33 6/7 weeks; consider 34–36 6/7 weeks if late preterm delivery anticipated and no prior course.

Procedures and Definitive Management — Delivery

— Notify NICU, anesthesia, OB team

— Type and crossmatch 2 units PRBCs

— Continuous maternal monitoring + continuous fetal monitoring

— Vaginal preferred if cervix favorable and no fetal distress; induce with oxytocin

— Cesarean for usual obstetric indications, non-reassuring fetal status, or rapidly deteriorating maternal condition with unfavorable cervix

— Neuraxial (epidural/spinal) preferred — reduces BP swings, avoids GA risks

— Platelet threshold: Generally ≥70,000/µL for neuraxial (institution-dependent; some accept 50–70k if stable trend)

— Below threshold or rapidly falling → general anesthesia (risk of difficult intubation from airway edema; pretreat to blunt hypertensive intubation response)

— Continue magnesium through delivery and 24 h postpartum

— Continue IV antihypertensives as needed

— Strict I/Os; total fluids ~80 mL/h

— Avoid ergot alkaloids (methylergonovine) for postpartum hemorrhage — causes severe hypertension; use oxytocin, carboprost (avoid in asthma), or misoprostol

— Platelet transfusion if <20k, or <50k with active bleeding or planned C-section

— FFP/cryo if fibrinogen <100–150 with bleeding

— Subcapsular hepatic hematoma: if unruptured and stable → observe with serial imaging; if ruptured → emergency laparotomy with packing, IR embolization, massive transfusion protocol

Step 3 management: Never give methylergonovine for PPH in preeclampsia — board favorite trap.

Board pearl: Steroids (dexamethasone) for HELLP do not improve maternal or fetal outcomes — only used for fetal lung maturity, not as HELLP treatment.

Delivery is the only definitive cure. Once decision made:

Mode of delivery:

Anesthesia considerations:

Intrapartum management:

HELLP-specific procedural considerations:

Postpartum: BP control, magnesium ×24 h, monitor for pulmonary edema (diuresis often begins 48–72 h postpartum as capillary leak resolves).

Special Populations — Renal and Hepatic Impairment

— Baseline proteinuria complicates diagnosis — diagnose superimposed preeclampsia by new severe BP, end-organ dysfunction, or substantial worsening of proteinuria plus angiogenic biomarkers

— Risk of preeclampsia 40–60% in stage 3–5 CKD; 20% in stage 1–2

— Earlier delivery often required; closer fetal surveillance

— Magnesium is renally cleared → accumulation risk

— Cr 1.0–2.5: load 4–6 g, maintenance 1 g/h (vs usual 2 g/h)

— Cr >2.5 or oliguria (<30 mL/h × 4 h): consider load only or load + 0.5–1 g/h with q4–6 h magnesium levels

— Monitor DTRs, respiratory rate, urine output hourly

— Labetalol and nifedipine safe

— Avoid ACEi/ARB antepartum (teratogenic)

— Postpartum: ACEi/ARB preferred for renoprotection; enalapril and captopril compatible with breastfeeding

— HELLP with severe transaminitis (AST/ALT >1000) — consider hepatic infarction, subcapsular hematoma, or AFLP

— Avoid hepatotoxic drugs (acetaminophen still acceptable in standard doses)

— Coagulopathy may worsen with hepatic dysfunction — monitor fibrinogen, INR

— Often deliver earlier; intensify dialysis to keep BUN <50

— Heparin during dialysis acceptable; switch to subcutaneous heparin or LMWH for VTE ppx

— Most cases resolve in days–weeks; persistent AKI beyond 1 week → consider thrombotic microangiopathy (aHUS, TTP) — escalate workup

— Long-term: women with preeclampsia have 2× lifetime risk of ESRD and CKD progression

Key distinction: Postpartum AKI that worsens instead of improving after 48–72 h is not resolving preeclampsia — think atypical HUS (complement-mediated); eculizumab may be needed.

Step 3 management: Check magnesium level at 4 h after load in any patient with Cr ≥1.2 or urine output <30 mL/h.

Pre-existing CKD:

Magnesium dosing in renal impairment:

Antihypertensives in CKD:

Hepatic considerations:

Dialysis patients:

Postpartum renal recovery:

Special Populations — Adolescent, Advanced Maternal Age, and Postpartum

— Higher baseline preeclampsia risk; often late to prenatal care

— Counsel on aspirin 81 mg starting at 12 weeks in subsequent pregnancies if prior preeclampsia

— Same management algorithm; ensure social support and follow-up

— Higher rates of chronic HTN → superimposed preeclampsia

— Consider low-dose aspirin (81 mg daily) from 12–28 weeks through delivery if ≥1 high-risk or ≥2 moderate-risk factors (USPSTF/ACOG)

— High-risk: prior preeclampsia, multifetal, chronic HTN, T1DM/T2DM, CKD, autoimmune disease

— Moderate: nulliparity, BMI >30, age ≥35, family hx, Black race (social determinant), low SES, IVF

— 2–3× increased preeclampsia risk; often earlier onset and more severe

— Higher pulmonary edema risk — strict fluid restriction

— 1/3 of eclampsia cases are postpartum; many present to ED with headache or seizure

— Same magnesium and BP control protocols

— NSAIDs: ACOG no longer absolutely contraindicates; acceptable for postpartum analgesia if BP controlled, but acetaminophen-first if BP labile

— Labetalol, nifedipine, methyldopa, hydralazine, enalapril, captopril — all compatible

— Avoid atenolol (concentrates in milk); avoid HCTZ at high doses (can suppress lactation)

— Recurrence risk 15–20% (higher with HELLP, early-onset, or severe features — up to 25–40%)

— Aspirin 81 mg from 12 weeks in next pregnancy

— Optimize BP and weight preconception

Board pearl: Eclampsia in a woman who delivered 10 days ago in the ED with a headache — give magnesium load + IV labetalol/hydralazine, head imaging to rule out ICH/CVT, admit.

Step 3 management: Discharge with BP cuff and structured follow-up at 3–7 days, then 1–2 weeks — postpartum preeclampsia readmissions peak day 3–7.

Adolescent pregnancy (<18 y):

Advanced maternal age (≥35):

Multifetal gestation:

Postpartum preeclampsia (up to 6 weeks):

Breastfeeding compatibility:

Future pregnancy counseling:

Complications and Adverse Outcomes

— Eclampsia (1–2% of severe preeclampsia): tonic-clonic seizure; mortality 1–2%

— Stroke: Hemorrhagic > ischemic; leading cause of preeclampsia mortality; driven by severe systolic BP — hence aggressive control at ≥160

— Pulmonary edema: 3–5%; postpartum > antepartum; from capillary leak + iatrogenic fluid + diastolic dysfunction

— Acute kidney injury: Usually reversible; persistent AKI suggests TMA

— Hepatic: Subcapsular hematoma (rare, mortality 30–60% if ruptured), hepatic infarction

— DIC: ~20% of HELLP; manage with blood products and delivery

— Placental abruption: 1–4% in severe preeclampsia

— PRES: Vasogenic edema; reversible with BP/seizure control

— Peripartum cardiomyopathy: Increased risk; presents within months postpartum

— Death: Preeclampsia/eclampsia accounts for ~7–8% of US maternal deaths; disproportionately affects Black women

— IUGR / FGR from chronic placental insufficiency

— Preterm birth (often iatrogenic for maternal indication)

— Oligohydramnios

— Non-reassuring fetal status, stillbirth

— Abruption-related morbidity

— 2× lifetime risk of CAD, stroke, HF

— 4× lifetime risk of chronic hypertension

— Increased risk of T2DM, CKD, venous thromboembolism

— Should be counseled as a sex-specific CV risk factor (incorporated into ACC/AHA primary prevention guidelines)

— Increased childhood hypertension, metabolic syndrome

— Neurodevelopmental risks tied to prematurity

Board pearl: A history of preeclampsia enhances 10-year ASCVD risk and should prompt earlier lipid/glucose screening — Step 3 favors this longitudinal angle.

Key distinction: Persistent hypertension >12 weeks postpartum = chronic hypertension, not residual preeclampsia.

Maternal complications:

Fetal/neonatal complications:

Long-term maternal cardiovascular risk:

Long-term offspring risk:

When to Escalate Care — ICU, Consult, and Inpatient Triage

— Any severe-range BP (SBP ≥160 or DBP ≥110)

— New severe headache, visual changes, RUQ pain, dyspnea

— Decreased fetal movement

— Any preeclampsia diagnosis ≥34 weeks

— Severe features (any criterion)

— HELLP (any grade)

— Non-reassuring fetal testing

— Suspected abruption

— Inability to follow up reliably with severe-range BPs

— Pulmonary edema requiring noninvasive or invasive ventilation

— Refractory hypertension despite 2 IV agents at maximum doses

— Eclampsia with persistent altered mental status, status epilepticus

— Stroke, ICH, or large PRES with neurologic deficit

— Acute kidney injury requiring renal replacement

— Hepatic rupture or massive transfusion

— DIC with hemodynamic instability

— Cardiomyopathy with cardiogenic shock

— MFM (maternal-fetal medicine): All severe features <34 weeks for expectant management decisions

— Anesthesia: Early for delivery planning, especially if thrombocytopenic

— Neonatology/NICU: Counseling for preterm delivery

— Hematology: Persistent thrombocytopenia >72 h postpartum, suspected TTP/aHUS

— Nephrology: AKI not improving, suspected TMA, dialysis decisions

— Hepatology/surgery: Hepatic hematoma

— Neurology: Atypical seizures, focal deficits

— Transfer before delivery if <34 weeks and your center lacks NICU/MFM, provided maternal stability for transport

— Stabilize first: magnesium load, IV antihypertensive, fetal monitoring documentation

CCS pearl: On CCS, advance the clock only after orders are in: BP agent, magnesium, fetal monitor, labs sent, consults placed. Reassess in 15–30 min.

Step 3 management: Do not transfer an unstable patient with active severe hypertension or ongoing seizures — stabilize first, then move.

Outpatient → L&D triage (immediately):

L&D triage → admission:

Floor → ICU transfer:

Consults to initiate early:

Interfacility transfer:

Key Differentials — Other Hypertensive Disorders of Pregnancy

— Hypertension predating pregnancy or diagnosed before 20 weeks

— Persists >12 weeks postpartum

— Treat with labetalol/nifedipine/methyldopa; ACOG target <140/90 in pregnancy (CHAP trial)

— New-onset HTN ≥20 weeks without proteinuria or end-organ dysfunction

— ~50% progress to preeclampsia

— Deliver at 37 0/7 weeks; weekly labs and BP

— HTN + proteinuria (or end-organ) but no severe-range BP, no severe lab/clinical features

— Deliver at 37 0/7 weeks

— Can sometimes manage outpatient with very close follow-up

— Severe-range BP, thrombocytopenia, hepatic, renal, pulmonary, or CNS features

— Deliver at 34 0/7 weeks (or sooner if unstable)

— Hemolysis + elevated LFTs + low platelets; can occur with or without severe HTN

— Deliver promptly; ≥34 weeks immediate; <34 weeks may delay 24–48 h for steroids if stable

— Preeclampsia + seizure; can be antepartum, intrapartum, or postpartum (up to 6 wk)

— Treat: magnesium, BP control, delivery

— New-onset proteinuria or end-organ dysfunction in patient with chronic HTN

— Sudden BP escalation requiring more meds

— Deliver at 37 weeks (no severe features) or 34 weeks (severe features)

Key distinction: Gestational HTN that develops severe-range BP or end-organ dysfunction is reclassified as preeclampsia with severe features — management changes accordingly.

Board pearl: Hypertension before 20 weeks is never preeclampsia (except in molar pregnancy or multifetal gestation, which can cause early preeclampsia) — it's chronic HTN.

Chronic hypertension:

Gestational hypertension:

Preeclampsia without severe features:

Preeclampsia with severe features:

HELLP syndrome:

Eclampsia:

Superimposed preeclampsia (on chronic HTN):

Key Differentials — Non-Hypertensive Mimics

— Third trimester; nausea, vomiting, RUQ pain, jaundice, encephalopathy, hypoglycemia, profound coagulopathy (low fibrinogen, high ammonia, prolonged INR)

— Swansea criteria: ≥6 of vomiting, abdominal pain, polydipsia/polyuria, encephalopathy, elevated bilirubin, hypoglycemia, elevated urate, leukocytosis, ascites/bright liver on US, transaminitis, hyperammonemia, AKI, coagulopathy, microvesicular steatosis

— Treatment: prompt delivery, supportive care, often ICU

— Pentad: thrombocytopenia, MAHA, fever, AKI, neuro changes

— ADAMTS13 <10% activity

— Treatment: plasma exchange (PLEX), caplacizumab, rituximab; doesn't resolve with delivery

— Complement dysregulation; predominant renal involvement

— Often presents/worsens postpartum, when HELLP should be resolving

— Treatment: eculizumab (anti-C5)

— Multisystem involvement; check ANA, anti-dsDNA, complement (low in lupus, normal/high in preeclampsia), antiphospholipid antibodies

— Transaminitis without hemolysis or thrombocytopenia early; serologies positive

— Pruritus (palms/soles), elevated bile acids, mild transaminitis; no hypertension or thrombocytopenia

— RUQ pain with imaging findings; lipase elevated in pancreatitis

— Paroxysmal severe HTN, palpitations, headache, sweating; plasma/urine metanephrines

Key distinction: HELLP improves within 48–72 h postpartum; TTP and aHUS worsen — that trajectory is the single most useful clue.

Board pearl: Persistent neuro symptoms + AKI + hemolysis postpartum → check ADAMTS13 and start empiric PLEX while awaiting results.

Acute fatty liver of pregnancy (AFLP):

Thrombotic thrombocytopenic purpura (TTP):

Atypical hemolytic uremic syndrome (aHUS):

Lupus flare / antiphospholipid syndrome:

Viral hepatitis:

Cholestasis of pregnancy:

Acute cholecystitis / pancreatitis:

Pheochromocytoma in pregnancy (rare but lethal):

Postpartum Management, Discharge, and Long-Term Plan

— Continue magnesium for 24 h after delivery (or last seizure)

— Continue IV antihypertensives until oral regimen controls BP

— Daily labs until trending toward normal

— Monitor strict I/Os; diuresis usually begins 48–72 h

— Watch for pulmonary edema and late-onset eclampsia

— BP <150/100 on stable oral regimen ×24 h

— Improving labs (platelets rising, LFTs falling, Cr stable/improving)

— Symptom resolution (no headache, vision changes, RUQ pain, dyspnea)

— Tolerating oral intake, ambulating

— Antihypertensives: Labetalol or nifedipine XR most common; titrate to BP <140/90

— VTE prophylaxis: Mechanical + LMWH if C-section + risk factors; ambulation

— Pain control: Acetaminophen first-line; NSAIDs acceptable if BP controlled (recent ACOG update)

— Contraception counseling: Progestin-only methods preferred if BP poorly controlled; estrogen-containing OK if BP normalized and no other CV risk

— Aspirin: Not routinely; restart 81 mg in next pregnancy at 12 weeks

— Provided automated BP cuff; check BP AM and PM

— Warning signs: SBP ≥150 or DBP ≥100, severe headache, vision changes, RUQ pain, dyspnea, leg swelling, decreased urine output, seizure

— Return precautions: severe-range BP, neurologic symptoms, chest pain

— Annual BP check, weight, lipids, fasting glucose (early CV risk screening)

— Lifestyle: DASH diet, exercise, weight optimization

— Counsel on 2× lifetime CV and stroke risk; incorporate into primary prevention

Step 3 management: Discharge follow-up: BP check at 3–7 days postpartum, comprehensive postpartum visit at 1–2 weeks for severe preeclampsia, then 6 weeks.

Board pearl: Persistent HTN beyond 12 weeks postpartum = chronic hypertension; switch to standard JNC/ACC/AHA management with ACEi/ARB if appropriate.

Inpatient postpartum:

Discharge criteria:

Discharge medications:

Patient education at discharge:

Long-term:

Follow-Up, Monitoring, and Counseling

— 72 h post-discharge: phone or in-person BP check

— 7–10 days: Office visit, BP, symptom review, taper antihypertensives if appropriate

— 2 weeks: Repeat labs (CBC, CMP) if not normalized at discharge

— 6 weeks: Comprehensive postpartum visit, document BP normalization, plan future pregnancy

— 3 months: If still on antihypertensives, reclassify as chronic HTN and transition to PCP

— Home BP log: AM and PM readings; goal <140/90

— Platelets, LFTs, Cr until normalized (usually 1–2 weeks)

— Urine protein (rarely persists; if persistent, consider underlying renal disease)

— Symptoms: headache, visual changes, RUQ pain, dyspnea, edema

— Recurrence: 15–20% overall; up to 40% with HELLP or early-onset (<28 wk) severe preeclampsia

— Low-dose aspirin 81 mg daily from 12 weeks (some recommend 162 mg) through 36 weeks or delivery

— Optimize BP, weight, glucose preconception

— Early prenatal care with MFM consultation

— Calcium supplementation 1.5–2 g/day if dietary intake low (<600 mg/day)

— Lifestyle counseling: smoking cessation, DASH/Mediterranean diet, 150 min/week moderate exercise

— Lipid panel by age 30 or earlier

— Fasting glucose / HbA1c screening earlier than general population

— Document preeclampsia history in problem list — it's a risk enhancer in 2018 ACC/AHA cholesterol guidelines

— Screen for postpartum depression/anxiety/PTSD (higher rates after severe preeclampsia, NICU stay, or eclampsia) using Edinburgh Postnatal Depression Scale

Board pearl: Aspirin prophylaxis in next pregnancy is the single most testable future-pregnancy intervention — start at 12 weeks, ideally before 16.

Step 3 management: Reclassify and treat as chronic HTN at 12 weeks if BP not normalized; transition care to PCP with clear handoff.

Postpartum follow-up cadence (ACOG severe preeclampsia bundle):

What to monitor:

Counseling for future pregnancies:

Cardiovascular risk reduction:

Mental health:

Ethical, Legal, and Patient Safety Considerations

— Severe preeclampsia <24 weeks (previable): expectant management has very poor neonatal outcomes and high maternal risk. ACOG recommends offering delivery (induction or D&E in some cases) to protect maternal life.

— Patient autonomy: A competent patient may decline delivery; document extensive counseling, MFM involvement, and ethics consultation

— If patient lacks capacity from eclampsia/PRES, two-physician emergency consent or surrogate may be used to proceed with life-saving delivery

— Magnesium toxicity, hypotension from antihypertensives, postpartum hemorrhage — disclose

— Cesarean delivery risks discussed if anticipated; general vs neuraxial anesthesia discussion if platelet count borderline

— Emergency delivery for fetal distress: implied consent acceptable if delay would cause harm

— Time-to-treatment for severe-range BP: ≤60 minutes — hospital-level quality metric

— Standardized order sets for severe preeclampsia and eclampsia

— Simulation training for eclampsia drills

— Postpartum follow-up at 7–10 days mandated by bundle

— Postpartum readmission for preeclampsia peaks day 3–7; ensure home BP cuff, written warning signs, scheduled follow-up before discharge

— Handoff to PCP with clear medication list, BP goals, and CV risk counseling note

— Black women have 3–4× higher maternal mortality, much of it preeclampsia-related

— Implicit bias contributes to delayed BP treatment — bundles aim to standardize and reduce variation

— Step 3 may test recognition of systemic disparities and quality-improvement interventions

— Maternal mortality reviews mandated in most states

— Severe maternal morbidity (SMM) events trigger root-cause analysis

Board pearl: Failure to treat severe-range BP within 60 minutes is a never event under maternal safety bundles — Step 3 favors the answer "give IV labetalol now," not "recheck in 4 hours."

Maternal-fetal conflict (rare but tested):

Informed consent edge cases:

Patient safety bundles (Alliance for Innovation on Maternal Health, AIM):

Transitions of care risks:

Disparities and equity:

Mandatory reporting / documentation:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: If gestational age <34 weeks and severe features with stable mother + fetus → betamethasone + magnesium + plan delivery at 34 weeks unless deterioration forces earlier.

Preeclampsia ≠ hypertension alone — needs proteinuria OR end-organ dysfunction

Severe BP threshold: ≥160/110; treat within 60 min

Magnesium load: 4–6 g over 20–30 min, then 1–2 g/h, continue 24 h postpartum

Magnesium toxicity antidote: calcium gluconate 1 g IV

Eclampsia on magnesium: give additional 2 g bolus

Antihypertensive first-line: labetalol, hydralazine, or oral nifedipine IR

Avoid in pregnancy: ACEi, ARBs, atenolol, nitroprusside (cyanide risk to fetus)

Avoid for PPH in preeclampsia: methylergonovine (severe HTN)

Delivery timing: 37 wk mild, 34 wk severe, immediate if unstable

HELLP: hemolysis + AST≥70 + plts<100k; LDH ≥600

Mississippi class 1 HELLP (plts ≤50k) = worst prognosis

Neuraxial anesthesia: platelets ≥70k (institution-dependent)

Aspirin prophylaxis: 81 mg from 12 weeks in high-risk

Calcium 1.5–2 g/day if dietary low

sFlt-1/PlGF ratio ≥40 → high risk of progression

Eclampsia is up to 6 weeks postpartum

PRES on MRI: parieto-occipital vasogenic edema, reversible

AFLP differentiators: hypoglycemia, low fibrinogen, encephalopathy, hyperammonemia

Postpartum worsening hemolysis + AKI → think TTP (ADAMTS13) or aHUS (complement)

Recurrence risk: 15–20%; up to 40% for early-onset/HELLP

Long-term CV risk: 2× lifetime stroke, CAD, HF

Fluid restriction in severe preeclampsia: ~80 mL/h total

Most common cause of preeclampsia mortality: stroke (hemorrhagic)

Steroids in HELLP: only for fetal lung maturity, not maternal benefit

Subcapsular hepatic hematoma: rare, mortality 30–60% if ruptured

Proteinuria threshold: 300 mg/24h or P/Cr ≥0.3 or dipstick 2+

Hypertension before 20 weeks → chronic HTN (unless molar/multifetal)

CHAP trial: treat chronic HTN in pregnancy to <140/90

Board Question Stem Patterns

— "32-week G1 with BP 168/112, headache, plts 92k, AST 110…"

— Answer: IV labetalol + magnesium sulfate + admit for delivery planning

— Distractors: "Schedule outpatient follow-up in 1 week" (wrong), "Start methyldopa PO" (too slow)

— "28-week pregnant patient has tonic-clonic seizure in ED…"

— Answer: Magnesium load 4–6 g IV, then 1–2 g/h; protect airway, left lateral decubitus, BP control, deliver after stabilization

— Distractor: lorazepam first-line (wrong — magnesium is first-line in eclampsia)

— "Loss of patellar reflex, RR 8, urine output 15 mL/h…"

— Answer: Stop magnesium, give calcium gluconate 1 g IV

— "10 days postpartum, severe headache, BP 178/114…"

— Answer: Postpartum preeclampsia/eclampsia — magnesium + IV labetalol, head imaging, admit

— "72 h postpartum, worsening thrombocytopenia, AKI, neuro changes, normal LFTs trend…"

— Answer: TTP — check ADAMTS13, start plasma exchange

— "Severe preeclampsia patient with uterine atony after vaginal delivery, BP 158/100…"

— Answer: Oxytocin, carboprost, or misoprostol — NOT methylergonovine

— "Prior severe preeclampsia at 30 weeks, now G2P1 at 10 weeks…"

— Answer: Start aspirin 81 mg at 12 weeks

— "Severe preeclampsia, platelets 58,000, urgent C-section…"

— Answer: General anesthesia (below neuraxial threshold); preoxygenate, blunt intubation response

— "Severe features, 33 weeks, stable, reassuring fetal testing…"

— Answer: Betamethasone, magnesium, deliver at 34 0/7 weeks

Board pearl: When two answers seem right, pick the time-sensitive intervention (BP control, magnesium, delivery) over the diagnostic test.

Stem 1 — Severe-range BP demands action:

Stem 2 — Eclamptic seizure:

Stem 3 — Magnesium toxicity:

Stem 4 — Postpartum headache + HTN:

Stem 5 — HELLP mimic distinction:

Stem 6 — PPH in preeclampsia:

Stem 7 — Future pregnancy:

Stem 8 — Anesthesia choice:

Stem 9 — When to deliver:

One-Line Recap

Severe preeclampsia and HELLP syndrome are placental-driven endothelial diseases of pregnancy whose management hinges on three simultaneous actions — rapid IV antihypertensive control of severe-range BP within 60 minutes, magnesium sulfate for seizure prophylaxis continued 24 hours postpartum, and timely delivery (immediate if unstable, 34 weeks for stable severe features, 37 weeks without severe features) — with vigilant postpartum follow-up because complications and eclampsia can occur up to 6 weeks after delivery.

Board pearl: When a Step 3 stem hands you a pregnant or postpartum patient with severe-range BP, the correct next step is never "outpatient follow-up" — it is admission, IV antihypertensive, magnesium, and delivery planning.

Step 3 management: Always close the loop with a structured postpartum follow-up plan and CV risk counseling — that longitudinal thinking is what distinguishes Step 3 answers from Step 2.

Threshold to act: SBP ≥160 or DBP ≥110 = treat with IV labetalol/hydralazine or PO nifedipine IR within 60 min; this is a quality-of-care metric.

Magnesium logistics: Load 4–6 g IV, maintain 1–2 g/h, continue 24 h postpartum or 24 h after last seizure; calcium gluconate for toxicity; reduce dose in renal impairment.

Delivery is curative: 37 weeks (no severe features), 34 weeks (severe features stable), immediate (unstable — uncontrolled HTN, eclampsia, pulmonary edema, abruption, non-reassuring fetal status, HELLP class 1, hepatic rupture).

Differential trajectory rule: HELLP improves 48–72 h postpartum; persistent or worsening hemolysis/AKI/neuro changes → think TTP (ADAMTS13), aHUS (complement), or AFLP (hypoglycemia + coagulopathy).

Long-term lens: Preeclampsia is a sex-specific CV risk enhancer — 2× lifetime stroke/CAD/HF risk; aspirin 81 mg from 12 weeks in next pregnancy; BP follow-up at 3–7 days, 1–2 weeks, and 6 weeks postpartum.