Approach to the Critical Patient

Immediate priorities

Airway and breathing

Seizure termination

Hemodynamic stabilization

Team activation and consults

Immediate OB consultation

Anesthesia consultation

Neonatology if <35 weeks or fetal compromise suspected

Transfer if facility lacks OB, anesthesia, NICU, or ICU capabilities

Monitoring targets

Vital signs and neurologic monitoring

Magnesium toxicity surveillance

Fetal monitoring

History

Seizure characterization

Onset and timing

Seizure type

Preceding prodromal symptoms (present in ~80%)

Associated symptoms

Neurologic

Gastrointestinal and hepatic

Renal

Pulmonary and cardiovascular

Obstetric

Risk factors

Obstetric risk factors

Medical comorbidities

Demographic risk factors

Important negatives

Prior seizure history or known epilepsy

Substance use

Recent head trauma

Fever or infectious symptoms (meningitis/encephalitis)

Prior BP measurements and proteinuria documentation

Physical Exam

Vital signs

Blood pressure

Heart rate and rhythm

Respiratory rate and oxygen saturation

Neurologic exam

Mental status

Deep tendon reflexes

Focal neurologic findings

Eyes

Fundoscopic examination

Pupillary reactivity

Abdominal and obstetric exam

Abdominal tenderness

Fundal height and fetal position

Pulmonary and cardiovascular exam

Lung auscultation

Cardiovascular

Edema assessment

Edema distribution and significance

Differential Diagnosis

Neurologic causes

Epilepsy

Intracranial hemorrhage

Cerebral venous sinus thrombosis

Posterior reversible encephalopathy syndrome (PRES)

Reversible cerebral vasoconstriction syndrome (RCVS)

Ischemic stroke

Infectious causes

Bacterial meningitis

Viral encephalitis

Metabolic and toxic causes

Hypoglycemia

Hyponatremia

Drug-related seizures

Pregnancy-specific mimics

Thrombotic thrombocytopenic purpura / hemolytic uremic syndrome

Acute fatty liver of pregnancy

HELLP syndrome without seizure

Laboratory Tests

Complete blood count

CBC with platelets

Metabolic and renal panel

Basic metabolic panel

Uric acid

Hepatic markers

Liver function tests

Lactate dehydrogenase

Coagulation and hematology

Coagulation panel

Peripheral blood smear

Urinalysis and proteinuria

Urinalysis with microscopy

Urine protein-to-creatinine ratio

Type and screen and preparation for delivery

Type and screen

Magnesium level

Biomarkers

sFlt-1/PlGF ratio

Diagnostic Tests

Scoring Systems

Fullerton diagnostic criteria for eclampsia

Preeclampsia with severe features (ACOG criteria)

HELLP diagnostic criteria (Tennessee classification)

Magee modified PIERS model

MRI

Brain MRI without contrast

MRI indications in eclampsia

MRI findings in eclampsia-related PRES

MRA

CT

Non-contrast CT head

CT angiography head and neck

Chest CT

Ultrasound

Obstetric ultrasound

Continuous electronic fetal monitoring

Focused cardiac ultrasound

Chest X-ray

Disposition

Admission criteria

ICU or high-acuity admission

Labor and delivery unit criteria

Transfer criteria

Immediate transfer indications

Transfer stabilization requirements

Specialist consultations

Required consultations

Conditional consultations

Postpartum monitoring

Inpatient postpartum monitoring

Discharge criteria

Treatment

Magnesium sulfate

Loading dose

Maintenance infusion

Toxicity monitoring

Antidote

Evidence level

IM alternative (resource-limited settings)

Antihypertensive therapy

Treatment threshold

IV labetalol

IV hydralazine

Oral nifedipine immediate-release

Contraindicated antihypertensives

Delivery planning

Delivery as definitive treatment

Mode of delivery

Corticosteroids for fetal lung maturity

Seizure recurrence management

Recurrent seizure on magnesium

Refractory seizures (not responding to magnesium)

Fluid management

Judicious IV fluid management

Special Populations

Pregnancy

Antepartum management (before delivery)

Medication safety in pregnancy

Postpartum-onset eclampsia

Geriatric

Eclampsia does not occur in elderly patients

Advanced maternal age (>=35 years) increases eclampsia risk

Pediatrics

Eclampsia in adolescent pregnancy

Neonatal effects of magnesium

Background

Epidemiology

Incidence and global burden

Demographics and disparities

Mortality

Pathophysiology

Central nervous system mechanism

Placental pathophysiology

End-organ effects

Therapeutic Considerations

Why magnesium works

Antihypertensive selection rationale

Delivery timing evidence

Long-term cardiovascular risk

Patient Discharge Instructions

copy discharge instructions

When to return to the emergency department immediately

Blood pressure monitoring instructions

Medications

Follow-up appointments

Future pregnancy considerations

References

Guidelines and key sources

Boushra M, Natesan SM, Koyfman A, Long B.

Fishel Bartal M, Sibai BM.

Committee on Practice Bulletins — Obstetrics.

Chappell LC, Cluver CA, Kingdom J, Tong S.

Magee LA, Nicolaides KH, von Dadelszen P.

Farahi N, Oluyadi F, Dotson AB.

Diaz V, Long Q, Oladapo OT.

Evidence levels and guidelines

Jones DW, Ferdinand KC, Taler SJ, et al.

Mehta LS, Warnes CA, Bradley E, et al.

US Preventive Services Task Force.

Rahim MN, Williamson C, Kametas NA, Heneghan MA.