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Approach to the Critical Patient
Immediate threats
Immediate stabilization priorities
Seizure activity
If active seizure, lateral position and suction readiness
If ongoing convulsions, airway protection and rapid sequence intubation
Magnesium sulfate for seizure control and prevention
Severe hypertension
Systolic blood pressure 160 mmHg or higher
Diastolic blood pressure 110 mmHg or higher
Persistent 15 minutes or more
IV or oral rapid acting antihypertensive within 60 minutes (Class I)
Respiratory compromise
Pulmonary edema concern
Oxygen saturation trend
Noninvasive ventilation vs intubation triggers
Hemorrhage concern
Placental abruption suspicion
Postpartum hemorrhage risk with coagulopathy
Stroke concern
Focal neurologic deficit
Altered mental status not explained by postictal state
Hemodynamic targets and monitoring
Monitoring and targets
Blood pressure measurement technique
Correct cuff size
Seated or left lateral position
Repeat after rest
Blood pressure goals during acute control
Systolic blood pressure 140 to 150 mmHg
Diastolic blood pressure 90 to 100 mmHg
Continuous monitoring
Cardiac monitoring for IV antihypertensives
Pulse oximetry
Strict intake and output
Magnesium toxicity surveillance
Respiratory rate
Deep tendon reflexes
Urine output
Team activation and consults
Escalation and consultation triggers
Obstetrics and maternal fetal medicine
Suspected severe features
Eclampsia
HELLP syndrome concern
Anesthesia
Anticipated operative delivery
Thrombocytopenia and neuraxial planning
Critical care
Refractory severe hypertension
Pulmonary edema
Persistent neurologic abnormality
Neonatology
Preterm delivery planning
Fetal compromise
Key decision points
Time critical decisions
Diagnosis category
Gestational hypertension
Preeclampsia without severe features
Preeclampsia with severe features
Eclampsia
HELLP syndrome
Delivery timing
Maternal instability
Fetal status
Gestational age
Transfer to higher level of care
Need for ICU
Need for tertiary neonatal care
Need for expectant management before 34 weeks
History
Presentation and timelines
Symptom pattern and timing
Gestational age and onset after 20 weeks
New hypertension timing
Prior normal blood pressure documentation
Neurologic symptoms
Headache persistent or severe
Visual disturbance
Confusion
Seizure events
Cardiopulmonary symptoms
Dyspnea
Orthopnea
Chest pain
Abdominal symptoms
Right upper quadrant pain
Epigastric pain
Nausea or vomiting
Bleeding and abruption symptoms
Vaginal bleeding
Abdominal pain with uterine tenderness
Decreased fetal movement
Risk factors
Risk profile
Prior preeclampsia
Early onset history
Severe features history
Chronic hypertension
Baseline blood pressure before 20 weeks
Antihypertensive use
Diabetes mellitus
Type 1
Type 2
Kidney disease
Baseline creatinine
Proteinuria baseline
Autoimmune disease
Antiphospholipid syndrome
Systemic lupus erythematosus
Multifetal gestation
Twins or higher
First pregnancy
Nulliparity
Assisted reproduction
IVF
Obesity
Prepregnancy BMI risk
Family history
First degree relative preeclampsia
Medications and exposures
Medication and substance history
Antihypertensives
Adherence
Recent dose changes
Seizure threshold modifiers
Stimulants
Illicit substances
NSAID use postpartum
Fluid retention concern
Blood pressure effect concern
Obstetric and fetal context
Pregnancy course details
Prenatal care and prior blood pressures
Trend of readings
Home readings reliability
Prior ultrasound growth assessment
Fetal growth restriction history
Abnormal Dopplers history
Symptoms suggesting labor or rupture of membranes
Contractions
Fluid leakage
Physical Exam
Vital signs and general
Vital signs and overall status
Blood pressure confirmation
Repeat measurements
Both arms if concern for error
Heart rate and rhythm
Bradycardia with magnesium concern
Tachycardia with hemorrhage concern
Respiratory status
Respiratory rate
Work of breathing
Oxygen saturation
Volume assessment
Peripheral edema
JVP if needed
Lung crackles
Neurologic
Neurologic findings
Mental status
Persistent confusion
Postictal resolution
Visual findings
Blurred vision
Scotoma
Reflexes
Hyperreflexia
Clonus
Focal deficits
Weakness
Aphasia
Cardiopulmonary
Cardiopulmonary findings
Lung exam
Pulmonary edema signs
Aspiration after seizure
Cardiac exam
New murmur
Signs of heart failure
Abdomen and obstetric
Abdominal and obstetric findings
Right upper quadrant tenderness
Liver capsule stretch concern
Uterine tenderness
Abruption concern
Fundal height and fetal position
Gestational age correlation
Vaginal bleeding
Quantification
PITFALLS
Common pitfalls
Normal edema as sole indicator
Low specificity
Single elevated blood pressure without repeat
Misclassification risk
Assuming postpartum seizures are epilepsy
Postpartum eclampsia risk up to 6 weeks
Differential Diagnosis
Hypertensive disorders and mimics
Related hypertensive conditions
Chronic hypertension with superimposed preeclampsia
Worsening blood pressure
New end organ features
Gestational hypertension
Hypertension without proteinuria or severe features
Preeclampsia
Hypertension with proteinuria or end organ involvement
Eclampsia
New onset generalized seizure in pregnancy or postpartum
HELLP syndrome
Hemolysis
Elevated liver enzymes
Low platelets
Neurologic emergencies
Neurologic differentials
Intracranial hemorrhage
Severe headache
Focal deficit
Ischemic stroke
Focal deficit
Persistent symptoms
Cerebral venous thrombosis
Headache postpartum
Seizure
Posterior reversible encephalopathy syndrome
Headache
Visual symptoms
Seizure
Meningitis or encephalitis
Fever
Neck stiffness
Abdominal and hematologic
Abdominal and hematologic differentials
Acute fatty liver of pregnancy
Hypoglycemia
Coagulopathy
Encephalopathy
Thrombotic thrombocytopenic purpura
Hemolysis
Neurologic symptoms
Severe thrombocytopenia
Hemolytic uremic syndrome
Kidney failure
Hemolysis
Viral hepatitis
Marked transaminitis
Cholecystitis or pancreatitis
RUQ pain
Lipase elevation
Coding aligned terms
ICD and SNOMED aligned labels
Preeclampsia (ICD 10 O14)
Mild to moderate (ICD 10 O14.0)
Severe (ICD 10 O14.1)
Unspecified (ICD 10 O14.9)
Eclampsia (ICD 10 O15)
In pregnancy (ICD 10 O15.0)
In labor (ICD 10 O15.1)
Puerperium (ICD 10 O15.2)
HELLP syndrome (commonly coded under O14.2)
Laboratory Tests
Core maternal labs
Maternal laboratory evaluation
Complete blood count
Platelet count trend for severe features
Hemoglobin for hemolysis and bleeding
Comprehensive metabolic panel
Creatinine for kidney involvement
AST
ALT
Bilirubin
Hemolysis markers
LDH elevation support
Peripheral smear schistocytes support
Haptoglobin low support when available
Urine protein assessment
Protein creatinine ratio
24 hour urine protein when needed for confirmation
Coagulation and complications
Complication directed labs
Coagulation studies when indicated
PT
INR
aPTT
Fibrinogen with abruption or DIC concern
Type and screen
Abruption concern
Delivery planning
Magnesium level
Renal impairment
Suspected toxicity
Thresholds supporting severity
Diagnostic thresholds and interpretation
Proteinuria definitions
Protein creatinine ratio 0.3 or higher
24 hour urine protein 300 mg or higher
Thrombocytopenia severe feature
Platelets below 100 x 10^9 per L
Kidney severe feature
Creatinine above 97 micromol per L
Doubling of baseline creatinine
Liver severe feature
AST or ALT at least twice normal
Hemolysis features for HELLP
LDH elevation
Indirect hyperbilirubinemia support
Diagnostic Tests
Scoring Systems
Risk stratification tools
fullPIERS score
Designed for adverse maternal outcomes in preeclampsia
Inputs include symptoms and labs and oxygen saturation
HELLP classification frameworks
Tennessee criteria
Hemolysis evidence
AST or ALT elevated
Platelets low
Mississippi classes
Class based on platelet nadir
Lower platelets correlate with severity
MRI
MRI indications and interpretation
Brain MRI for suspected PRES
Persistent headache
Visual symptoms
Persistent altered mental status
MR venography for cerebral venous thrombosis concern
Postpartum headache
Seizure
MRI safety considerations in pregnancy
Noncontrast preferred when feasible
CT
CT indications and interpretation
Head CT without contrast for acute neurologic emergency
Focal deficit
Concern for hemorrhage
Persistent decreased consciousness
CT pulmonary angiography when pulmonary embolism concern
Hypoxia not explained by edema
Pleuritic chest pain
Radiation counseling
Maternal benefit prioritized in emergencies
Ultrasound (or US)
Ultrasound evaluation
Fetal growth ultrasound
Estimated fetal weight trend
Amniotic fluid assessment
Umbilical artery Dopplers when fetal growth restriction
Absent end diastolic flow concern
Reversed end diastolic flow concern
Placental assessment
Abruption may be occult on ultrasound
Point of care lung ultrasound
B lines supporting pulmonary edema
Disposition
Level of care
Disposition decisions
ICU or high dependency criteria
Eclampsia
Refractory severe hypertension
Pulmonary edema
Stroke or intracranial hemorrhage
DIC or massive hemorrhage
Inpatient obstetric admission criteria
Preeclampsia with severe features
Worsening labs
Persistent symptoms
Need for magnesium infusion
Transfer criteria
Gestational age less than 34 weeks with severe features
Need for tertiary maternal fetal medicine
Need for tertiary neonatal care
Discharge and follow up
Outpatient pathway
Appropriate only for nonsevere disease and reliable follow up
No severe features
Stable labs
Reassuring fetal testing plan
Blood pressure follow up plan
Home monitoring instructions
Early postpartum check within 3 to 7 days
Return precautions
Neurologic symptoms
Dyspnea
RUQ pain
Treatment
Seizure prophylaxis and management
Magnesium sulfate protocol
Standard dosing
Loading dose 4 g IV over 15 to 20 minutes
Alternative loading dose 6 g IV for high risk or active seizure per local protocol
Maintenance 1 g per hour IV infusion
Alternative maintenance 2 g per hour IV infusion per local protocol
Continue 24 hours postpartum for severe features or eclampsia typical practice
Recurrent seizure on magnesium
Additional bolus 2 g IV
Repeat once if needed per local protocol
Toxicity monitoring
Respiratory rate below 12 per minute concern
Stop infusion and urgent evaluation
Loss of deep tendon reflexes concern
Stop infusion and urgent evaluation
Urine output below 25 to 30 mL per hour concern
Dose adjustment or hold
Antidote
Calcium gluconate 1 g IV over 3 minutes
10 percent solution 10 mL equals 1 g
Acute severe hypertension
Rapid acting antihypertensive options
Labetalol IV
Initial 20 mg IV
Repeat 40 mg IV after 10 minutes if still severe
Repeat 80 mg IV after 10 minutes if still severe
Maximum cumulative 220 mg
Contraindications
Asthma with active bronchospasm
Bradycardia
Heart block
Decompensated heart failure
Hydralazine IV
Initial 5 mg IV
Repeat 5 to 10 mg IV after 20 minutes if still severe
Typical maximum 20 to 30 mg in acute episode per protocol
Adverse effects
Reflex tachycardia
Headache
Nifedipine immediate release oral
Initial 10 mg oral
Repeat 20 mg oral after 20 minutes if still severe
Repeat 20 mg oral after 20 minutes if still severe
Maximum 50 mg within 1 hour typical protocol
Cautions
Avoid sublingual use
Monitor for hypotension with magnesium
Ongoing blood pressure control
Maintenance antihypertensives
Labetalol oral
Typical starting 100 to 200 mg oral twice daily
Titration based on blood pressure response
Nifedipine extended release oral
Typical starting 30 mg oral daily
Titration based on blood pressure response
Methyldopa oral
Alternative option when needed
Slower onset
Fluids and pulmonary edema
Volume strategy
Restrictive fluids
Avoid routine bolus
Maintenance only if needed
Pulmonary edema management
Oxygen support escalation
Loop diuretic
Furosemide 20 mg IV
Repeat dosing based on response and renal function
Delivery and obstetric management
Definitive management considerations
Delivery as cure
Maternal stabilization before delivery when possible
Timing guidance commonly used
Preeclampsia without severe features
Delivery at 37 weeks gestation typical recommendation
Preeclampsia with severe features
Delivery at 34 weeks gestation or later typical recommendation
Earlier delivery for maternal or fetal deterioration
Expectant management before 34 weeks
Tertiary center requirement
Close maternal and fetal monitoring
Antenatal corticosteroids
Betamethasone 12 mg IM
Repeat 12 mg IM in 24 hours
Magnesium for fetal neuroprotection
Preterm delivery anticipated before 32 weeks per many protocols
Postpartum considerations
Postpartum management
Continued risk window
New onset hypertension and symptoms up to 6 weeks postpartum
Blood pressure peak postpartum
Commonly 3 to 6 days postpartum
Medication compatibility with breastfeeding
Labetalol generally compatible
Nifedipine generally compatible
Special Populations
Pregnancy
Pregnancy specific considerations
Diagnostic definitions
New hypertension after 20 weeks
Systolic blood pressure 140 mmHg or higher
Diastolic blood pressure 90 mmHg or higher
Two readings at least 4 hours apart
Severe range hypertension
Systolic blood pressure 160 mmHg or higher
Diastolic blood pressure 110 mmHg or higher
Preeclampsia criteria
Hypertension plus proteinuria
Hypertension plus severe feature without proteinuria
Severe features list
Thrombocytopenia
Platelets below 100 x 10^9 per L
Kidney injury
Creatinine above 97 micromol per L
Doubling of baseline creatinine
Liver involvement
AST or ALT at least twice normal
Persistent RUQ or epigastric pain
Pulmonary edema
Clinical or imaging support
Cerebral or visual symptoms
Severe headache
Visual disturbance
Eclampsia definition
Generalized tonic clonic seizure
No alternative cause identified
Geriatric
Geriatric considerations
Not applicable to typical obstetric population
Rare pregnancy at advanced maternal age still follows same criteria
Comorbidity burden
Chronic hypertension more common
Kidney disease more common
Pediatrics
Pediatric and adolescent pregnancy considerations
Same diagnostic thresholds
Blood pressure criteria unchanged
Weight based medication considerations
Anesthesia and airway equipment sizing
Safeguarding and support
Social support assessment
Follow up reliability planning
Background
Epidemiology
Epidemiology essentials
Incidence range commonly reported
Preeclampsia affects roughly 2 to 8 percent of pregnancies in many populations
Timing
Most cases after 20 weeks gestation
Postpartum onset possible up to 6 weeks
Maternal outcomes
Major contributor to maternal morbidity and mortality worldwide
Pathophysiology
Core mechanisms
Abnormal placentation
Poor spiral artery remodeling
Endothelial dysfunction
Increased vascular permeability
Vasoconstriction
Multisystem involvement
Brain
Liver
Kidney
Hematologic system
Therapeutic Considerations
Treatment rationale
Severe hypertension treatment goal
Prevent intracranial hemorrhage and stroke
Magnesium sulfate mechanism
Central anticonvulsant effect
Reduces recurrent seizures better than many alternatives
Delivery as definitive therapy
Placenta as driver of disease process
Patient Discharge Instructions
copy discharge instructions
Discharge instructions for nonsevere disease or postpartum follow up
Home blood pressure monitoring plan
Same arm and position
Rest 5 minutes before reading
Record readings with date and time
Medication instructions
Exact dose and schedule
Missed dose guidance per prescriber
Return immediately for emergency care
Severe headache
Vision changes
Seizure
Shortness of breath
Chest pain
New severe swelling with breathing difficulty
Right upper quadrant or epigastric pain
Heavy vaginal bleeding
Decreased fetal movement during pregnancy
Follow up timeline
Blood pressure check within 72 hours to 7 days postpartum
Earlier review if symptoms occur
References
Clinical guidelines and core sources
Key references
ACOG Practice Bulletin No 222 Gestational Hypertension and Preeclampsia 2020
Society for Maternal Fetal Medicine consensus guidance on severe hypertension and preeclampsia management
NICE guideline NG133 Hypertension in pregnancy diagnosis and management
World Health Organization recommendations on prevention and treatment of preeclampsia and eclampsia
Standard obstetric emergency treatment bundles for acute severe hypertension and eclampsia management
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.