Eclampsia & Severe Preeclampsia Management (ACOG 2020)

Algorithm Steps

1. ▶

   Start

   ECLAMPSIA: Seizure in Pregnancy/Postpartum

   New-onset tonic-clonic seizure in patient with preeclampsia or unexplained in pregnancy

   1. ●

      Action

      Eclampsia: Immediate Actions

      Protect patient, establish airway, give magnesium

      • Call for help - activate emergency response
      • Position patient on left side
      • Protect from injury - padded bed rails
      • Suction secretions, maintain airway
      • Apply oxygen via face mask
      • Establish IV access
      1. ●

         Action

         Magnesium Sulfate - Loading

         Immediate seizure control and prevention

         • Loading: MgSO4 4-6g IV over 15-20 minutes
         • If seizure recurs: additional 2g IV bolus
         • Maintenance: 1-2g/hour continuous IV infusion
         • Monitor: reflexes, respiratory rate, urine output
         • Keep calcium gluconate at bedside (antidote)
         1. ●

            Action

            Acute Blood Pressure Control

            Target: <160/110 mmHg within 30-60 minutes

            • FIRST LINE: Labetalol 20mg IV, then 40mg, then 80mg q10min (max 300mg)
            • OR Hydralazine 5-10mg IV q20min (max 20mg)
            • OR Nifedipine IR 10-20mg PO q20min (max 50mg in 1hr)
            • If refractory: Nicardipine or Esmolol infusion
            • Avoid precipitous drops - risk of placental hypoperfusion
            • Continuous fetal monitoring during treatment
            1. ◆

               Decision

               Gestational Age Assessment

               Determine timing of delivery

               1. ●

                  Action

                  ≥34 weeks: Deliver

                  Delivery indicated for severe preeclampsia at ≥34 weeks

                  • Stabilize BP and initiate magnesium
                  • Mode of delivery based on obstetric factors
                  • Induction of labor appropriate if cervix favorable
                  • Cesarean if urgent maternal/fetal indications
                  • Continue magnesium through delivery and 24h postpartum
                  1. ◆

                     Decision

                     HELLP Syndrome Present?

                     Hemolysis, Elevated Liver enzymes, Low Platelets

                     • Hemolysis: LDH >600, schistocytes, bilirubin >1.2
                     • Elevated liver enzymes: AST/ALT >2x normal
                     • Low platelets: <100,000/μL
                     1. ●

                        Action

                        HELLP Syndrome Management

                        High-risk - delivery usually indicated

                        • Delivery is definitive treatment
                        • Platelet transfusion if <20K or <50K with bleeding/surgery
                        • Correct coagulopathy with FFP if needed
                        • Monitor for liver hematoma/rupture (RUQ pain)
                        • CT/MRI if suspect hepatic complications
                        • Dexamethasone controversial - limited evidence
                        1. ✓

                           Outcome

                           Patient Stabilized - Continued Care

                           Ongoing monitoring and supportive care

                     2. ✓

                        Outcome

                        Postpartum Monitoring

                        Continue monitoring, gradual resolution expected

                        • Continue magnesium 24-48 hours postpartum
                        • BP monitoring every 4 hours
                        • Most patients improve within 48 hours
                        • May worsen initially postpartum - remain vigilant
                        • Antihypertensives for BP >150/100
                        • Counsel on recurrence risk (15-25% next pregnancy)
               2. ●

                  Action

                  <34 weeks: Stabilize & Consider Expectant

                  Balance prematurity risks vs. disease progression

                  • Betamethasone 12mg IM x2 doses, 24h apart
                  • Stabilize BP and initiate magnesium
                  • Expectant management at facility with maternal-fetal medicine
                  • 24-48h for steroid benefit if stable
                  • Serial labs: CBC, LFTs, Cr q6-12h
                  • Continuous fetal monitoring
                  1. ⚠

                     Warning

                     Indications for Immediate Delivery

                     Do NOT delay for steroids

                     • Uncontrolled severe hypertension despite maximum therapy
                     • Eclampsia
                     • Pulmonary edema
                     • Placental abruption
                     • DIC
                     • Non-reassuring fetal status
                     • Persistent severe symptoms despite treatment