Management of Pre-eclampsia and Eclampsia

1. Definitions and Classification

• Without severe features (previously "mild")
• With severe features: BP ≥ 160/110 mmHg, thrombocytopenia (<100,000/µL), renal insufficiency (creatinine >1.1 mg/dL), impaired liver function (LFTs 2× normal), pulmonary edema, new-onset headache unresponsive to medication, or visual disturbances

2. Pre-eclampsia WITHOUT Severe Features

Delivery Timing

• ≥37 weeks: Deliver
• 34-36+6 weeks: Expectant management with corticosteroids if appropriate; deliver no later than 37 weeks
• <34 weeks: Expectant management with close monitoring

Monitoring During Expectant Management

• Blood pressure and symptoms assessed at least weekly
• Labs (CBC, LFTs, creatinine) weekly
• Nonstress test or biophysical profile at least weekly; amniotic fluid assessment weekly; fetal growth every 3 weeks
• Repeated proteinuria measurements are not recommended - they do not change management once the diagnosis is made

Intrapartum MgSO4

3. Pre-eclampsia WITH Severe Features

Delivery Timing

Intrapartum Magnesium Sulfate (MgSO4)

• The Magpie Trial (10,000 women) proved MgSO4 reduces eclamptic seizures vs. placebo
• MgSO4 is superior to phenytoin and superior to diazepam for both prophylaxis and treatment

• Loading dose: 4-6 g IV over 15-20 minutes
• Maintenance: 2 g/hr IV continuous infusion

• Loss of deep tendon reflexes: first sign (~7-10 mEq/L)
• Respiratory depression: ~10-13 mEq/L
• Cardiac arrest: >15 mEq/L
• Antidote: Calcium gluconate 1 g IV slowly

4. Acute Antihypertensive Therapy

5. Management of Eclampsia (Active Seizure)

Immediate Steps (Parkland Protocol)

1. Protect airway - left lateral decubitus position, suction if needed, supplemental O2
2. Terminate seizure with MgSO4: 4-6 g IV over 15-20 minutes (if not already on it), then 2 g/hr maintenance
3. Recurrent seizures on MgSO4: Give an additional 2 g IV bolus; if still seizing, consider diazepam or lorazepam
4. Control BP after seizure control: if diastolic BP > 105 mmHg, give hydralazine 5-10 mg IV or labetalol 20 mg IV bolus
5. Labs: CBC + platelets, LFTs, BUN/creatinine, uric acid, coagulation studies
6. Urine output: Foley catheter; maintain ≥ 25 mL/hr
7. IV fluids: Restrict; limit to prevent pulmonary edema. Avoid diuretics and hyperosmotic agents unless specific indication
8. CT head: Indicated if decreased consciousness, persistent/refractory seizures, lateralizing neurological signs
9. Initiate steps to delivery - eclampsia is an indication for delivery after maternal stabilization

6. HELLP Syndrome

• Confirmed by: LDH >600 U/L, AST/ALT ≥ 2× normal, platelets <100,000/µL
• Management mirrors severe pre-eclampsia: MgSO4, BP control, delivery (expedite, especially at ≥ 34 weeks)
• DIC may develop; procoagulant therapy before delivery if spontaneous hemorrhage risk

7. Postpartum Management

• Approximately 1/3 of eclamptic seizures occur postpartum, most within 24 hours and almost all within 48 hours
• Continue MgSO4 for 24 hours postpartum (standard practice); can discontinue when brisk diuresis occurs (signals resolution of pathophysiology)
• BP may improve in first 48 hrs then worsen again at 3-6 days postpartum - monitor carefully
• Blood pressure evaluation at 7-10 days after discharge (or earlier if symptomatic)
• Women still hypertensive at 6 weeks postpartum may eventually normalize; long-term cardiovascular risk is elevated

8. Prevention

• Low-dose aspirin (81 mg/day, started at 12-28 weeks, ideally before 16 weeks) is recommended for women with ≥1 high-risk factor (prior pre-eclampsia, multifetal gestation, chronic hypertension, diabetes, renal disease, autoimmune disease)
• Calcium supplementation (1.5-2 g/day) in women with low dietary calcium intake reduces pre-eclampsia risk
• No proven benefit from vitamins C/E, salt restriction, or bed rest in prevention

9. Summary Algorithm

Pre-eclampsia suspected
       ↓
Classify: without severe features vs. with severe features
       ↓
Without severe features:         With severe features:
- Expectant if <37 wks           - MgSO4 immediately
- Deliver at 37 wks              - IV antihypertensives if BP ≥160/110
- Weekly monitoring              - Deliver (gestational age guides timing)
- MgSO4 not routine              
       ↓
Eclampsia (seizure):
- MgSO4 4-6g load → 2g/hr
- Airway, BP control
- Labs + Foley
- CT if indicated
- Stabilize → Deliver

• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice - comprehensive guidance on classification, MgSO4 dosing, antihypertensives, postpartum care
• Rosen's Emergency Medicine - Parkland Protocol, emergency management box (Box 173.4)
• Magpie Trial (2002): MgSO4 vs. placebo in 10,000 preeclamptic women - foundational evidence for MgSO4 use