Advanced•9 min read•High Yield
Preeclampsia - CCS Case Guide
Key Takeaway: Preeclampsia is a hypertensive disorder of pregnancy characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks gestation. It can rapidly progress to eclampsia, HELLP syndrome, or maternal and fetal death.
Preeclampsia is a hypertensive disorder of pregnancy characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks gestation. It can rapidly progress to eclampsia, HELLP syndrome, or maternal and fetal death. Timely diagnosis, seizure prophylaxis with magnesium sulfate, blood pressure control, and delivery planning are the cornerstones of management on CCS.
Recognizing the Preeclampsia Presentation
- History: Pregnant patient >20 weeks gestation with new-onset headache, visual changes (scotomata, blurred vision), right upper quadrant or epigastric pain, and rapid weight gain or edema
- Physical Exam: Elevated blood pressure (≥140/90 mmHg on two readings), peripheral edema, hyperreflexia with clonus, right upper quadrant tenderness
- Vital Signs: Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg; severe features if ≥160/110 mmHg
- Obstetric Exam: Assess fundal height, fetal heart tones, and cervical status for delivery planning
- Risk Factors: Nulliparity, chronic hypertension, diabetes, renal disease, obesity, multiple gestation, advanced maternal age, prior preeclampsia
- Severe Features: Systolic BP ≥160 or diastolic ≥110 mmHg, thrombocytopenia (<100,000), elevated liver enzymes (twice normal), renal insufficiency (creatinine >1.1 mg/dL), pulmonary edema, or new-onset cerebral or visual disturbances
Immediate Actions (First 5 Minutes)
These orders should be placed immediately — timing is scored:
Critical First Orders
- ✓ Confirm blood pressure with repeat measurement 4 hours apart (or immediately if severe)
- ✓ Start IV magnesium sulfate 4 g loading dose then 1-2 g/hr for seizure prophylaxis
- ✓ Administer IV labetalol or IV hydralazine for acute severe hypertension (≥160/110)
- ✓ Place Foley catheter and monitor urine output hourly
- ✓ Obtain stat labs: CBC, CMP, LDH, uric acid, coagulation studies
- ✓ Continuous fetal heart rate monitoring
- ✓ Assess for severe features to guide delivery timing
Complete Workup
After initial stabilization, complete the diagnostic workup:
- CBC with platelet count (thrombocytopenia suggests HELLP)
- CMP including AST, ALT, creatinine, and albumin
- LDH (elevated in hemolysis/HELLP)
- Uric acid level
- Spot urine protein-to-creatinine ratio or 24-hour urine protein
- Peripheral blood smear (schistocytes suggest HELLP)
- Coagulation studies (PT, PTT, fibrinogen)
- Type and screen
- Nonstress test (NST) and biophysical profile (BPP)
- Ultrasound for fetal growth, amniotic fluid volume, and estimated fetal weight
Treatment
Seizure Prophylaxis
- Magnesium sulfate 4 g IV loading dose over 15-20 minutes
- Maintenance infusion 1-2 g/hr IV
- Monitor magnesium levels, deep tendon reflexes, urine output, and respiratory rate
- Continue for 24-48 hours postpartum
- Keep calcium gluconate at bedside for magnesium toxicity
Antihypertensive Therapy
- IV labetalol 20 mg initial dose, escalating to 40 mg then 80 mg every 10-20 minutes
- IV hydralazine 5-10 mg every 20 minutes as alternative
- Oral nifedipine 10-20 mg for less acute cases
- Target BP <160/110 mmHg; avoid precipitous drops that compromise uteroplacental perfusion
Delivery Planning
- Deliver at ≥37 weeks for preeclampsia without severe features
- Deliver at ≥34 weeks (or earlier if maternal or fetal instability) for severe features
- Administer betamethasone 12 mg IM x 2 doses 24 hours apart if <34 weeks for fetal lung maturity
- Induction of labor preferred if cervix favorable; cesarean for obstetric indications
HELLP Syndrome Management
- Expedite delivery regardless of gestational age if platelets <50,000 or rapidly declining
- Transfuse platelets if <50,000 and delivery imminent or <20,000 regardless
- Monitor for hepatic rupture, DIC, and placental abruption
Common Pitfalls
Scoring Tip: These are the most commonly missed actions for Preeclampsia cases.
- Failing to start magnesium sulfate promptly for seizure prophylaxis
- Not recognizing severe features that mandate earlier delivery
- Overlooking HELLP syndrome by not checking platelet count, LFTs, and LDH
- Using ACE inhibitors or ARBs (teratogenic and contraindicated in pregnancy)
- Delaying delivery when maternal or fetal status is deteriorating
- Stopping magnesium sulfate too early postpartum (continue 24-48 hours)
- Forgetting to administer antenatal corticosteroids when <34 weeks gestation
Disposition
- Admit to labor and delivery for continuous monitoring
- ICU transfer for eclampsia, refractory hypertension, pulmonary edema, or HELLP with DIC
- Postpartum monitoring for at least 48-72 hours as preeclampsia can worsen after delivery
- Outpatient follow-up with OB and maternal-fetal medicine within 1 week
Key Orders Checklist
- ☐ Magnesium sulfate IV infusion
- ☐ IV labetalol or hydralazine
- ☐ CBC every 6-12 hours
- ☐ CMP every 6-12 hours
- ☐ LDH level
- ☐ Urine protein-to-creatinine ratio
- ☐ Continuous fetal monitoring
- ☐ Betamethasone IM (if <34 weeks)
- ☐ Foley catheter with hourly urine output
- ☐ Type and screen
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