This handout is for severe pre-eclampsia / eclampsia (peripartum hypertensive crisis). Your care team identified this based on: bp ≥160/110 in pregnancy or postpartum (acog 2020).
Other reasons your team may use this plan: severe features: severe ha, vision changes, ruq/epigastric pain, ams, low platelets, aki, transaminitis, pulmonary edema (acog 2020); seizure on background of pre-eclampsia → eclampsia (acog 2020); currently pregnant or within 6 weeks postpartum (acog 2020).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| labetalol | 20 mg IV → 40 mg → 80 mg q10 min (max 300 mg cumulative) | IV | bolus | ACOG 2020 first-line; safe in pregnancy; mortality benefit data from CHIPS (PMID 25629739) |
| hydralazine | 5-10 mg IV q15-20 min (max 30 mg cumulative) | IV | q15-20 min | ACOG 2020 alternative; less predictable BP drop than labetalol but acceptable; safe in pregnancy |
| nifedipine | 10-20 mg PO (immediate-release), repeat in 30 min if no response (max 50 mg/h cumulative) | PO | q30 min × 2 then q4-6h | ACOG 2020 first-line oral option; useful when IV access pending; monitor for hypotension with concurrent MgSO4 |
| magnesium sulfate | 4-6 g IV load over 20 min then 1-2 g/h infusion | IV | continuous | MAGPIE (PMID 12053139) + Lucas (PMID 7494569) — primary anti-seizure prophylaxis + treatment per ACOG 2020; goal Mg 4.8-8.4 mg/dL; check reflexes + RR + UOP q1h |
| lorazepam | 2-4 mg IV | IV | PRN for seizure breakthrough on MgSO4 | Adjunct AED for refractory seizures; consider levetiracetam if recurrent |
| metoprolol | 25 mg PO BID titrate (postpartum only — not first-line antepartum) | PO | BID | Postpartum oral BB; AVOID atenolol antepartum (FGR association); metoprolol acceptable postpartum + during lactation |
| AVOID ACE inhibitors / ARBs in pregnancy | AVOID | N/A | N/A | Fetotoxic — oligohydramnios, renal dysgenesis, lung hypoplasia, IUGR; FDA Pregnancy Category D; ACOG Class III in pregnancy |
| AVOID nitroprusside in pregnancy | AVOID | N/A | N/A | Cyanide → fetal toxicity (cyanide crosses placenta); ACOG 2020 AVOID in pregnancy |
| AVOID atenolol in pregnancy | AVOID | N/A | N/A | FGR association in 1st-trimester exposure; ACOG suggests labetalol or metoprolol if BB needed |
| Delivery (definitive treatment) | Per OB judgment — induction vs C-section based on severity + cervical readiness | OR_or_LD | as needed | ACOG 2020 — delivery is curative; ≥34 wk severe → deliver; <34 wk severe → individualized with steroids + MgSO4 + tertiary center transfer |
Plan: Severe pre-eclampsia / eclampsia — pregnancy-safe BP control + MgSO4 seizure prophylaxis + delivery as definitive Tx
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Postpartum: continue MgSO4 24 h post-delivery; transition to oral labetalol or nifedipine for postpartum HTN; 1-2 wk postpartum BP check; 3-mo cardiology + nephrology assessment; lifetime CV risk elevation discussion (pre-eclampsia is independent CV risk factor)
Guideline: ACOG Practice Bulletin 222 (2020/2022) Severe Pre-eclampsia + 2025 ACC/AHA HTN (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493)