ob.preeclampsia-early-onset.v1

Pre-eclampsia, Early-Onset (< 34 weeks gestational age)

obstetricsacutepregnancyadultacuteinpatientoutpatient

Start encounter →Print handoutPRODUCTION

NEW dossier 2026-05-15 — Phase C wave-3 coverage expansion (shard-5-obped-id autonomous build). Early-onset pre-eclampsia (< 34 wk) split out from the broad-coverage parent ob.pre-eclampsia.core.v1 because (1) different pathophysiology than late-onset (placental-insufficiency-driven via abnormal trophoblast invasion + angiogenic imbalance, vs late-onset maternal-cardiovascular-driven), (2) substantially higher maternal-fetal morbidity, (3) higher sFlt-1/PlGF likelihood-ratio for adverse outcome within 1 wk (PARROT 2019 + PROGNOSIS 2016), (4) ASPRE 2017 aspirin prophylaxis most-impactful for preterm/early-onset variant specifically (~ 62 % reduction), (5) remote-from-term fetal-lung-immaturity creates the antenatal-corticosteroid-window decision absent in late-onset. Same "split-from-parent" pattern as sibling ob.hellp-syndrome.v1 (Phase-C-wave-1). Status: INTEGRATED — NEW dossier in coverage expansion; INTEGRATED-quality content (flow with 12 phases + entry_points + required_inputs, regimen_axes with 9 stepwise tiers + RxCUIs validated against parent, 4 setting playbooks ed/inpatient/icu/outpatient, 10 severity triggers including all 10 user-specified ones, 4 sibling differentiations vs parent + HELLP + GHTN + chronic HTN, 12 PMIDs, terminology with ICD-10 / SNOMED / LOINC, test_files declared); seed manifest authored 2026-05-25. Seed manifest authored 2026-05-25 at prisma/seed/manifests/ob.preeclampsia-early-onset.v1.ts (defineBatch23ScaffoldManifest; terminology anchors projected 1:1 from this dossier). package field remains undefined (src/lib/tier3/problem-package/packages/preeclampsia-early-onset/ does not exist in this shard). Phenotype matrix (encoded in co-located _briefs/ob.preeclampsia-early-onset.v1.md): 9-axis cross-product (GA at onset × severity × proteinuria × end-organ involvement × HELLP-overlap × eclampsia-history × FGR × placental abruption × sFlt-1/PlGF ratio tier). First-class TS field for phenotype matrix remains schema-blocked. Bayesian linkage (encoded in co-located _briefs/ob.preeclampsia-early-onset.v1.md): sFlt-1/PlGF ratio > 85 LR+ ≈ 10 for adverse outcome within 1 wk in early-onset (PARROT 2019 PMID 30948284); ratio ≤ 38 NPV ~99.3 % (PROGNOSIS 2016 PMID 26735990); absent/reverse end-diastolic flow on umbilical artery Doppler LR+ ≈ 5–8 (TRUFFLE / GRIT); severe-feature criteria LR+ ≈ 5–7 (ACOG 222 + ISSHP 2024); ASPRE 2017 first-trimester screening derives the pre-test priors (high-risk ≈ 10 % of all pregnancies captures ~ 75 % of preterm-PE cases at 10 % FPR). T_treat thresholds: aspirin prophylaxis at high-risk per USPSTF 2021 (PMID 34581729); emergent delivery regardless of GA at rapid deterioration / HELLP / eclampsia / abruption / refractory HTN / pulmonary edema / AKI requiring CRRT; 48 h glucocorticoid window at 24+0–33+6 wk + stable + tertiary centre + no complications; magnesium prophylaxis at severe-features confirmation (Magpie 2002 NNT ≈ 100). Cross-dossier routing: ob.pre-eclampsia.core.v1 (parent — late-onset takeover at 34+0 wk), ob.hellp-syndrome.v1 (HELLP overlap), ob.gestational-hypertension.v1 (precursor), ob.postpartum-hemorrhage.core.v1 (abruption / PPH overlay), neph.aki.core.v1 (AKI overlay), cardio.htn.core.v1 (chronic-HTN-superimposed + long-term postpartum). Severity triggers: 10 rows authored — all 10 user-specified — early_onset_severe_features_with_glucocorticoid_window_eligible (severe); early_onset_severe_rapid_deterioration_emergent_delivery (life_threatening); eclampsia_seizure_in_early_onset (life_threatening); sflt_plgf_ratio_above_85_within_72h_delivery_likely (severe); fgr_with_abnormal_doppler_indication_for_delivery (severe); magnesium_timing_miss_in_severe_features (severe); aspirin_prophylaxis_eligible_at_high_risk_history (mild); recurrent_early_onset_in_subsequent_pregnancy (severe); postpartum_severe_htn_early_onset_residual (severe); pulmonary_edema_in_early_onset (life_threatening). Setting playbooks: 4 authored (ed / inpatient / icu / outpatient). Prehospital remains schema-blocked (no 'prehospital' DossierSetting value); encoded via ed playbook escalation with CRADLE-3 Lancet 2019 (PMID 30784635) anchor for low-resource recognition-and-referral. PMIDs: 12 canonical (PARROT 30948284, PROGNOSIS 26735990, ASPRE 28657417, USPSTF aspirin 34581729, CHAP 35363951, CHIPS 25629739, Magpie 12057549, Roberts Cochrane antenatal steroids 28321847, Liggins 1972 4561295, CRADLE-3 30784635, HYPITAT-II 25817374, ISSHP 2018 29899139). All citations + RxCUIs live-verified 2026-05-25 (8 PMIDs + 4 rxcui corrected from fabrications). All verified against parent dossier (ob.pre-eclampsia.core.v1) + sibling (ob.hellp-syndrome.v1) research bundles; no fresh PubMed loop this pass per §10 budget pivot. Registry registration deferred — main session batches per Phase C wave-3 refined contract (DO NOT touch _registry.ts). Audit row may not appear pre-registry; this is expected and orchestrator-acknowledged.

Entry points (8)

vital_abnormality
BP ≥ 160/110 sustained × 15 min at < 34 wk gestation (ACOG 767; ACOG 222 2020)
severe_htn_pregnancy_lt_34w
vital_abnormality
New BP ≥ 140/90 between 20+0 and 33+6 wk (ACOG Practice Bulletin 222 2020)
new_htn_20_34w
symptom
Severe HA + visual changes + RUQ pain at < 34 wk (ACOG 222 severe-feature criteria)
severe_features_symptoms_early_onset
lab_abnormality
Spot UPCR ≥ 0.3 or urine protein ≥ 300 mg/24 h at < 34 wk (ACOG 222 2020)
proteinuria_significant_early_onset
lab_abnormality
sFlt-1/PlGF ratio > 38 in suspected PE between 24+0 and 33+6 wk (PARROT Lancet 2019 PMID 30948284; PROGNOSIS NEJM 2016 PMID 26735990)
sflt_plgf_ratio_elevated
lab_abnormality
Plt < 100 K OR Cr ≥ 1.1 mg/dL or doubling OR AST/ALT ≥ 2× ULN at < 34 wk (ACOG 222 severe-feature criteria)
early_onset_severe_feature_labs
imaging
EFW < 10th centile + absent / reverse end-diastolic flow on umbilical artery Doppler at < 34 wk (TRUFFLE / GRIT decision-anchor; routes to MFM)
fgr_abnormal_umbilical_doppler
symptom
New seizure in pregnancy at < 34 wk (Magpie Trial Lancet 2002 PMID 12057549; ACOG 222)
eclampsia_seizure_lt_34w

Required inputs (23)

gestational_agerequired
demographic • used at CONTEXT
Drives delivery timing tier: < 24 wk extreme-early (counsel re termination); 24+0–27+6 very-early (extreme-NICU coordination); 28+0–33+6 early (glucocorticoid window 48 h); also defines the < 34 wk scope of this dossier (≥ 34 wk routes to ob.pre-eclampsia.core.v1 parent)
sbprequired
vital • used at RED_FLAGS
≥ 160 = severe; sustained × 15 min triggers IV antihypertensive within 30–60 min (ACOG 767); same threshold as late-onset
dbprequired
vital • used at RED_FLAGS
≥ 110 = severe; same trigger as SBP (ACOG 222 2020)
plateletsrequired
lab • used at INITIAL_WORKUP
< 100 K = severe feature; also HELLP-overlap criterion (routes to ob.hellp-syndrome.v1) (ACOG 222 2020)
creatininerequired
lab • used at INITIAL_WORKUP
Cr ≥ 1.1 mg/dL OR doubling = severe-feature criterion + AKI overlay (routes to neph.aki.core.v1) (ACOG 222 2020)
ast_altrequired
lab • used at INITIAL_WORKUP
AST/ALT ≥ 2× ULN = severe-feature criterion; HELLP-overlap if combined with thrombocytopenia + LDH > 600 (ACOG 222 + Sibai 1993/2004)
ldh
lab • used at INITIAL_WORKUP
LDH > 600 IU/L signals hemolysis + HELLP-overlap; routes to ob.hellp-syndrome.v1 if Tennessee criteria met (ISSHP 2024)
urine_proteinrequired
lab • used at INITIAL_WORKUP
UPCR ≥ 0.3 or 24-h ≥ 300 mg = pre-eclampsia diagnosis substrate; not required if severe features present (ACOG 222)
sflt_plgf_ratio
lab • used at RISK_STRATIFICATION
Ratio > 85 → LR+ ≈ 10 for adverse outcome / delivery within 1 wk in early-onset (PARROT 2019 PMID 30948284); ≤ 38 → NPV ~99.3 % for adverse outcome within 1 wk (PROGNOSIS 2016 PMID 26735990)
haptoglobin
lab • used at BRANCHING_WORKUP
< 25 mg/dL confirms intravascular hemolysis; supports HELLP-overlap diagnosis (ISSHP 2024)
uric_acid
lab • used at INITIAL_WORKUP
Elevated uric acid is a supportive marker in pre-eclampsia + correlates with severity (ACOG 222)
severe_headacherequired
symptom • used at CONTEXT
Persistent severe HA = severe feature; eclampsia precursor (ACOG 222 2020; Magpie 2002 PMID 12057549)
visual_disturbancerequired
symptom • used at CONTEXT
Scotomata / blurred vision / photopsia = severe feature; PRES precursor (ACOG 222 2020)
epigastric_ruq_painrequired
symptom • used at CONTEXT
Persistent RUQ / epigastric pain = severe feature; also AFLP / hepatic-capsular-distension differential (ACOG 222 2020)
eclampsia_seizure
symptom • used at RED_FLAGS
New tonic-clonic seizure → magnesium load 4–6 g IV (Magpie 2002 PMID 12057549) + delivery + neuro imaging if focal/atypical
abruption_signs
symptom • used at RED_FLAGS
Painful uterine bleeding ± fetal distress = placental abruption → emergent delivery + MTP anticipation; routes to ob.postpartum-hemorrhage.core.v1 (ACOG 222 2020)
pulmonary_edema_signs
symptom • used at RED_FLAGS
New dyspnea + SpO2 < 94 % + bilateral crackles + tachypnea = severe-feature criterion + life-threatening overlay (ACOG 222; NICE NG133 fluid-restriction pattern 80 mL/h)
fetal_doppler
imaging • used at MONITORING
Umbilical artery Doppler: absent / reverse end-diastolic flow → MFM + expedited delivery decision (TRUFFLE / GRIT decision-anchor)
fetal_growth_us
imaging • used at MONITORING
EFW < 10th centile + AC < 5th centile = FGR; q1–2 wk in early-onset PE (ACOG 222 2020)
chronic_htnrequired
history • used at CONTEXT
Pre-existing chronic HTN = substrate for superimposed pre-eclampsia; CHAP target < 140/90 (Tita NEJM 2022 PMID 35363951)
prior_early_onset_perequired
history • used at CONTEXT
Recurrence ≈ 25–40 % in subsequent pregnancy after prior early-onset PE (higher than late-onset ≈ 16–25 %); strongest indication for aspirin prophylaxis (USPSTF 2021 PMID 34581729; ASPRE 2017 PMID 28657417)
autoimmune_or_aps
history • used at CONTEXT
Autoimmune disease + antiphospholipid syndrome = high-risk per USPSTF 2021; aspirin + low-dose LMWH consideration
current_meds
medication • used at CONTEXT
Aspirin prophylaxis status per ASPRE / USPSTF; ACE-I / ARB / renin-inhibitor teratogen check; LMWH if VTE history

12-phase flow (12)

1FRAME
Confirm early-onset pre-eclampsia (HTN ≥ 140/90 after 20 wk + < 34 wk + proteinuria OR severe features) per ACOG 222 (2020) + ISSHP 2024; distinguish from gestational HTN (no proteinuria + no severe features), chronic HTN (pre-existing or before 20 wk), and late-onset PE (≥ 34 wk → routes to parent ob.pre-eclampsia.core.v1)
inputs: gestational_age, sbp, dbp, urine_protein, chronic_htn
advance: Early-onset classification assigned (< 34 wk + PE-criteria met)
2ENTRY
Capture trigger (severe HTN per ACOG 767, new HTN after 20 wk + < 34 wk, severe-feature symptom, severe-feature lab pattern, sFlt-1/PlGF elevation, eclamptic seizure, FGR + abnormal Doppler) per ACOG 222 + PARROT 2019 + PROGNOSIS 2016
inputs: gestational_age
advance: Trigger documented; team activated
3CONTEXT
Capture baseline BP / chronic HTN substrate (CHAP target < 140/90, Tita NEJM 2022 PMID 35363951), prior early-onset PE history (recurrence 25–40 %), aspirin prophylaxis status (ASPRE 2017 PMID 28657417 + USPSTF 2021 PMID 34581729), autoimmune / APS, severe-feature symptom screen, fetal status, current medications including ACE-I / ARB teratogen check (ACOG 222 2020)
inputs: chronic_htn, prior_early_onset_pe, severe_headache, visual_disturbance, epigastric_ruq_pain, current_meds
advance: Severe-feature screen + fetal status + risk-factor profile documented
4RED_FLAGS
Sustained severe HTN ≥ 160/110 × 15 min → IV antihypertensive within 30–60 min (ACOG 767); eclamptic seizure → STAT magnesium 4–6 g IV (Magpie 2002 PMID 12057549); pulmonary edema (severe-feature criterion); HELLP overlay with plt < 50 K (routes to ob.hellp-syndrome.v1); abruption (routes to ob.postpartum-hemorrhage.core.v1); AKI requiring CRRT (routes to neph.aki.core.v1)
inputs: sbp, dbp
advance: Life-threatening overlays assessed; severe HTN or eclampsia treated; airway secured if seizing; emergent delivery indication evaluated
5INITIAL_WORKUP
CBC with peripheral smear (schistocytes), CMP (Cr, AST/ALT, total bilirubin), LDH, haptoglobin, UPCR or 24-h urine, T&S, coags + fibrinogen + D-dimer (DIC screen), uric acid; fetal monitoring (NST / BPP); fetal growth ultrasound + umbilical artery Doppler at MFM consult (ACOG 222 2020)
inputs: platelets, creatinine, ast_alt, urine_protein, uric_acid
actions: panel.cbc, panel.lft, panel.renal, panel.coag, panel.ua, workup.preeclampsia
advance: Severe-feature labs returned; fetal status documented; HELLP / DIC screen complete
6BRANCHING_WORKUP
sFlt-1/PlGF ratio if available (PARROT 2019 PMID 30948284 + PROGNOSIS 2016 PMID 26735990); ADAMTS13 if features atypical (TTP differential per Scully 2017 PMID 27868334); Swansea criteria + glucose + ammonia if AFLP suspected (Ch'ng 2002 PMID 12427793); head CT / MRI if eclampsia atypical / focal deficit (PRES vs CVA); echo if HF / peripartum cardiomyopathy
inputs: sflt_plgf_ratio, haptoglobin
actions: workup.preeclampsia
advance: Differential mimics ruled out or branched out; sFlt-1/PlGF tier assigned if available
7DIFFERENTIAL
Phenotype per ACOG 222 + ISSHP 2024 + first-trimester risk-stratification: early-onset PE with vs without severe features; superimposed-on-chronic-HTN; HELLP-overlap (routes to ob.hellp-syndrome.v1); eclampsia; rule out gestational HTN, chronic HTN, secondary HTN, AFLP, TTP, aHUS, SLE flare, viral hepatitis, peripartum cardiomyopathy
advance: Phenotype assigned; differential mimics excluded
8RISK_STRATIFICATION
Stratify by GA tier (< 24 extreme-early / 24+0–27+6 very-early / 28+0–33+6 early) + severity (mild vs severe-features) + sFlt-1/PlGF ratio tier (≤ 38 low / 38–85 intermediate / > 85 high) + overlays (HELLP / eclampsia / abruption / FGR + abnormal Doppler / pulmonary edema / AKI); PIERS / fullPIERS if available; MAP target ≥ 65 if shock (ACOG 222 + ISSHP 2024 + PARROT 2019 + PROGNOSIS 2016)
actions: calc.map
advance: GA tier + severity + sFlt-1/PlGF tier + overlay assessment complete; delivery timing decided
9TREATMENT
Sustained severe BP → IV labetalol 20→40→80→80 mg q10min (max 220) OR IV hydralazine 5–10 mg q20min × 3 (max 30) OR PO IR nifedipine 10–20 mg q20min (ACOG 767); goal SBP < 160 / DBP < 110 within 30–60 min; magnesium 4–6 g IV load + 1–2 g/h × 24 h post-delivery for severe-features OR eclampsia (Magpie 2002 PMID 12057549); antenatal corticosteroids if 24+0–33+6 wk + delivery anticipated < 7 d (ACOG 713 + Roberts Cochrane 2017 PMID 28321847); delivery timing per phenotype per ACOG 222 + ISSHP 2024 (immediate for HELLP / eclampsia / rapidly deteriorating / abruption / refractory HTN / pulmonary edema / AKI requiring CRRT; expectant 48 h glucocorticoid window if stable + tertiary centre + eligible)
inputs: sbp, dbp, gestational_age
advance: BP controlled + magnesium running for severe features + delivery plan made (immediate vs 48 h glucocorticoid window)
10DISPOSITION
L&D / OB ICU for severe features / eclampsia / HELLP / refractory HTN / pulmonary edema / AKI requiring CRRT per ACOG 222; antepartum admission with continuous fetal monitoring if remote-from-term + stable + glucocorticoid-window-eligible at tertiary centre; ICU for refractory HTN / DIC / eclamptic status / AKI requiring CRRT (ACOG 222 + ISSHP 2024); postpartum monitoring × 72 h minimum
advance: Level of care + delivery timing assigned
11MONITORING
Continuous fetal monitoring antepartum; BP q15min during severe-HTN treatment then q1h × 24 h then q4h (ACOG 767); magnesium toxicity (DTRs, RR ≥ 12, urine output ≥ 30 mL/h, Mg level if AKI per ACOG 222); CBC + LFT + Cr + LDH + fibrinogen + UPCR q6–12 h (q4–6 h if severe-features or HELLP-overlap); fetal growth + umbilical artery Doppler q1–2 wk (TRUFFLE / GRIT decision-anchor); daily fluid balance; postpartum 72-h continued deterioration window
inputs: sbp, dbp, platelets, creatinine, ast_alt
actions: panel.cbc, panel.lft, panel.renal, panel.coag
advance: Mother + fetus stable; labs trending; postpartum monitoring through 72 h–6 wk
12FOLLOWUP
BP + lab check 3–7 d postpartum + 1–2 wk + 4–6 wk per ACOG 222 + ACOG 2025; lifetime CV-risk follow-up (early-onset PE doubles future CV risk, with risk gradient steepest after early-onset variant per AHA 2021); next-pregnancy aspirin 81–150 mg PO daily from 12 wk per USPSTF 2021 (PMID 34581729) given recurrence 25–40 %; preconception MFM consultation for next pregnancy; postpartum BP self-monitoring daily × 1 wk → weekly × 6 wk; psychosocial screen (PE / preterm delivery increase PPD / PTSD risk); endocrine-renal review at 6 wk (lipid panel, fasting glucose / HbA1c, UACR, Cr, BMI per AHA 2021 + ACOG 2025)
advance: Postpartum BP + recurrence counseling + next-pregnancy aspirin plan + preconception MFM plan + lifetime CV surveillance documented