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cardio.hypertensive-emergency.eclampsia.v1PRODUCTION
cardio.hypertensive-emergency.eclampsia.v1

Severe pre-eclampsia / eclampsia (peripartum hypertensive crisis)

cardiologyacuteadultpregnancy
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Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Severe pre-eclampsia / eclampsia = pregnancy or postpartum (within 6 wk) + BP ≥160/110 ± severe features ± seizure. Pregnancy-safe drug profile (labetalol / hydralazine / nifedipine). MgSO4 for seizure prophylaxis + treatment (MAGPIE PMID 12053139; Lucas PMID 7494569). DELIVERY is curative (ACOG 2020). Inherits parent HTN-emergency framework.

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eclampsia/pre-eclampsia phenotype confirmed

Patient inputs (12)

Maternal age extremes (<20 or >35) increase pre-eclampsia risk + complication severity

Gestational age drives delivery decision (≥34 wk severe features → delivery; <34 wk individualized with steroids + MgSO4)

Plt <100k = severe feature (HELLP component); <50k contraindicates regional anesthesia

AKI (Cr ≥1.1 or doubling) = severe feature

Transaminitis (>2× upper limit) = severe feature (HELLP component)

Goal 4.8-8.4 mg/dL during MgSO4 infusion; reflex check + RR check + UOP

Continuous fetal monitoring during HTN crisis + delivery planning

Severe features (HA, vision, RUQ, AMS, low plt, AKI, transaminitis, pulm edema) define severe pre-eclampsia → MgSO4 + delivery planning

Seizure → eclampsia → MgSO4 reload + emergent delivery

Goal SBP <160 within 30-60 min (ACOG 2020); avoid drop below 130/80 (preserves placental perfusion)

Goal DBP <110 within 30-60 min (ACOG 2020)

Proteinuria ≥300 mg/24h or ≥2+ on UA supports pre-eclampsia diagnosis

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningeclampsia_seizure_breakthrough_on_mgso4
    Recurrent seizure during MgSO4 infusion — requires reload + benzodiazepine + emergent delivery
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghellp_with_progressive_thrombocytopenia
    HELLP syndrome with platelets <50k OR LDH >600 OR worsening transaminitis — high risk for hepatic hemorrhage + DIC
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmagnesium_toxicity_loss_of_reflexes
    Loss of patellar reflexes OR RR <12 OR UOP <20 mL/h on MgSO4 — signs of magnesium toxicity (Mg >9 mg/dL)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningplacental_abruption_with_severe_pre_eclampsia
    Vaginal bleeding + uterine tenderness + non-reassuring fetal HR + severe pre-eclampsia — placental abruption
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpostpartum_eclampsia_late
    Eclampsia seizure occurring postpartum (up to 6 weeks after delivery) — late postpartum eclampsia
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Severe pre-eclampsia / eclampsia — pregnancy-safe BP control + MgSO4 seizure prophylaxis + delivery as definitive Tx
axis: eclampsia_pregnancy_safe_bp_control_with_mgso4
Selected axis "Severe pre-eclampsia / eclampsia — pregnancy-safe BP control + MgSO4 seizure prophylaxis + delivery as definitive Tx" by default fallback (first axis)
  • labetalol
    first line
    mixed_alpha_beta_blocker
    20 mg IV → 40 mg → 80 mg q10 min (max 300 mg cumulative) • IV • bolus
    triggers: preeclampsia_severe_features, pregnancy_htn_emergency
    ACOG 2020 first-line; safe in pregnancy; mortality benefit data from CHIPS (PMID 25629739)
    rxcui 6185
  • hydralazine
    first line
    arteriolar_vasodilator
    5-10 mg IV q15-20 min (max 30 mg cumulative) • IV • q15-20 min
    triggers: preeclampsia_alt_to_labetalol, labetalol_contraindication
    ACOG 2020 alternative; less predictable BP drop than labetalol but acceptable; safe in pregnancy
    rxcui 5487
  • nifedipine
    first line
    DHP_CCB
    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
    triggers: preeclampsia_PO_route_available, IV_access_unavailable
    ACOG 2020 first-line oral option; useful when IV access pending; monitor for hypotension with concurrent MgSO4
    rxcui 7417
  • magnesium sulfate
    first line
    NMDA_antagonist_anticonvulsant
    4-6 g IV load over 20 min then 1-2 g/h infusion • IV • continuous
    triggers: eclampsia, preeclampsia_with_severe_features
    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
    rxcui 6585
  • lorazepam
    rescue
    benzodiazepine
    2-4 mg IV • IV • PRN for seizure breakthrough on MgSO4
    triggers: eclampsia_seizure_breakthrough_on_mgso4
    Adjunct AED for refractory seizures; consider levetiracetam if recurrent
    rxcui 6470
  • metoprolol
    add on
    beta_blocker_postpartum_only
    25 mg PO BID titrate (postpartum only — not first-line antepartum) • PO • BID
    triggers: postpartum_HTN_management
    Postpartum oral BB; AVOID atenolol antepartum (FGR association); metoprolol acceptable postpartum + during lactation
    rxcui 6918
  • AVOID ACE inhibitors / ARBs in pregnancy
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: pregnancy_diagnosis
    Fetotoxic — oligohydramnios, renal dysgenesis, lung hypoplasia, IUGR; FDA Pregnancy Category D; ACOG Class III in pregnancy
  • AVOID nitroprusside in pregnancy
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: pregnancy_diagnosis
    Cyanide → fetal toxicity (cyanide crosses placenta); ACOG 2020 AVOID in pregnancy
  • AVOID atenolol in pregnancy
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: pregnancy_diagnosis
    FGR association in 1st-trimester exposure; ACOG suggests labetalol or metoprolol if BB needed
  • Delivery (definitive treatment)
    first line
    obstetric_intervention
    Per OB judgment — induction vs C-section based on severity + cervical readiness • OR_or_LD • as needed
    triggers: severe_preeclampsia_at_or_after_34_weeks, eclampsia, HELLP, placental_abruption
    ACOG 2020 — delivery is curative; ≥34 wk severe → deliver; <34 wk severe → individualized with steroids + MgSO4 + tertiary center transfer

outpatient playbook — drug actions (1)

  1. 1. continue oral antihypertensive if needed
    rxcui 6918
    Labetalol or nifedipine maintenance; ACEi/ARB if non-lactating + appropriate • PO • daily
    trigger: Persistent HTN
    ACOG 2020 + ACC/AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: BP ≥160/110 in pregnancy or postpartum (ACOG 2020); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Severe pre-eclampsia / eclampsia (peripartum hypertensive crisis)** (cardio.hypertensive-emergency.eclampsia.v1).
Scope: Severe pre-eclampsia / eclampsia = pregnancy or postpartum (within 6 wk) + BP ≥160/110 ± severe features ± seizure. Pregnancy-safe drug profile (labetalol / hydralazine / nifedipine). MgSO4 for seizure prophylaxis + treatment (MAGPIE PMID 12053139; Lucas PMID 7494569). DELIVERY is curative (ACOG 2020). Inherits parent HTN-emergency framework.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Severe pre-eclampsia / eclampsia — pregnancy-safe BP control + MgSO4 seizure prophylaxis + delivery as definitive Tx**.
1. labetalol 20 mg IV → 40 mg → 80 mg q10 min (max 300 mg cumulative) IV bolus (mixed_alpha_beta_blocker, first line) — ACOG 2020 first-line; safe in pregnancy; mortality benefit data from CHIPS (PMID 25629739)
2. hydralazine 5-10 mg IV q15-20 min (max 30 mg cumulative) IV q15-20 min (arteriolar_vasodilator, first line) — ACOG 2020 alternative; less predictable BP drop than labetalol but acceptable; safe in pregnancy
3. 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 (DHP_CCB, first line) — ACOG 2020 first-line oral option; useful when IV access pending; monitor for hypotension with concurrent MgSO4
4. magnesium sulfate 4-6 g IV load over 20 min then 1-2 g/h infusion IV continuous (NMDA_antagonist_anticonvulsant, first line) — 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
5. lorazepam 2-4 mg IV IV PRN for seizure breakthrough on MgSO4 (benzodiazepine, rescue) — Adjunct AED for refractory seizures; consider levetiracetam if recurrent
6. metoprolol 25 mg PO BID titrate (postpartum only — not first-line antepartum) PO BID (beta_blocker_postpartum_only, add on) — Postpartum oral BB; AVOID atenolol antepartum (FGR association); metoprolol acceptable postpartum + during lactation
7. AVOID ACE inhibitors / ARBs in pregnancy AVOID N/A N/A (do_not_use, contraindication substitute) — Fetotoxic — oligohydramnios, renal dysgenesis, lung hypoplasia, IUGR; FDA Pregnancy Category D; ACOG Class III in pregnancy
8. AVOID nitroprusside in pregnancy AVOID N/A N/A (do_not_use, contraindication substitute) — Cyanide → fetal toxicity (cyanide crosses placenta); ACOG 2020 AVOID in pregnancy
9. AVOID atenolol in pregnancy AVOID N/A N/A (do_not_use, contraindication substitute) — FGR association in 1st-trimester exposure; ACOG suggests labetalol or metoprolol if BB needed
10. Delivery (definitive treatment) Per OB judgment — induction vs C-section based on severity + cervical readiness OR_or_LD as needed (obstetric_intervention, first line) — ACOG 2020 — delivery is curative; ≥34 wk severe → deliver; <34 wk severe → individualized with steroids + MgSO4 + tertiary center transfer

Setting playbook (outpatient) — Long-term postpartum follow-up — chronic HTN 40% develop within 1 yr (NEJM postpartum HTN cohort); lifetime CV risk elevation discussion; subsequent pregnancy planning
11. continue oral antihypertensive if needed Labetalol or nifedipine maintenance; ACEi/ARB if non-lactating + appropriate PO daily — Persistent HTN (ACOG 2020 + ACC/AHA 2025)

Non-pharmacologic actions:
- Lifetime CV risk discussion (pre-eclampsia is independent CV risk factor — Bellamy BMJ 2007)
- Subsequent pregnancy: low-dose aspirin starting 12-28 wk per USPSTF 2021
- Annual BP + lipid + A1c

AVOID / contraindication checks:
- ACEi_ARB_avoid_in_pregnancy_fetotoxic (ACOG 2020)
- Nitroprusside_avoid_in_pregnancy_fetal_cyanide (ACOG 2020)
- Atenolol_avoid_in_pregnancy_FGR (ACOG 2020)
- Avoid_BP_drop_below_130_80_preserves_placental_perfusion (ACOG 2020)
- Mgso4_check_reflexes_RR_UOP_q1h_during_infusion (ACOG 2020)
- Nifedipine_immediate_release_caution_with_mgso4_hypotension (ACOG 2020)

Monitoring

Regimen monitoring:
- q5-15min BP during acute phase (ACOG 2020)
- continuous fetal HR monitoring (ACOG 2020)
- q1h reflexes RR UOP during mgso4 infusion (ACOG 2020)
- mg level q6h target 4.8-8.4 (ACOG 2020)
- CBC LFTs Cr q6-12h for HELLP progression (ACOG 2020)
- daily fetal assessment if pregnancy ongoing (ACOG 2020)
- continuous postpartum monitoring for 24h after delivery (ACOG 2020)

Setting (outpatient) monitoring:
- Annual BP + lipid + A1c
- Quarterly visits if persistent HTN

Follow-up plan: 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)
- Close-out criterion: postpartum oral regimen + 1-2 wk follow-up booked

Monitoring phase: q5-15 min BP; continuous fetal monitoring; q1h reflexes + RR + UOP during MgSO4 infusion; goal Mg 4.8-8.4 mg/dL; CBC + LFTs + Cr q6-12h; daily fetal assessment if ongoing pregnancy

Disposition

Current setting: outpatient — Long-term postpartum follow-up — chronic HTN 40% develop within 1 yr (NEJM postpartum HTN cohort); lifetime CV risk elevation discussion; subsequent pregnancy planning

Disposition criteria:
- Long-term continuation; cross-link to cardio.htn.core.v1 + lifetime CV risk panel

Escalation triggers (move to higher acuity):
- BP rebound → escalate per HTN ladder
- Subsequent pregnancy → preconception counseling + early aspirin

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Recurrent seizure during MgSO4 infusion — requires reload + benzodiazepine + emergent delivery
- [LIFE_THREATENING] HELLP syndrome with platelets <50k OR LDH >600 OR worsening transaminitis — high risk for hepatic hemorrhage + DIC
- [LIFE_THREATENING] Loss of patellar reflexes OR RR <12 OR UOP <20 mL/h on MgSO4 — signs of magnesium toxicity (Mg >9 mg/dL)

Citations

- ACOG Practice Bulletin 222 (2020/2022) Severe Pre-eclampsia + 2025 ACC/AHA HTN (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493) [PMID:38316810](https://pubmed.ncbi.nlm.nih.gov/38316810/)
- Cited evidence (PMID 38613493) [PMID:38613493](https://pubmed.ncbi.nlm.nih.gov/38613493/)
- Cited evidence (PMID 12053139) [PMID:12053139](https://pubmed.ncbi.nlm.nih.gov/12053139/)
- Cited evidence (PMID 7494569) [PMID:7494569](https://pubmed.ncbi.nlm.nih.gov/7494569/)
- Cited evidence (PMID 25629739) [PMID:25629739](https://pubmed.ncbi.nlm.nih.gov/25629739/)

Last reconciled with current guidelines: 2026-05-14.
References
  • ACOG Practice Bulletin 222 (2020/2022) Severe Pre-eclampsia + 2025 ACC/AHA HTN (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493) — PMID:38316810
  • Cited evidence (PMID 38613493) — PMID:38613493
  • Cited evidence (PMID 12053139) — PMID:12053139
  • Cited evidence (PMID 7494569) — PMID:7494569
  • Cited evidence (PMID 25629739) — PMID:25629739