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ob.pre-eclampsia.core.v1PRODUCTION
ob.pre-eclampsia.core.v1

Pre-eclampsia / Eclampsia / HELLP

obstetricsacutepregnancyadult
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12/12 authored

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

Current phase

Frame

Detailed

Confirm pre-eclampsia (HTN ≥140/90 after 20 wk + proteinuria OR severe features) vs gestational HTN vs chronic HTN vs superimposed pre-eclampsia (ACOG 222 2020; ISSHP 2021)

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classification assigned

Patient inputs (15)

Drives delivery timing (37 wk for non-severe, 34 wk for severe features per ACOG 222 2020); affects fetal viability decisions

Persistent severe headache = severe feature (ACOG 222 2020)

Scotomata, blurred vision, photopsia = severe feature (ACOG 222 2020)

Persistent epigastric/RUQ pain = severe feature per ACOG 222; also AFLP / acute pancreatitis differential

Superimposed pre-eclampsia substrate; CHAP target <140/90 (Tita NEJM 2022)

Recurrence ≥20%; aspirin prophylaxis indication (ASPRE, Rolnik NEJM 2017)

<100K = severe feature / HELLP criterion (ACOG 222 2020; ISSHP 2021)

Cr doubling or ≥1.1 mg/dL = severe feature per ACOG 222; PE-AKI

≥2× upper limit = severe feature / HELLP (ACOG 222 2020)

≥160 / ≥110 = severe; sustained × 15 min triggers 30-60 min IV antihypertensive (ACOG 767)

≥110 = severe per ACOG 222; same trigger as SBP

Aspirin prophylaxis status per ACOG 222; ACE-I/ARB teratogen check

Elevated in HELLP (hemolysis); >600 supports diagnosis (ISSHP 2021)

Hemolysis confirmation in HELLP; differentiates from TTP/AFLP (ISSHP 2021)

UPCR ≥0.3 or 24h ≥300 mg or dipstick ≥2+; not required if severe features present (ACOG 222)

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

Severity triggers (11)

11 need judgement
  • informationallife_threateningeclamptic seizure — Magpie 2002
    New tonic-clonic seizure in pregnancy or up to 6 wk postpartum (ACOG 222; Magpie Trial, Lancet 2002)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningHELLP class I — ISSHP 2021
    Platelets <50K + AST/ALT >70 + LDH >600 + LDH/AST > schistocytes (Mississippi classification; ISSHP 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningeclampsia_seizure_recurrence
    Second eclamptic seizure on adequate magnesium infusion (1–2 g/h running, prior 4–6 g IV load given) — antepartum, intrapartum, or postpartum (ACOG 222; Magpie 2002 + Altman 2002)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsuperimposed_severe_hypertension_pulmonary_edema
    Superimposed pre-eclampsia + sustained severe HTN ≥160/110 refractory to maximum IV antihypertensive (labetalol max 220 mg + hydralazine 30 mg cumulative) AND new pulmonary edema (SpO2 <94%, bilateral crackles, CXR vascular congestion) within 30–60 min (ACOG 222 severe feature + ACOG 767 refractory definition)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresustained severe htn 160 110 — ACOG 767
    BP ≥160/110 sustained × 15 min antepartum/intrapartum/postpartum (ACOG 767)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere features present — ACOG 2020
    Any severe feature per ACOG 222: BP ≥160/110, severe HA, vision changes, RUQ pain, AST/ALT ≥2× ULN, plt <100K, Cr ≥1.1 (or doubling), pulmonary edema, new neuro symptoms
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremgso4 toxicity — ACOG 2020
    Loss of DTRs OR RR <12 OR UOP <30 mL/h OR Mg >9 mEq/L (ACOG 222)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepulmonary edema in PE — ACOG 2020
    New SpO2 <94% + crackles + tachypnea (ACOG 222 severe feature)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum severe HTN late — AHA 2021
    New severe HTN ≥160/110 up to 6 weeks postpartum (ACOG 222; AHA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremagnesium_timing_miss
    Magnesium sulphate NOT loaded (4–6 g IV over 15–20 min) within 1 h of severe-features confirmation OR within minutes of any eclamptic seizure (ACOG 222 + ACOG 2025; ISSHP 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehellp_class_progression
    HELLP Mississippi class progression within 24 h: class III → II (plt 100-150 → 50-100) OR class II → I (plt 50-100 → <50), OR rapidly rising AST/ALT >2× baseline, OR new schistocytes (ISSHP 2024 progression criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Pre-eclampsia / eclampsia / HELLP — severity-driven (severe HTN → IV antihypertensive; severe features → MgSO4 + delivery)
axis: preeclampsia_severity_drivenstep 1 - Tier 1 — Acute severe HTN (≥160/110 sustained × 15 min): IV antihypertensive within 30–60 min
Selected step "Tier 1 — Acute severe HTN (≥160/110 sustained × 15 min): IV antihypertensive within 30–60 min" — Sustained SBP ≥160 OR DBP ≥110 × 15 min
  • labetalol
    first line
    mixed_alpha_beta_blocker
    20 mg IV bolus, then 40 mg if no response in 10 min, then 80 mg in 10 min, then 80 mg in 10 min (max cumulative 220 mg); maintenance 1–2 mg/min infusion if needed • IV • q10 min escalating
    triggers: severe_htn_sustained, no_severe_asthma_or_HF
    ACOG 767 — first-line; avoid in severe asthma/HF/heart block
    rxcui 6185
  • hydralazine
    first line
    arterial_vasodilator
    5–10 mg IV bolus over 1–2 min, repeat 10 mg q20 min × 2 if needed (max 30 mg) • IV • q20 min
    triggers: severe_htn_sustained, labetalol_contraindicated
    ACOG 767 — equivalent first-line; can cause maternal tachycardia + reflex hypotension
    rxcui 5487
  • nifedipine immediate-release
    first line
    CCB_dihydropyridine
    10 mg PO, repeat 20 mg q20 min × 2 if needed • PO • q20 min
    triggers: IV_access_unavailable, severe_htn_sustained
    ACOG 767 — equivalent first-line; PO option when IV unavailable
    rxcui 7417

outpatient playbook — drug actions (3)

  1. 1. aspirin 81 mg
    rxcui 1191
    81 mg PO daily from 12–28 wk (preferably ≤16 wk); 81–150 mg/d acceptable per USPSTF 2021 • PO • daily
    trigger: ≥1 high-risk or ≥2 moderate-risk PE factors (current pregnancy) OR next-pregnancy prophylaxis post-PE history
    USPSTF 2021 (PMID 34581729) + ASPRE 2017 (Rolnik NEJM 2017, PMID 28657417) + ACOG 222
  2. 2. PO labetalol or nifedipine ER
    Labetalol 100–200 mg BID; nifedipine ER 30–60 mg daily • PO • BID/daily
    trigger: BP ≥140/90 chronic or new
    CHAP target <140/90 (Tita NEJM 2022, PMID 35363951)
  3. 3. methyldopa
    250 mg BID-QID • PO • BID-QID
    trigger: Alternative if labetalol/nifedipine intolerated
    Pregnancy-safe alternative per CHIPS (Magee NEJM 2015, PMID 25629739)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: BP ≥160/110 in pregnancy / postpartum (ACOG 767); New BP ≥140/90 after 20 wk (ACOG Practice Bulletin 222 2020); Headache + visual changes + RUQ pain (ACOG 222 severe-feature criteria).

Objective

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

Assessment

**Pre-eclampsia / Eclampsia / HELLP** (ob.pre-eclampsia.core.v1).
Phenotype framing: Phenotype per ACOG 222 / ISSHP 2021: gestational HTN, pre-eclampsia without severe features, pre-eclampsia with severe features, eclampsia, HELLP, superimposed PE, postpartum PE; rule out TTP, aHUS, AFLP, lupus flare, secondary HTN
Scope: Confirm pre-eclampsia (HTN ≥140/90 after 20 wk + proteinuria OR severe features) vs gestational HTN vs chronic HTN vs superimposed pre-eclampsia (ACOG 222 2020; ISSHP 2021)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pre-eclampsia / eclampsia / HELLP — severity-driven (severe HTN → IV antihypertensive; severe features → MgSO4 + delivery)** — step "Tier 1 — Acute severe HTN (≥160/110 sustained × 15 min): IV antihypertensive within 30–60 min".
1. labetalol 20 mg IV bolus, then 40 mg if no response in 10 min, then 80 mg in 10 min, then 80 mg in 10 min (max cumulative 220 mg); maintenance 1–2 mg/min infusion if needed IV q10 min escalating (mixed_alpha_beta_blocker, first line) — ACOG 767 — first-line; avoid in severe asthma/HF/heart block
2. hydralazine 5–10 mg IV bolus over 1–2 min, repeat 10 mg q20 min × 2 if needed (max 30 mg) IV q20 min (arterial_vasodilator, first line) — ACOG 767 — equivalent first-line; can cause maternal tachycardia + reflex hypotension
3. nifedipine immediate-release 10 mg PO, repeat 20 mg q20 min × 2 if needed PO q20 min (CCB_dihydropyridine, first line) — ACOG 767 — equivalent first-line; PO option when IV unavailable

Setting playbook (outpatient) — Surveillance for non-severe PE (ACOG 222 + ACOG 2025 update), prevention with aspirin (ASPRE 2017; USPSTF 2021), postpartum follow-up through 6-week visit, lifelong CV risk reduction (AHA 2021), endocrine-renal review post-PE, future-pregnancy aspirin counseling
4. aspirin 81 mg 81 mg PO daily from 12–28 wk (preferably ≤16 wk); 81–150 mg/d acceptable per USPSTF 2021 PO daily — ≥1 high-risk or ≥2 moderate-risk PE factors (current pregnancy) OR next-pregnancy prophylaxis post-PE history (USPSTF 2021 (PMID 34581729) + ASPRE 2017 (Rolnik NEJM 2017, PMID 28657417) + ACOG 222)
5. PO labetalol or nifedipine ER Labetalol 100–200 mg BID; nifedipine ER 30–60 mg daily PO BID/daily — BP ≥140/90 chronic or new (CHAP target <140/90 (Tita NEJM 2022, PMID 35363951))
6. methyldopa 250 mg BID-QID PO BID-QID — Alternative if labetalol/nifedipine intolerated (Pregnancy-safe alternative per CHIPS (Magee NEJM 2015, PMID 25629739))

Non-pharmacologic actions:
- Aspirin counseling per ACOG 222 / ASPRE (USPSTF 2021 + Rolnik NEJM 2017)
- BP self-monitoring training — daily × 1 wk post-discharge → weekly through 6 wk (AHA 2021)
- Severe-feature symptom education + return precautions (ACOG 222)
- Postpartum BP plan + 6-week comprehensive visit (ACOG 222 + ACOG 2025)
- Lifetime CV follow-up education — PE doubles future CV risk; annual BP/lipid/glucose screening (AHA 2021)
- Next-pregnancy aspirin counseling: aspirin 81–150 mg PO daily from 12 wk per USPSTF 2021 (PMID 34581729); pre-pregnancy weight / BP optimisation (ACOG 222 + ACOG 2025)
- Endocrine-renal review at 6 wk: lipid panel, fasting glucose / HbA1c, UACR + Cr, BMI trajectory (AHA 2021 + ACOG 2025)
- Vaccinations review

AVOID / contraindication checks:
- Never ACE ARB in pregnancy (ACOG 2020)
- Never renin inhibitor in pregnancy (ACOG 2020)
- Nitroprusside caution cyanide toxicity after 4h (ACOG 767)
- Methylergonovine avoid in severe HTN (ACOG 2020)
- NSAIDs avoid post partum PE (ACOG 2020)
- Check DTRs RR urine output with MgSO4 (ACOG 2020)
- Mg level if AKI or oliguria (ACOG 2020)

Monitoring

Regimen monitoring:
- BP q15min during severe HTN treatment (ACOG 767)
- BP q1h after control x 4h then q4h (ACOG 767)
- continuous fetal monitoring when delivery pending (ACOG 2020)
- MgSO4 DTRs q1h (ACOG 2020)
- MgSO4 RR q1h minimum 12 per min (ACOG 2020)
- MgSO4 urine output q1h minimum 30 mL per h (ACOG 2020)
- Mg level if oliguria or AKI (ACOG 2020)
- CBC LFT Cr LDH q6-12h in HELLP (ISSHP 2021)
- fetal kick counts q visit (ACOG 2020)
- postpartum BP 72h then weekly x 6w (ACOG 2020)

Setting (outpatient) monitoring:
- BP q visit (q2 wk in third trimester for PE history per ACOG 222)
- UPCR if BP elevated (ACOG 222)
- Fetal growth US per protocol (ACOG 2020)
- Postpartum BP: daily × 1 wk → weekly × 6 wk + visits at 3–7 d, 1–2 wk, 4–6 wk, 6-week comprehensive visit (ACOG 222 + ACOG 2025)
- Annual CV-risk screening (BP, lipids, glucose, BMI, UACR) lifelong post-PE (AHA 2021)

Follow-up plan: BP check 3-7 days postpartum + 1-2 wk + 4-6 wk per ACOG 222; lifelong CV risk follow-up (PE doubles future CV risk per AHA 2021); aspirin 81-162 mg from 12-16 wk in next pregnancy (ASPRE, Rolnik NEJM 2017); AHA/CDC postpartum hypertension awareness
- Close-out criterion: postpartum BP plan + lifetime CV surveillance documented

Monitoring phase: Continuous fetal monitoring; BP q15min during severe-HTN treatment then q1h (ACOG 767); MgSO4 toxicity (DTRs, RR, urine output, Mg level if AKI per ACOG 222); platelet/AST/Cr/Hgb q6-12h; daily fluid balance; postpartum 72-h continued risk

Disposition

Current setting: outpatient — Surveillance for non-severe PE (ACOG 222 + ACOG 2025 update), prevention with aspirin (ASPRE 2017; USPSTF 2021), postpartum follow-up through 6-week visit, lifelong CV risk reduction (AHA 2021), endocrine-renal review post-PE, future-pregnancy aspirin counseling

Disposition criteria:
- Outpatient management acceptable for non-severe PE remote from term with reassuring fetal status + reliable surveillance per ACOG 222
- 6-week postpartum: BP <140/90 on oral regimen (or off), no severe features, endocrine-renal review complete, next-pregnancy aspirin counseling documented → transition to long-term annual CV surveillance (AHA 2021)

Escalation triggers (move to higher acuity):
- New severe HTN → ED (ACOG 767)
- New severe-feature symptoms → ED (ACOG 222)
- Decreased fetal movement → L&D (ACOG 2020)
- Postpartum severe HTN ≥160/110 within 6 wk → ED for IV antihypertensive + magnesium prophylaxis (AHA 2021 + ACOG 222)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New tonic-clonic seizure in pregnancy or up to 6 wk postpartum (ACOG 222; Magpie Trial, Lancet 2002)
- [LIFE_THREATENING] Platelets <50K + AST/ALT >70 + LDH >600 + LDH/AST > schistocytes (Mississippi classification; ISSHP 2021)
- [LIFE_THREATENING] Second eclamptic seizure on adequate magnesium infusion (1–2 g/h running, prior 4–6 g IV load given) — antepartum, intrapartum, or postpartum (ACOG 222; Magpie 2002 + Altman 2002)

Citations

- ACOG Practice Bulletin 222 (2020, reaffirmed 2023) + ACOG 2025 update on severe-features pre-eclampsia management + ACOG 767 (severe HTN in pregnancy) + ACOG 203 (chronic HTN, CHAP) + ISSHP 2024 (Mol et al; supersedes ISSHP 2021) + NICE NG133 (2023) + USPSTF aspirin 2021 + MAGPIE Lancet 2002 + CHAP NEJM 2022 + CHIPS NEJM 2015 + HYPITAT-II Lancet 2015 + ASPRE NEJM 2017 + PARROT Lancet 2019 + CRADLE-3 Lancet 2019 [PMID:35363951](https://pubmed.ncbi.nlm.nih.gov/35363951/)
- Cited evidence (PMID 25629739) [PMID:25629739](https://pubmed.ncbi.nlm.nih.gov/25629739/)
- Cited evidence (PMID 29899139) [PMID:29899139](https://pubmed.ncbi.nlm.nih.gov/29899139/)
- Cited evidence (PMID 12057549) [PMID:12057549](https://pubmed.ncbi.nlm.nih.gov/12057549/)
- Cited evidence (PMID 34581729) [PMID:34581729](https://pubmed.ncbi.nlm.nih.gov/34581729/)

Last reconciled with current guidelines: 2026-05-14.
References
  • ACOG Practice Bulletin 222 (2020, reaffirmed 2023) + ACOG 2025 update on severe-features pre-eclampsia management + ACOG 767 (severe HTN in pregnancy) + ACOG 203 (chronic HTN, CHAP) + ISSHP 2024 (Mol et al; supersedes ISSHP 2021) + NICE NG133 (2023) + USPSTF aspirin 2021 + MAGPIE Lancet 2002 + CHAP NEJM 2022 + CHIPS NEJM 2015 + HYPITAT-II Lancet 2015 + ASPRE NEJM 2017 + PARROT Lancet 2019 + CRADLE-3 Lancet 2019 — PMID:35363951
  • Cited evidence (PMID 25629739) — PMID:25629739
  • Cited evidence (PMID 29899139) — PMID:29899139
  • Cited evidence (PMID 12057549) — PMID:12057549
  • Cited evidence (PMID 34581729) — PMID:34581729