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🔬 Laboratory Values
Spot Urine Protein:Creatinine Ratio (optional)
▶ Interpret Labs
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📋 Recommended Investigations
1
CBC with PBF – Haemoglobin, platelets, microangiopathic haemolytic anaemia (schistocytes)
2
LFT – AST, ALT, LDH, bilirubin, serum albumin (HELLP screen)
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Renal function – Serum creatinine, urea, uric acid, eGFR
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Coagulation profile – PT, aPTT, fibrinogen (DIC screen if platelets <100)
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Urinalysis – Dipstick, spot UPCR; 24-hr urine if time permits
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Blood glucose – Especially if on MgSO₄ or antihypertensives
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Fetal surveillance – CTG, BPP, Doppler if <37 wks
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Neuroimaging – CT/MRI brain if atypical seizure, prolonged coma, focal deficit
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ABG / Pulse oximetry – If respiratory compromise or pulmonary oedema
💊 MgSO₄ Dose Calculator
ℹ️
Pritchard / WHO / FOGSI Protocol
⚠️ MgSO₄ Toxicity Monitoring
Continue if: Patellar reflex present · RR ≥ 16/min · Urine output ≥ 25 mL/hr · SpO₂ ≥ 95%
Hold dose if: RR 10–15/min or UO 15–24 mL/hr – reassess in 30 min
STOP & give antidote if: Loss of patellar reflex · RR < 12/min · Serum Mg > 9 mEq/L
Antidote: Calcium Gluconate 10% – 10 mL (1 g) IV slowly over 10 minutes
💉 Antihypertensive Therapy
Patient weight (kg)
🚨
Treat if SBP ≥ 160 mmHg OR DBP ≥ 110 mmHg – Target: SBP 140–155, DBP 90–105 mmHg. Avoid abrupt reduction.
🌟 Corticosteroids for Fetal Lung Maturity
ℹ️ Indicated for gestational age < 34 weeks when delivery likely within 7 days. Give if time permits.
Drug Dose & Route Schedule
Betamethasone (preferred)12 mg IM 2 doses, 24 hrs apart Dexamethasone 6 mg IM 4 doses, 12 hrs apart
🚨 Immediate Management – Eclamptic Seizure (A-B-C-D)
A – Airway & Airway Protection
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Position patient in left lateral decubitus position
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Call for help immediately – activate emergency team
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Insert airway adjunct (nasopharyngeal airway if tolerated), do NOT forcibly open jaw during active seizure
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Padded tongue blade only if teeth not clenched; protect head from injury
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Suction oropharynx after seizure stops
B – Breathing & Oxygenation
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Administer oxygen via face mask 8–10 L/min
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Monitor SpO₂ continuously; aim ≥ 95%
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Prepare for intubation if airway unprotected or SpO₂ < 90%
C – Circulation
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Secure 2 large-bore IV cannulae (16G or larger)
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Draw blood for CBC, LFT, RFT, coagulation, LDH, blood group & cross-match
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Insert urinary catheter – strict fluid balance hourly
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IV fluid: Ringer's Lactate or Normal Saline – restrict to 80 mL/hr unless indicated otherwise (avoid fluid overload)
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Monitor BP every 5–15 minutes initially, then every 30 min when stable
D – Drugs (MgSO₄ & Antihypertensives)
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MgSO₄ loading dose immediately – see Drug Dosing tab for protocol
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If seizure continues after 15 min: repeat MgSO₄ 2 g IV or consider Diazepam/Thiopentone (with ICU backup)
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If SBP ≥ 160 or DBP ≥ 110: give Labetalol/Hydralazine/Nifedipine – see Drug Dosing tab
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Continue MgSO₄ for 24 hours after delivery or last seizure (whichever is later)
🏥 Delivery Decision
🚨
Eclampsia is an indication for delivery. Delivery is the only definitive treatment. Decision on mode and timing depends on gestational age, maternal and fetal condition.
Timing of Delivery (FOGSI/ACOG)
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Eclampsia at any gestation: Stabilise mother first (at least 4–6 hours), then deliver. Fetal distress may necessitate immediate delivery.
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≥ 34 weeks: Deliver after stabilisation. Mode based on obstetric indications.
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32–34 weeks: Give corticosteroids if feasible (> 24 hrs), then deliver. Do not delay > 24–48 hrs if maternal condition deteriorating.
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< 32 weeks: Consider tertiary centre transfer. Deliver if HELLP, uncontrolled BP, renal failure, fetal distress, or progressive disease.
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Mode of delivery: Vaginal delivery preferred if cephalic presentation and favourable cervix. LSCS for obstetric indications or rapid deterioration.
🔴 HELLP Syndrome Management
⚠️
Haemolysis · Elevated Liver enzymes · Low Platelets. Associated with 1–25% maternal mortality if unrecognised.
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Diagnosis: Platelets < 100 × 10³ + LDH > 600 + AST > 70 + microangiopathic haemolysis
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Platelet transfusion if: < 50 × 10³ prior to CS; < 20 × 10³ regardless
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Dexamethasone 10 mg IV q12h – may accelerate platelet recovery (especially antepartum)
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Monitor for DIC: check PT, aPTT, fibrinogen q6h if deteriorating
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Deliver if > 34 weeks. If < 34 weeks, stabilise in ICU and deliver within 24–48 hrs
🌙 Postpartum Care
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Continue MgSO₄ for 24 hours post-delivery or 24 hrs after last seizure
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Continue antihypertensives – Methyldopa is safe for breastfeeding; switch IV to oral when BP controlled
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Monitor BP every 4–6 hrs for 48 hrs; re-escalate if SBP > 150 or DBP > 100
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Strict fluid balance – beware fluid mobilisation causing pulmonary oedema at 24–48 hrs postpartum
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Watch for late postpartum eclampsia (up to 6 weeks). Educate patient on warning signs.
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Thromboprophylaxis with LMWH (Enoxaparin 40 mg SC daily) after 6–12 hrs if haemostasis achieved
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Counselling: future pregnancy risk, contraception, aspirin prophylaxis advice for next pregnancy (75–150 mg/day from 12 wks)
📚 Diagnostic Criteria
Hypertension in Pregnancy (ACOG 2020 / FOGSI)
Gestational Hypertension: BP ≥ 140/90 mmHg after 20 weeks with no proteinuria or systemic features
Pre-eclampsia: New hypertension ≥ 140/90 + proteinuria (≥ 0.3 g/24h or UPCR ≥ 0.3) after 20 weeks, OR severe features without proteinuria
Eclampsia: New-onset grand mal seizure in a woman with pre-eclampsia, or unexplained seizure not attributable to other cause
HELLP Syndrome: Haemolysis (LDH > 600, bili > 1.2) + Elevated enzymes (AST ≥ 70) + Low platelets (< 100 × 10³)
Chronic Hypertension: BP ≥ 140/90 before 20 weeks or pre-existing hypertension
Superimposed Pre-eclampsia: Worsening hypertension + new proteinuria or thrombocytopaenia in a woman with chronic hypertension
Severe Features of Pre-eclampsia (Any one = Severe)
SBP ≥ 160 mmHg or DBP ≥ 110 mmHg on two occasions ≥ 4 hours apart (while patient at bed rest)
Platelet count < 100,000/µL
Renal insufficiency: Creatinine > 1.1 mg/dL or doubling of baseline
Impaired liver function: Elevated transaminases > 2× normal; severe RUQ/epigastric pain unresponsive to medication
New-onset headache unresponsive to medication + not explained by other diagnoses
BP Thresholds for Treatment
140/90 mmHg: Diagnosis threshold – start monitoring, consider antihypertensives, initiate assessment
150/100 mmHg: Start oral antihypertensive therapy (Methyldopa, Labetalol, Nifedipine)
160/110 mmHg: ACUTE HYPERTENSIVE CRISIS – IV antihypertensive IMMEDIATELY within 30–60 min
⚡ Differential Diagnosis of Seizure in Pregnancy
Condition Key Differentiating Feature
Epilepsy History of seizures before pregnancy; no hypertension/proteinuria Cerebral venous thrombosis Focal neurological signs; MRI/MRV confirms TTP / HUS Fever, MAHA, renal failure; ADAMTS13 activity < 10% Hypertensive encephalopathy BP very high; imaging shows PRES (posterior reversible encephalopathy) Metabolic (hypoglycaemia/hyponatraemia) Electrolytes, blood glucose abnormal; responds to correction Meningitis / Encephalitis Fever, neck stiffness, CSF findings; MRI brain abnormalities Intracranial haemorrhage Sudden onset, focal deficit, CT/MRI diagnostic
📊 HELLP Syndrome Classification (Mississippi Triple Class)
Class Platelets AST/ALT LDH
Class 1 (Severe) < 50 × 10³/µL ≥ 70 U/L ≥ 600 U/L Class 2 (Moderate) 50–100 × 10³/µL ≥ 70 U/L ≥ 600 U/L Class 3 (Mild) 100–150 × 10³/µL ≥ 70 U/L ≥ 600 U/L
💧 Fluid Balance Calculator
⚠️
Fluid restriction is essential. Pre-eclamptic/eclamptic patients are at high risk of pulmonary oedema. Avoid aggressive fluid resuscitation.
Max recommended rate
80 mL/hr
📋 Fluid Management Principles (FOGSI / WHO)
IV Fluid Guidelines
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Maintenance rate: Restrict to 80 mL/hr (or 1 mL/kg/hr) of Ringer's Lactate or Normal Saline unless haemorrhage or dehydration
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Total fluid: Aim for ≤ 3000 mL per 24 hours (including all drug infusions)
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Urine output target: ≥ 0.5 mL/kg/hr (≥ 25–30 mL/hr) – oliguria alone is NOT an indication for fluid bolus in pre-eclampsia
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Avoid: Hypotonic fluids (5% dextrose alone), large volume crystalloids, colloids without specific indication
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Pulmonary oedema: If SpO₂ falls or crackles develop – stop all IV fluids, give furosemide 20–40 mg IV, oxygen, seek ICU support
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Hourly monitoring: Urine output chart mandatory. Restrict fluids if UO < 100 mL in 4 hours without clear cause of dehydration
Fluid in Specific Situations
Situation Fluid Strategy
Antepartum (no labour) RL 80 mL/hr; strict I&O hourly Intrapartum (active labour) RL 80–125 mL/hr; include oxytocin fluid volume in total Postoperative (CS) RL 80 mL/hr; mobilise carefully after 24 hrs; monitor diuresis PPH co-existing Balanced resuscitation; 1:1:1 PRBC:FFP:Platelets if massive transfusion Pulmonary oedema STOP fluids; Furosemide 20–40 mg IV; ICU support; intubation if refractory Oliguria (<25 mL/hr >2 hrs) 250 mL fluid challenge ONCE; reassess; nephrology consult if persists