What are the management steps for a severe preeclamptic and eclamptic patient within the golden hour, with a critical care team?

Management of Severe Preeclampsia and Eclampsia in the Golden Hour

In the first hour of managing severe preeclampsia or eclampsia with a critical care team, immediately administer intravenous magnesium sulfate for seizure prophylaxis, initiate urgent antihypertensive therapy to achieve blood pressure <160/105-110 mmHg, establish comprehensive maternal monitoring including continuous vital signs and laboratory assessment, and coordinate expedited delivery planning after maternal stabilization. 1, 2

Immediate Pharmacological Interventions (Within Minutes)

Magnesium Sulfate Administration - First Priority

• Administer magnesium sulfate immediately upon diagnosis for all patients with severe preeclampsia or eclampsia 3, 1, 2
• Loading dose: 4-5g IV over 5 minutes 1
• Maintenance infusion: 1-2g/hour continuous IV 1
• Alternative regimen: After IV loading, 4-5g IM into alternate buttocks every 4 hours 2
• Continue until 24 hours postpartum or until seizures cease 2
• Magnesium sulfate reduces eclampsia risk by more than half (NNT=100) and likely reduces maternal death 4

Blood Pressure Control - Concurrent Priority

• Initiate IV antihypertensive therapy immediately when BP ≥160/110 mmHg persists for >15 minutes 3, 1, 2
• Target BP: Systolic 110-140 mmHg and diastolic 85 mmHg (minimum <160/105 mmHg) 3, 1, 2
• Goal: Decrease mean BP by 15-25% to prevent maternal cerebral hemorrhage while maintaining uteroplacental perfusion 1

First-line IV antihypertensive options:

• IV Labetalol (preferred): 20mg IV bolus, then 40mg after 10 minutes, followed by 80mg every 10 minutes to maximum cumulative dose of 220mg (or 800mg/24h to prevent fetal bradycardia) 3, 1, 2
• IV Nicardipine: Safe and effective alternative 3
• IV Hydralazine: Second-line option, though associated with adverse perinatal outcomes 3, 2

Medications to AVOID:

• Nitroprusside is contraindicated due to fetal cyanide toxicity risk (use only as last resort in extreme emergencies) 3, 1
• Short-acting oral nifedipine should be avoided, especially with concurrent magnesium sulfate, due to uncontrolled hypotension risk 1
• ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated due to severe fetotoxicity 1
• Diuretics are contraindicated as they further reduce plasma volume 3, 2

Critical Monitoring Requirements (Establish Within First Hour)

Maternal Monitoring - Continuous

• Blood pressure monitoring every 15 minutes until stable, then hourly 1, 2
• Continuous pulse oximetry (maternal early warning if <95%) 1
• Hourly urine output via Foley catheter with target ≥100 mL/4 hours (>35 mL/hour) 3, 1, 5
• Deep tendon reflexes assessment before each magnesium dose to monitor for toxicity 3, 5
• Respiratory rate monitoring (approximately ≥16 breaths/min; magnesium toxicity causes respiratory depression) 3, 5
• Assess for neurological deterioration: maternal agitation, confusion, unresponsiveness, non-remitting headache 1
• Monitor for pulmonary symptoms: shortness of breath, oxygen saturation 1

Laboratory Assessment - Immediate

• Complete blood count with peripheral smear (assess for hemolysis, thrombocytopenia indicating HELLP syndrome) 1
• Comprehensive metabolic panel (creatinine, liver transaminases, uric acid) 1, 2
• Serum magnesium levels (therapeutic range 3-6 mg/100 mL or 2.5-5 mEq/L; reflexes diminish >4 mEq/L; respiratory paralysis risk at 10 mEq/L) 5
• Coagulation studies: PT, PTT, fibrinogen, fibrin degradation products 3
• Repeat labs at least twice weekly or more frequently with clinical deterioration 1, 2

Fetal Monitoring

• Continuous fetal heart rate monitoring 3, 1
• Ultrasound assessment: fetal biometry, amniotic fluid volume, umbilical artery Doppler 1, 2

Critical Care Team Coordination (Within First Hour)

Immediate Team Assembly

• Obstetric team for delivery planning 1, 2
• Anesthesia team for potential operative delivery and airway management 3
• Neonatal team for anticipated preterm or compromised infant 1
• Critical care/ICU team for maternal stabilization and monitoring 3

Transfer Considerations

• Medicalized transport to specialized obstetric center should be systematically considered for all severe preeclampsia patients 2
• Coordinate with receiving facility's obstetric and anesthetic-intensivist teams via phone before transfer 1
• Initiate magnesium sulfate and blood pressure control PRIOR to transport 1

Delivery Planning (After Initial Stabilization)

Immediate Delivery Indications (Regardless of Gestational Age)

• Inability to control BP despite ≥3 antihypertensive classes 1, 2
• Maternal pulse oximetry <90% 2
• Progressive deterioration in liver function, creatinine, hemolysis, or platelet count 1, 2
• Ongoing neurological features (severe intractable headache, visual scotomata, eclampsia) 1, 2
• Pulmonary edema 1
• Placental abruption 2
• Non-reassuring fetal status or reversed end-diastolic flow on Doppler 1, 2

Gestational Age-Based Approach

• ≥37 weeks: Immediate delivery after stabilization 1, 2
• 34-37 weeks: Expectant management with close monitoring if stable 1, 2
• <34 weeks: Conservative management at Maternal-Fetal Medicine center; administer corticosteroids for fetal lung maturity 1, 2
• <24 weeks: High maternal morbidity with limited perinatal benefit; counsel regarding pregnancy termination 1

Special Considerations for Pulmonary Edema

• Drug of choice: IV nitroglycerin starting at 5 mcg/min, gradually increased every 3-5 minutes to maximum 100 mcg/min 3, 1
• Plasma volume expansion is NOT recommended 3, 2

Critical Safety Monitoring for Magnesium Toxicity

• Have injectable calcium salt (calcium gluconate) immediately available to counteract magnesium toxicity 3, 5
• Signs of toxicity: Loss of patellar reflex, respiratory depression (<16 breaths/min), decreased urine output 3, 5
• If reflexes absent, hold additional magnesium until they return 5

Common Pitfalls to Avoid

• Do not attempt to diagnose "mild versus severe" preeclampsia clinically—all cases may become emergencies rapidly 1
• Do not use serum uric acid or level of proteinuria as indication for delivery 1
• Do not reduce antihypertensives if diastolic BP falls <80 mmHg 3
• Do not "run dry" a preeclamptic woman—she is already at risk of acute kidney injury despite capillary leak 3
• Avoid NSAIDs for pain relief as they may worsen hypertension and renal function 3