What is the recommended peripartum management for a woman with severe preeclampsia/eclampsia undergoing delivery, including active management of the third stage, uterotonic therapy, magnesium sulfate, prophylactic cefazolin for cesarean delivery, venous thrombo‑embolism prophylaxis, blood pressure control, analgesia, early ambulation, breastfeeding support, postpartum depression screening, and contraceptive counseling?

Peripartum Management of Severe Preeclampsia/Eclampsia

For women with severe preeclampsia/eclampsia undergoing delivery, immediately administer magnesium sulfate (4–5 g IV loading dose over 5 minutes, then 1–2 g/h infusion) for seizure prophylaxis, treat severe hypertension (≥160/110 mmHg) urgently with IV labetalol (20 mg bolus, repeat 40 mg after 10 min, then 80 mg every 10 min up to 220 mg total) targeting systolic 110–140 mmHg and diastolic <110 mmHg, give oxytocin 10 IU IM or slow IV immediately after delivery of the anterior shoulder for active third-stage management, administer prophylactic cefazolin 2 g IV before cesarean incision, apply sequential compression devices preoperatively and continue until fully ambulatory, and continue magnesium sulfate for 24 hours postpartum with close blood pressure monitoring every 4–6 hours for at least 3 days. 1, 2, 3, 4

Immediate Intrapartum Management

Seizure Prophylaxis

• Administer magnesium sulfate immediately to all women with severe preeclampsia (BP ≥160/110 mmHg with symptoms) or eclampsia: loading dose 4–5 g IV over 5 minutes, followed by continuous infusion 1–2 g/hour. 2, 3
• Continue magnesium sulfate throughout labor, delivery, and for 24 hours postpartum. 2, 3
• Monitor for magnesium toxicity by checking deep tendon reflexes before each dose adjustment, respiratory rate (watch for depression), and urine output (target ≥100 mL per 4 hours or >35 mL/hour via Foley catheter). 2, 3

Blood Pressure Control

• Treat severe hypertension (≥160/110 mmHg persisting >15 minutes) as a hypertensive emergency requiring immediate IV antihypertensive therapy within 30–60 minutes. 2, 3
• First-line agent: IV labetalol 20 mg bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes to maximum cumulative dose of 220 mg. 2, 3
• Alternative IV agents if labetalol contraindicated or unavailable: hydralazine 5–10 mg bolus repeated every 20 minutes, or nicardipine infusion. 2, 3
• Target blood pressure: systolic 110–140 mmHg and diastolic ≈85 mmHg (minimum goal <160/105 mmHg) to prevent maternal cerebral hemorrhage while maintaining uteroplacental perfusion. 2, 3
• Avoid short-acting oral nifedipine, especially when combined with magnesium sulfate, due to risk of uncontrolled hypotension and fetal compromise. 3
• Avoid sodium nitroprusside except as last resort in extreme emergencies (risk of fetal cyanide toxicity with >4 hours use). 3

Critical Maternal Monitoring

• Continuous blood pressure monitoring until hemodynamically stable, then every 15 minutes until controlled, then every 4–6 hours while awake for minimum 3 days postpartum. 2, 3
• Hourly urine output via Foley catheter with target ≥100 mL per 4 hours. 2, 3
• Restrict IV fluids to 60–80 mL/hour to reduce pulmonary edema risk. 3
• Monitor oxygen saturation continuously (maternal early warning if <95%). 3
• Assess neurological status for severe headache, visual scotomata, confusion, agitation, or altered mental status. 2, 3
• Monitor for epigastric or right upper quadrant pain (suggests hepatic capsule distension or HELLP syndrome). 3

Laboratory Surveillance

• Obtain baseline complete blood count (hemoglobin, platelet count), liver transaminases, serum creatinine, and uric acid. 2, 3
• Repeat laboratory tests at least twice weekly or more frequently with clinical deterioration. 2, 3
• Watch for HELLP syndrome (hemolysis, elevated liver enzymes, platelets <100 × 10³/µL). 3

Active Management of Third Stage of Labor

Uterotonic Administration

• Administer oxytocin 10 IU intramuscularly immediately after delivery of the anterior shoulder (or whole infant) and before placental delivery as the preferred uterotonic for prevention of postpartum hemorrhage. 1, 5, 6
• Alternative IV route: oxytocin 5–10 IU by slow IV infusion over 1–2 minutes (never as rapid bolus to avoid hypotension and tachycardia), or 20–40 IU in 1000 mL normal saline at 150 mL/hour. 1, 6
• Avoid ergometrine (ergot alkaloids) in women with severe preeclampsia/eclampsia because it is contraindicated in hypertension and carries higher risk of severe hypertension, manual placental removal, and bronchospasm. 1
• Avoid prostaglandin F2α if the patient has any history of asthma or reactive airway disease due to risk of bronchoconstriction. 1

Additional Third-Stage Components

• Delay cord clamping for approximately 60 seconds after delivery to allow placental transfusion, which benefits neonatal hematological outcomes without increasing maternal blood loss when combined with immediate oxytocin administration. 1, 5
• Perform controlled cord traction while awaiting placental separation and delivery. 5, 6
• Do not perform manual removal of the placenta routinely; reserve this only for severe and uncontrollable postpartum hemorrhage. 1

Postpartum Hemorrhage Rescue

• If postpartum hemorrhage occurs despite prophylactic oxytocin, administer tranexamic acid 1 g IV within 1–3 hours of bleeding onset. 1, 5
• Consider intraumbilical cord injection of oxytocin 10–30 IU or misoprostol 800 µg before proceeding to manual removal if placenta is retained beyond 30 minutes with active bleeding. 1

Cesarean Delivery-Specific Management

Antibiotic Prophylaxis

• Administer prophylactic cefazolin 2 g IV (or 3 g if weight >120 kg) within 60 minutes before skin incision for cesarean delivery. 4

Venous Thromboembolism Prophylaxis

• Apply sequential compression devices (pneumatic) starting before surgery and continue continuously until the patient is fully ambulatory. 4
• For women with severe preeclampsia undergoing cesarean delivery, consider combined mechanical and pharmacologic prophylaxis given the additional VTE risk factors. 4
• Preferred pharmacologic agent: low-molecular-weight heparin (enoxaparin) for 6 weeks postoperatively if additional risk factors present. 4
• Do not initiate pharmacologic prophylaxis until postpartum bleeding has stopped and epidural catheter has been removed. 1

Intraoperative Blood Pressure Management

• Continue antihypertensive infusions throughout the operative period to maintain systolic <160 mmHg and diastolic <110 mmHg. 3
• Continue magnesium sulfate infusion throughout surgery. 2, 3

Postpartum Management (First 6 Weeks)

Blood Pressure Management

• Continue magnesium sulfate for 24 hours postpartum. 2, 3
• Continue antihypertensive medications postpartum and taper slowly only after days 3–6, unless blood pressure becomes low (<110/70 mmHg) or patient becomes symptomatic. 2
• Monitor blood pressure at least every 4–6 hours while awake for minimum 3 days postpartum, as preeclampsia may develop de novo or worsen during this period (greatest risk days 3–6). 2
• Maintain systolic BP <160 mmHg and diastolic BP <110 mmHg to prevent cerebrovascular complications. 2

Transition to Oral Antihypertensives

• First-line oral agents compatible with breastfeeding: labetalol (200 mg twice daily, titratable up to 900 mg/day), nifedipine (30–60 mg daily in divided doses), or amlodipine (5–10 mg daily). 2
• Avoid methyldopa for acute blood pressure reduction (onset too slow); it may be used for maintenance but should be replaced with alternative agents postpartum. 2, 3
• Discontinue losartan in the postpartum period; it is contraindicated in breastfeeding mothers. 2

Analgesia

• Avoid NSAIDs for postpartum analgesia in women with preeclampsia, especially when renal disease, acute kidney injury, placental abruption, sepsis, or postpartum hemorrhage are present. 2
• Use alternative analgesics (acetaminophen, opioids) as first-line agents. 2

Laboratory Follow-up

• Repeat hemoglobin, platelets, creatinine, and liver transaminases the day after delivery and then every second day until stable if any were abnormal before delivery. 2

Early Ambulation

• Encourage early ambulation once the patient is hemodynamically stable and magnesium sulfate has been discontinued. 4
• Continue sequential compression devices until fully ambulatory. 4

Discharge Planning

• Most women can be discharged by day 5 postpartum if blood pressure is controlled and they have capability for home blood pressure monitoring. 2
• Ensure patient has access to home blood pressure monitoring device. 2
• Arrange follow-up visit within 1 week if patient remains on antihypertensive medication at discharge. 2

Patient Education

• Educate women about warning signs: severe headache, visual changes, abdominal pain, shortness of breath, or markedly elevated blood pressure. 2
• Instruct patients to contact healthcare professionals immediately if warning signs develop during the first 4 weeks postpartum. 2
• Counsel about 50% risk of postpartum eclampsia occurring within first 48 hours after delivery. 2

Long-Term Follow-up and Counseling

Three-Month Postpartum Review

• Review all women at 3 months postpartum to ensure blood pressure, urinalysis, and laboratory tests have normalized. 2
• Refer women with persisting hypertension or proteinuria at 3 months to a specialist for investigation of secondary hypertension or renal disease. 2

Future Pregnancy Counseling

• Counsel about approximately 15% risk for recurrent preeclampsia and 15% risk for gestational hypertension in future pregnancies. 2
• Prescribe low-dose aspirin (75–162 mg daily) for future pregnancies, ideally started before 16 weeks (no later than 20 weeks). 2

Cardiovascular Risk Counseling

• Counsel about markedly increased lifetime risks of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease. 2
• Recommend annual medical review lifelong. 2
• Provide lifestyle counseling aiming for return to pre-pregnancy weight by 12 months and limiting inter-pregnancy weight gain through healthy diet, regular exercise, and weight management. 2

Breastfeeding Support

• Provide breastfeeding support and reassurance that labetalol, nifedipine, and amlodipine are compatible with breastfeeding. 2
• Encourage skin-to-skin contact immediately after delivery. 5

Postpartum Depression Screening

• Screen for postpartum depression at routine postpartum visits, recognizing that women with severe preeclampsia may be at higher risk for mood disorders. 2

Contraceptive Counseling

• Provide contraceptive counseling before discharge, noting that combined hormonal contraceptives should be avoided in women with history of severe preeclampsia due to increased thrombotic risk. 2
• Recommend progesterone-only methods or non-hormonal options as safer alternatives. 2

Critical Pitfalls to Avoid

• Do not delay IV antihypertensive therapy when BP ≥160/110 mmHg persists >15 minutes; immediate treatment is mandatory to prevent stroke. 2, 3
• Do not give oxytocin as rapid IV bolus (must be given over at least 1–2 minutes to avoid hypotension). 1
• Do not postpone oxytocin administration until after placental delivery; timing immediately after anterior shoulder delivery is critical for effectiveness. 1
• Do not abruptly discontinue antihypertensive therapy; taper gradually after the critical 3–6 day postpartum period. 2
• Do not use ergometrine in women with hypertension or severe preeclampsia. 1
• Do not use NSAIDs as first-line analgesics in women with preeclampsia. 2
• Do not neglect counseling about long-term cardiovascular and future-pregnancy risks. 2
• Do not classify preeclampsia as "mild" versus "severe" for management decisions; all cases can rapidly become emergencies. 3