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Pre-Eclampsia and Preterm Labor – Time Sensitive Management

The guidelines for MgSo4 doses vary significantly in various study protocols, textbooks, and online clinical resources. The Society of Obstetrics and Gynecology of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) both recommend starting at lower dose MgSo4 which is thought to result in fewer side effects.

Loading dose: MgSO4 4g IV over 20 – 30 minutes: Use a 50 ml syringe and draw up 4 g (8 ml) MgSO4 and then add 22 ml 2⁄3/1⁄3 to make a total volume of 30 ml. Administer over 30 minutes at an infusion rate of 60 ml/hour, using a volumetric infusion pump.

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Articles of Interest

ED Management of Severe Preeclampsia

Labetalol 20 mg IV as a bolus can be given initially. Further 40 mg 10 minutes later if needed followed by two further doses at 80 mg 10 minutes apart, to a maximum dose of 220 mg. If adequate response is not achieved, an alternative agent can be used.

Postpartum Preeclampsia: A Rare Complication

Postpartum preeclampsia is uncommon, and it can be easily overlooked as a diagnosis when a postpartum patient has no prior symptoms of preeclampsia. At one time, it was thought that women could not develop eclampsia if they did not have preeclampsia during pregnancy; however, this has been found to be untrue.

Preeclampsia

The treatment of preeclampsia can be broken down into three parts: treating the hypertension, reducing the risk or recurrence of seizures, and delivery of the fetus and the placenta. In the ED- our focus is on the first two, and involving our obstetric colleagues immediately. Blood pressure is most commonly treated with labetolol or hydralazine IV in the ED, and Mag should be given immediately for seizure prophylaxis (or to reduce recurrence of seizures in eclampsia).

Preeclampsia & HELLP

HELLP is a manifestation of preeclampsia (not a separate disorder). It's a thrombotic microangiopathy which may be closely related to atypical hemolytic uremic syndrome. HELLP is a subset of preeclampsia. Therefore, patients with HELLP also have preeclampsia. Magnesium infusion is indicated in HELLP syndrome, as these patients are at risk for seizure. If hypertension is present, it should be treated in the same fashion as preeclampsia in general.

Preeclampsia and Eclampsia

Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery.

Preeclampsia and Eclampsia: Common Pitfalls in Diagnosis and Management

The first line medication for this is magnesium sulfate. Magnesium is given IM if necessary while IV access is being obtained. Magnesium is provided at 4-6 g IV load over 15 minutes, followed by 2-3 g/hr. The IM route includes up to 10 g. Benzodiazepines can be given in refractory situations, or if magnesium is not readily available. A gravid-appearing woman having seizures should be presumed to have eclampsia until proven otherwise.

Preeclampsia in the ED

Notably, women can experience preeclampsia and eclampsia up to 4 weeks postpartum. These patients are of particular importance to the emergency medicine clinician, since many of them may not have had any signs of hypertensive disease during their pregnancy and may be more likely to present in an emergency department than to their OB providers.

Resources

ACOG Practice Bulletin - Gestational Hypertension and Preeclampsia

Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2–8% of pregnancies globally.