EM · Hypertensive disorders of pregnancy
Hypertensive disorders of pregnancy (ED)
Also known as Pre-eclampsia · Eclampsia · Severe pre-eclampsia · HELLP syndrome · Gestational hypertension
The hypertensive disorders of pregnancy on the spectrum from the gestational hypertension through the pre-eclampsia (with and without the severe features) and the eclampsia (the seizures) to the HELLP syndrome (the haemolysis, the elevated liver enzymes, the low platelets), the pathophysiology of the abnormal placentation and the endothelial dysfunction (the failed second-wave trophoblastic invasion, the anti-angiogenic sFlt-1 with the depletion of the PlGF), the ACOG and the NICE diagnostic criteria, the severe features that trigger the severe management and the delivery, the HELLP syndrome with the Mississippi and the Tennessee classifications, the ED acute management (the intravenous labetalol or the hydralazine or the nifedipine for the blo…
Checked against its sources on 1 Sept 2026
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- The pre-eclampsia is the hypertension after 20 weeks with the proteinuria or the end-organ dysfunction — the severe features (the blood pressure above 160 over 110, the thrombocytopenia, the transaminitis, the pulmonary oedema, the cerebral or the visual symptoms) trigger the severe management and the delivery
- The magnesium sulphate is the cornerstone for the seizure prophylaxis and the treatment — the loading 4 to 6 grams over 20 minutes and the infusion 1 to 2 grams per hour, with the calcium gluconate as the antidote for the toxicity
- The intravenous labetalol or the hydralazine or the oral nifedipine control the severe-range blood pressure — the ACE inhibitors, the direct renin inhibitors, and the angiotensin receptor blockers are contraindicated (teratogenic and fetotoxic)
- The delivery is the only cure for the pre-eclampsia — the magnesium sulphate continues for the 24 hours postpartum
- The pre-eclampsia may develop or worsen in the postpartum period (48 hours to six weeks) — with particular vigilance in the first two weeks
Meet the patient
A 31-year-old primigravida at 34 weeks is referred by her midwife with a two-day frontal headache, visual flashing lights, and epigastric pain. Blood pressure is 168 over 114, confirmed on repeat. The urine protein-to-creatinine ratio is 64. Platelets 78, AST 132, LDH 720. The fetal heart rate is 142 with a reactive trace.[1]
Three questions decide the next hour, and they are the three that decide every hypertensive disorder of pregnancy: is this pre-eclampsia with severe features? (yes — the BP, the platelets, the transaminases), which three-pillar bundle do I start now? (magnesium, BP control, the obstetric call for delivery), and what is the one drug I must never give? (an ACE inhibitor, an ARB, or a direct renin inhibitor — teratogenic and fetotoxic).[1]
References17ShowHide
- [1]Magley M, Hinson MR, Haddad LM. Eclampsia (Nursing) StatPearls, 2024.PMID 34033310
- [2]Hauspurg A, Jeyabalan A Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy Am J Obstet Gynecol, 2022.PMID 35177218
- [3]Lu JF, Nightingale CH. Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic principles Clin Pharmacokinet, 2000.PMID 10803454
- [4]The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial Lancet, 1995.PMID 7769899
- [5]Altman D, Carroli G, Duley L, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial Lancet, 2002.PMID 12057549
- [6]von Dadelszen P, Payne B, Li J, et al. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model Lancet, 2011.PMID 21185591
- [7]Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy N Engl J Med, 2015.PMID 25629739
- [8]Rolnik DL, Wright D, Poon LC, et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia N Engl J Med, 2017.PMID 28657417
- [9]Quan A. Fetopathy associated with exposure to angiotensin converting enzyme inhibitors and angiotensin receptor antagonists Early Hum Dev, 2006.PMID 16427219
- [10]Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review BMC Pregnancy Childbirth, 2009.PMID 19245695
- [11]Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count Obstet Gynecol, 2004.PMID 15121574
- [12]Fonseca JE, Méndez F, Cataño C, et al. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial Am J Obstet Gynecol, 2005.PMID 16260197
- [13]Matchaba P, Moodley J. Corticosteroids for HELLP syndrome in pregnancy Cochrane Database Syst Rev, 2004.PMID 14973983
- [14]Maynard SE, Min JY, Merchan J, et al. Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia J Clin Invest, 2003.PMID 12618519
- [15]Bellamy L, Casas JP, Hingorani AD, et al. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis BMJ, 2007.PMID 17975258
- [16]Zeisler H, Llurba E, Chantraine F, et al. Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia N Engl J Med, 2016.PMID 26735990
- [17]Koopmans CM, Bijlenga D, Groen H, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial Lancet, 2009.PMID 19656558