Pre-eclampsia with severe features, eclampsia, and HELLP: ICU management

Also known as Pre-eclampsia severe · Eclampsia · HELLP syndrome · Hypertensive emergency pregnancy · Magnesium sulfate · Pre-eclampsia ICU

Pre-eclampsia (new hypertension after 20 weeks + proteinuria/end-organ dysfunction) complicates 2-8% of pregnancies (ACOG). SEVERE FEATURES: BP ≥160/110 (ISSHP), thrombocytopenia (<100), elevated transaminases, renal insufficiency, pulmonary oedema, cerebral/visual symptoms. ECLAMPSIA = new-onset seizures with no other cause. HELLP = Haemolysis, Elevated Liver enzymes, Low Platelets (platelets <100 x 10^9/L, Sibai). MANAGEMENT: (1) MAGNESIUM SULFATE for seizure prophylaxis/treatment (4 g IV loading then 1-2 g/h IV infusion, or 4 g IV + 10 g IM then 5 g IM q4h — reflexes lost at 3.5-5 mmol/L, respiratory paralysis at 5-6.5 mmol/L, renally excreted). (2) BP control: treat acute-onset severe hypertension as soon as possible within 30-60 min of confirmation with IV labetalol, IV hydralazine or immediate-release oral nifedipine (ACOG CO 767) — avoid precipitous drops. (3) DELIVERY is the definitive treatment (timing based on maternal/fetal status). (4) Antenatal corticosteroids for fetal lung maturity (<34 weeks). COMPLICATIONS: deaths mainly follow eclampsia, uncontrolled hypertension or systemic inflammation (fullPIERS); also pulmonary oedema, AKI, hepatic haemorrhage/rupture, DIC, abruption. POSTPARTUM: pre-eclampsia can develop or worsen after delivery — a seizure in a recently delivered woman is eclampsia until proven otherwise.

high18 referencesUpdated 26 July 202612 min readSource-verified · Sept 2026

Checked against its sources on 3 Sept 2026

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8 MCQs

The one-line answer

Severe pre-eclampsia, eclampsia and HELLP are one disease — new hypertension after 20 weeks with end-organ dysfunction — read across three escalating faces: severe pre-eclampsia (BP at least 160 over 110, or thrombocytopenia, transaminitis, renal impairment, pulmonary oedema, cerebral or visual symptoms), eclampsia (generalised seizure), and HELLP (haemolysis, elevated liver enzymes, low platelets). Every patient with severe features gets magnesium sulphate for seizure prophylaxis (4 g IV loading then 1 to 2 g per h, watching reflexes, respirations and urine; antidote calcium gluconate), urgent BP treatment (as soon as possible within 30 to 60 minutes of confirmed severe hypertension, with IV labetalol or hydralazine or immediate-release oral nifedipine — never a precipitous drop), and delivery as the definitive cure once the mother is stabilised. Untreated severe hypertension risks maternal stroke, and most pre-eclampsia deaths follow eclampsia, uncontrolled hypertension or systemic complications.^[10]^[14]

Meet the patient

A 27-year-old primigravida at 36 weeks is in the HDU on a magnesium infusion for severe pre-eclampsia (BP 168 over 108, platelets 112, AST 95) when she has a 90-second generalised tonic-clonic seizure. She is post-ictal, her respiratory rate is 8, her reflexes are absent, her urine output is 12 mL per hour, and her BP has climbed to 184 over 116. Two questions decide the next hour.^[10]^[18]

The two questions that decide every eclamptic seizure are: is the magnesium now toxic? (absent reflexes plus a depressed respiratory rate plus oliguria say yes — magnesium is renally excreted and accumulates when urine output falls, so reach for calcium gluconate) and is the pressure threatening her brain? (acute-onset severe hypertension carries a stroke risk — treat it as soon as possible within 30 to 60 minutes with a first-line agent, without a precipitous drop). Hold those two and the protocol slots into place.^[10]^[14]

References18Show

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