Version 1.0 — Published April 2026
Quick Answer
Severe pre-eclampsia is the leading direct cause of maternal mortality in India after hemorrhage. In a 28-year-old G2P1 at 34 weeks with BP 170/110, headache, blurred vision, and 3+ proteinuria, follow this 6-step workflow:
- Confirm severe features — BP >=160/110, neurological symptoms, proteinuria, lab abnormalities (platelets, AST/ALT, creatinine)
- Magnesium sulfate seizure prophylaxis FIRST — Pritchard 4 g IV + 10 g IM loading, 5 g IM 4-hourly maintenance for 24 hr
- Antihypertensive control — IV labetalol 20 mg or IV hydralazine 5-10 mg or oral nifedipine 10-20 mg; target 140-150 / 90-100
- Plan delivery within 24-48 hours — at 34 weeks deliver regardless; give betamethasone if <34 weeks (do not delay if unstable)
- Monitor for HELLP, abruption, pulmonary edema, eclampsia — strict input-output, hourly UO, repeat platelets/LFTs
- Continue magnesium for 24 hours post-delivery — postpartum eclampsia accounts for 30 percent of cases
The case
A 28-year-old G2P1 at 34 weeks gestation by reliable LMP and first-trimester ultrasound is brought to the labour ward by her husband. Her last antenatal visit was 2 weeks ago when BP was 132/86 and urine dipstick was negative. For the past 3 days she has noticed gradually worsening frontal headache, dimness of vision in both eyes (described as "spots floating"), nausea with one episode of vomiting this morning, and right-upper-quadrant discomfort radiating to the right shoulder. There is no abdominal pain in the lower abdomen, no per-vaginal bleeding, no leaking of liquor. Fetal movements are reduced today compared to baseline.
Past obstetric history: first pregnancy 4 years ago — full-term normal vaginal delivery, baby weighed 2.6 kg, no hypertension. Past medical history: nil. Family history: mother had eclampsia in her last pregnancy. No history of chronic hypertension, diabetes, renal disease, autoimmune disease, or thrombophilia. She is a homemaker, non-smoker, non-alcoholic, BMI 29.
On arrival at 11:40 PM, vitals are: BP 174/112 mmHg in the left arm seated, repeated after 5 minutes BP 168/108. Pulse 96/min regular, respiratory rate 20/min, SpO2 98 percent on room air, temperature 37.0 C. She is alert (GCS 15), responds to questions slowly, complains of severe frontal headache. Pupils equal and reactive, no neck stiffness, no focal motor deficit, brisk patellar and biceps reflexes (3+) with 2 beats of clonus on the right ankle, plantars flexor. Funduscopy: AV crossing changes, no papilledema. No pedal edema apparent (presence/absence of edema is no longer used in diagnosis). RUQ tender on deep palpation; no organomegaly. Uterus 32 cm symphysio-fundal height, single fetus longitudinal lie cephalic, no tenderness, no bleeding per vaginum, FHS 138/min on Doppler. Urine dipstick at the bedside: protein 3+, glucose negative, blood negative.
The on-call obstetrician initiates the severe pre-eclampsia protocol immediately, before sending samples.
ABCD assessment and parallel actions
Severe pre-eclampsia is a time-critical obstetric emergency. The first 60 minutes determine maternal and fetal outcome.
A — Airway: Patent. Position left lateral tilt to prevent aortocaval compression. Suction at bedside. If eclamptic seizure occurs, protect from injury, do NOT insert oral airway during the convulsion, give oxygen by mask post-ictally.
B — Breathing: SpO2 98 percent. Continuous pulse oximetry. Listen for crackles (pulmonary edema is a severe feature and presents with bibasal crackles, dyspnea, pink frothy sputum). Avoid fluid overload.
C — Circulation: BP 174/112, pulse 96. Two large-bore IV lines (16-18 G), one for magnesium sulfate, one for antihypertensive and maintenance fluids. Total maintenance fluid restricted to 80 mL/hour (1 mL/kg/hr) — pre-eclamptic women have leaky capillaries, and fluid overload precipitates pulmonary edema.
D — Disability/Dextrose: GCS 15, glucose 96. Brisk reflexes with clonus suggest impending eclampsia. Magnesium sulfate is started immediately as both anticonvulsant prophylaxis and to abolish hyperreflexia.
Initial investigations (sent simultaneously with treatment):
- CBC: Hb 11.6 g/dL, platelets 88,000 (low — borderline for severe feature), WBC 12,400
- Peripheral smear: occasional schistocytes — points to microangiopathic hemolysis
- LFT: AST 142 U/L, ALT 118 U/L (both more than twice normal), bilirubin 1.4 mg/dL, LDH 720 U/L, albumin 3.0
- RFT: creatinine 1.3 mg/dL (elevated for pregnancy — pregnancy-adjusted upper limit ~0.9), urea 32, urine output last hour 32 mL
- Coagulation: PT 13.2 sec, aPTT 30 sec, INR 1.1, fibrinogen 380 mg/dL (normal — DIC unlikely yet)
- Urine: protein 3+ on dipstick; spot urine protein-to-creatinine ratio 1.8 (severe proteinuria)
- Uric acid: 7.4 mg/dL (raised — supports pre-eclampsia)
- Glucose: 96 mg/dL
- Blood group and crossmatch: B+, 2 units PRBC kept ready
- CTG (cardiotocography): baseline FHR 138, reduced beat-to-beat variability, no decelerations, reactive — non-reassuring but not pathological
- Ultrasound (bedside): single fetus, cephalic, EFW 1.9 kg (less than 10th centile — IUGR), AFI 6 cm (low-normal), placenta posterior fundic grade 2, umbilical artery Doppler PI elevated
- CXR: clear, no pulmonary edema (yet)
- NCCT brain (deferred unless seizure): to rule out PRES, intracerebral bleed, sinus thrombosis if focal signs develop
Diagnosis
Severe pre-eclampsia at 34 weeks gestation in a G2P1 (recurrence risk after eclamptic mother) with multiple severe features — BP >=160/110, persistent severe headache, visual disturbance, RUQ pain, brisk reflexes with clonus, thrombocytopenia (platelets 88,000), elevated transaminases (AST 142, ALT 118), creatinine 1.3, with overlapping early HELLP syndrome (Mississippi class 2). Fetus IUGR (EFW <10th centile) with reduced variability on CTG.
ACOG severe-feature criteria are clearly met. Although classic proteinuria-based pre-eclampsia is also present here (3+ urine protein), proteinuria is no longer mandatory if severe features are otherwise documented.
Management — five parallel streams
The order matters. Magnesium goes up first (within minutes), antihypertensive next (within 15 minutes if BP >=160/110), then delivery planning. Do not chase normal BP — uteroplacental perfusion will fall.
Stream 1: Magnesium sulfate seizure prophylaxis
Magnesium sulfate is the agent of choice (Magpie trial, NICE, FOGSI). It does NOT lower BP — its job is to prevent eclampsia and abolish hyperreflexia.
Pritchard regimen (most commonly tested in NEET PG):
| Step | Dose | Route |
|---|
| Loading dose IV | 4 g (20 mL of 20% MgSO4) over 10-15 min | Slow IV push |
| Loading dose IM | 10 g total — 5 g into each buttock (50% solution, 10 mL each side, deep IM Z-track) | IM |
| Maintenance | 5 g IM every 4 hours, alternating buttocks | IM |
| Duration | 24 hours after delivery OR after the last seizure (whichever is later) | — |
Zuspan regimen (IV-only, more common in tertiary units with infusion pumps):
- 4-6 g IV over 20 minutes (loading)
- Then 1-2 g/hr continuous IV infusion for 24 hours after delivery or last seizure
Therapeutic range: 4-7 mEq/L (4.8-8.4 mg/dL).
Toxicity monitoring (assess every hour):
| Magnesium level | Clinical sign | Action |
|---|
| 4-7 mEq/L | Therapeutic | Continue |
| 8-10 mEq/L | Loss of patellar reflex | Reduce or stop infusion |
| 10-12 mEq/L | Respiratory depression (RR <14) | Stop magnesium, give antidote |
| >15 mEq/L | Cardiac arrest | Resuscitate, give antidote |
Antidote: 10% calcium gluconate 10 mL IV over 3 minutes (1 g calcium).
Monitoring during therapy: patellar reflex every hour (must be present), respiratory rate every hour (must be more than 14), urine output every hour (must be more than 25 mL/hr — magnesium is renally excreted; oliguria predisposes to toxicity).
Stream 2: Antihypertensive control
Treat severe-range BP (>=160/110) within 15 minutes. Target 140-150 / 90-100. Aggressive lowering reduces uteroplacental perfusion and causes fetal distress.
| Drug | Dose | Notes |
|---|
| IV labetalol | 20 mg over 2 min, double every 10 min (40, 80, 80, 80) up to cumulative 300 mg | First-line in many centres; avoid in asthma, bradycardia, heart failure |
| IV hydralazine | 5-10 mg over 2 min, repeat every 20-30 min, max cumulative 30 mg | Classic Indian first-line; can cause maternal hypotension and reflex tachycardia |
| Oral nifedipine immediate-release | 10-20 mg, repeat after 30 min if needed; max 40 mg | Useful when IV access delayed; avoid sublingual route |
| IV nicardipine | 5 mg/hr titrated to effect | Tertiary unit only |
Avoid in pregnancy:
- ACE inhibitors and ARBs — teratogenic, fetal renal failure, oligohydramnios
- Atenolol — IUGR with prolonged use
- Nitroprusside — cyanide toxicity to fetus on use beyond 4 hours
- Diuretics — already volume-depleted
Stream 3: Plan delivery — the timing matrix
Delivery is the only definitive cure. The decision matrix balances gestational age and maternal/fetal stability.
| Gestational age | Severe pre-eclampsia | Eclampsia / HELLP / abruption / unstable |
|---|
| <24 weeks | Counsel termination; survival rare; expectant management with maternal life-threatening risk | Immediate delivery |
| 24-33+6 weeks | Expectant management at tertiary centre (corticosteroids, MgSO4, antihypertensives, daily monitoring) IF stable; deliver if instability develops | Immediate delivery after MgSO4 and BP control |
| 34-36+6 weeks | Deliver — risk of expectant management exceeds benefit | Immediate delivery |
| >=37 weeks | Deliver any pre-eclampsia (even mild) | Immediate delivery |
Corticosteroids (betamethasone 12 mg IM, 2 doses 24 hours apart, OR dexamethasone 6 mg IM Q12h × 4 doses): indicated 24-34 weeks for fetal lung maturity. Do not delay delivery for steroids if maternal status is unstable.
Mode of delivery: vaginal delivery is preferred if obstetric situation permits. Cesarean for fetal distress, breech, prior CS, failed induction, or maternal contraindication to labour.
Anesthesia: epidural is preferred for vaginal delivery and CS — controls BP and reduces sympathetic surges. Avoid general anesthesia (intubation surge, aspiration risk) if platelets >75,000. Spinal is safe at platelets >75,000-80,000 in most institutional protocols.
Active management of third stage: oxytocin is the uterotonic of choice. Avoid ergometrine and methylergometrine — they cause severe hypertensive crisis. Misoprostol is acceptable.
For our patient at 34 weeks: deliver within 24-48 hours. Plan: stabilise BP and magnesium first, give first dose of betamethasone (still beneficial up to 34+0), induce labour with vaginal misoprostol or oxytocin if cervix favourable. Reassess fetal status hourly.
Stream 4: Fluid balance
Pre-eclamptic women have leaky capillaries, low oncotic pressure, and risk of pulmonary edema. Total fluids 80 mL/hr (1 mL/kg/hr) including all infusions. Strict input-output charting hourly. Aim urine output >30 mL/hr. Oliguria in stable BP and magnesium does NOT need fluid challenge — it usually reflects renal vasoconstriction and self-resolves. Pulmonary edema is the most common cause of death from severe pre-eclampsia.
Stream 5: Treat complications proactively
- HELLP: transfuse platelets if <20,000 or active bleeding or pre-cesarean <50,000; FFP for coagulopathy; continue MgSO4
- Pulmonary edema: sit up, oxygen, IV furosemide 20-40 mg, fluid restriction
- Eclamptic seizure: protect from injury; do not put anything in mouth during seizure; left lateral; oxygen post-ictal; if seizure recurs despite Mg, give a second 2 g IV bolus over 5 min; if still recurring, lorazepam 4 mg IV
- Abruptio placentae: clinical (vaginal bleeding, board-like uterus, fetal distress); deliver immediately; transfuse; manage DIC
Eclampsia — when seizure occurs
Eclampsia is defined as a generalised tonic-clonic convulsion in a woman with pre-eclampsia, in the absence of other neurological cause. 50 percent occur antepartum, 25 percent intrapartum, 25 percent postpartum (up to 6 weeks).
Acute management of an eclamptic seizure
- Call for help. Note time. Most seizures self-terminate in 90 seconds.
- Protect from injury. Padded sides, head-down left lateral, suction.
- Do NOT insert anything in the mouth during the convulsion. Do not restrain.
- Oxygen 10 L/min by mask post-ictally.
- Magnesium sulfate — if not already running, give Pritchard loading; if already on Mg, give a further 2 g IV over 5 min (recurrent seizure dose).
- Persistent or refractory seizure despite second Mg bolus: lorazepam 4 mg IV or thiopental 50-100 mg IV; rule out alternative causes (hypoglycemia, intracranial bleed, sinus thrombosis, PRES).
- Stabilise mother first, then continuous fetal monitoring. Do NOT rush to cesarean during a seizure — fetus often recovers within 5-10 minutes after maternal stabilisation.
- Investigate — repeat platelets, LFT, coagulation, creatinine, NCCT brain if focal signs, prolonged altered sensorium, or atypical seizure pattern.
- Plan delivery after maternal stabilisation — usually within hours.
- Continue MgSO4 for 24 hours after the last seizure or after delivery, whichever is later.
Differential of seizure in pregnancy
- Eclampsia (most common — assume until proven otherwise)
- Cerebral venous sinus thrombosis (focal signs, headache; MRV diagnostic)
- Intracerebral hemorrhage (focal signs, HTN; CT diagnostic)
- Posterior Reversible Encephalopathy Syndrome — PRES (seizure, blindness; MRI shows posterior parieto-occipital edema)
- Hypoglycemia, hyponatremia
- Pre-existing epilepsy
- Drug toxicity, withdrawal
HELLP syndrome — recognition and management
HELLP overlaps with severe pre-eclampsia in 10-20 percent. About 15 percent of HELLP cases occur without overt hypertension or proteinuria — making the diagnosis purely lab-based.
Diagnostic criteria (Tennessee classification):
- Hemolysis: peripheral smear schistocytes, LDH >600, indirect bilirubin >1.2
- Elevated Liver enzymes: AST >70 (or twice baseline)
- Low Platelets: <100,000
Mississippi severity classification (by platelet count):
| Class | Platelets | Severity |
|---|
| Class 1 | <50,000 | Severe — high maternal risk |
| Class 2 | 50,000-100,000 | Moderate |
| Class 3 | 100,000-150,000 | Mild — partial HELLP |
Management:
- Stabilise mother — MgSO4, antihypertensives, fluid restriction.
- Plan delivery promptly — at any gestational age >=34 weeks; consider 48-hour delay only if <34 weeks AND stable AND betamethasone benefit clear.
- Blood products: transfuse platelets if <20,000 or active bleeding or <50,000 pre-CS; FFP if coagulopathy; PRBC for hemorrhage.
- Dexamethasone for HELLP (10 mg IV Q12h) is controversial — improves platelet count transiently but does NOT reduce maternal morbidity in randomised trials. Many centres no longer use it routinely.
- Watch for hepatic rupture (RUQ pain with shock — rare but fatal; immediate laparotomy + packing), DIC, AKI, abruption, pulmonary edema.
Postpartum care
Eclampsia recurs postpartum in up to 30 percent of cases (mostly within 48 hours, but can occur up to 6 weeks). The protocol is unforgiving.
- Continue MgSO4 for 24 hours after delivery or last seizure, whichever is later.
- Continue antihypertensives — switch to oral labetalol (100-200 mg BD), nifedipine SR (20-30 mg BD), or methyldopa (250-500 mg TDS) for at least 6 weeks.
- Strict input-output for 48 hours — pulmonary edema is most common in this window.
- Counsel about postpartum eclampsia — return immediately for headache, blurred vision, or seizure.
- Discharge when BP <150/100 on oral therapy for 24 hours, no severe features, no laboratory worsening.
- Long-term follow-up — pre-eclampsia doubles cardiovascular risk lifelong. Annual BP, lipid, glucose check; encourage lifestyle measures.
- Future pregnancies — start low-dose aspirin 75-150 mg/day from 12-16 weeks for prevention of recurrence. Calcium supplementation 1 g/day in low-calcium-intake populations (most of India).
How NEET PG tests pre-eclampsia and eclampsia
NEET PG OBG carries 8-10 questions; pre-eclampsia and eclampsia together yield 1-2 questions almost every paper. Six dominant patterns:
Pattern 1 — The diagnostic criteria question: Vignette gives BP, urine protein, lab values. Identify mild vs severe pre-eclampsia. Trap: answers requiring proteinuria for severe disease — wrong; severe features alone are sufficient.
Pattern 2 — The first drug question: "What drug is given first in eclampsia?" Answer: magnesium sulfate. Trap: answers offering "labetalol" or "diazepam" — magnesium is the seizure prophylaxis and the seizure-treatment drug; antihypertensives only address BP.
Pattern 3 — The Pritchard regimen question: "Loading dose of MgSO4 in Pritchard regimen?" Answer: 4 g IV + 10 g IM. Trap: memorise both Pritchard and Zuspan; NEET has tested both in different years.
Pattern 4 — The toxicity question: "Patient on MgSO4, RR 10, no patellar reflex. Next step?" Answer: stop magnesium, give 10% calcium gluconate 10 mL IV. Trap: answers offering "give more magnesium" — opposite of the right action.
Pattern 5 — The delivery timing question: Severe pre-eclampsia at 33 weeks, stable. Action? Answer: betamethasone, expectant management at tertiary centre, deliver if instability develops. At 34 weeks, deliver regardless. Trap: answers offering "deliver immediately at 33 weeks if stable" — wrong; betamethasone benefit is real.
Pattern 6 — The third-stage question: Pre-eclamptic woman delivered, atonic PPH. Uterotonic of choice? Answer: oxytocin. Trap: answers offering "ergometrine" or "methylergometrine" — both contraindicated due to hypertensive crisis risk.
High-yield one-liners:
- Severe BP threshold = 160/110
- Severe pre-eclampsia features: BP, neuro symptoms, RUQ pain, platelets <100, AST/ALT >2×, creatinine >1.1, pulmonary edema
- MgSO4 = first drug in eclampsia
- Pritchard = 4 g IV + 10 g IM loading; 5 g IM Q4H maintenance
- Zuspan = 4-6 g IV loading + 1-2 g/hr infusion
- Antidote = calcium gluconate 10 mL of 10%
- Antihypertensives: labetalol, hydralazine, nifedipine — target 140-150 / 90-100
- Avoid: ACEi/ARB, atenolol, nitroprusside (long), ergometrine
- Deliver at 34 weeks regardless; corticosteroids 24-34 weeks
- HELLP class 1 = platelets <50; transfuse platelets if <20 or actively bleeding
- Oxytocin (NOT ergometrine) for third stage in pre-eclampsia
- 30 percent of eclampsia is postpartum — continue Mg 24 hr after delivery
- Aspirin 75-150 mg from 12-16 weeks for prevention in next pregnancy
Frequently Asked Questions
What are the ACOG/FOGSI diagnostic criteria for severe pre-eclampsia?
Severe features (any one) on a background of new-onset hypertension after 20 weeks: BP at least 160/110 on two readings 4 hours apart (or once if antihypertensives needed urgently), thrombocytopenia (platelets less than 100,000), impaired liver function (AST/ALT more than twice normal or persistent RUQ pain), renal insufficiency (creatinine more than 1.1 or doubling of baseline), pulmonary edema, new-onset visual or cerebral symptoms (headache, blurred vision, scotomata, altered sensorium). Proteinuria is no longer required for diagnosis if severe features are present.
What is the Pritchard regimen for magnesium sulfate?
Pritchard regimen (intramuscular, classic Indian protocol): loading dose 4 g IV over 10-15 minutes plus 10 g IM (5 g into each buttock) — total 14 g loading. Maintenance 5 g IM every 4 hours into alternate buttocks for 24 hours after delivery or last seizure. Zuspan regimen (IV-only): 4-6 g IV over 20 min, then 1-2 g/hr infusion for 24 hours. Therapeutic range 4-7 mEq/L; loss of patellar reflex at 8-10; respiratory depression at 10-12; cardiac arrest at more than 15. Antidote: 10 percent calcium gluconate 10 mL IV over 3 minutes.
Which antihypertensives are first-line for severe acute hypertension in pregnancy?
Three first-line agents: IV labetalol (start 20 mg over 2 min, double every 10 min to maximum cumulative 300 mg), IV hydralazine (5-10 mg over 2 min every 20-30 min, max 30 mg), and oral nifedipine immediate-release (10-20 mg, repeat after 30 min if needed). Target BP 140-150/90-100 — do not lower aggressively as it impairs uteroplacental perfusion. Avoid: ACE inhibitors and ARBs (teratogenic, fetal renal failure), atenolol (IUGR), nitroprusside (cyanide toxicity to fetus on prolonged use).
When should you deliver in severe pre-eclampsia?
Deliver at 34 weeks for severe pre-eclampsia regardless of stability — the only definitive treatment is delivery. Earlier delivery (less than 34 weeks) is mandatory if uncontrolled BP despite maximum therapy, eclampsia, HELLP with worsening labs, abruption, pulmonary edema, persistent severe symptoms, or non-reassuring fetal status. Give corticosteroids (betamethasone 12 mg IM × 2 doses 24 hours apart) for fetal lung maturity if 24-34 weeks, but do not delay delivery for steroids if maternal status is unstable. Vaginal delivery is preferred unless obstetric indication for cesarean.
What is HELLP syndrome and how does it differ from severe pre-eclampsia?
HELLP = Hemolysis (LDH more than 600, schistocytes on smear, indirect bilirubin more than 1.2), Elevated Liver enzymes (AST more than 70 or twice baseline), Low Platelets (less than 100,000). Occurs in 10-20 percent of severe pre-eclampsia, can occur without hypertension or proteinuria in 15 percent. Mississippi classification: class 1 platelets less than 50, class 2 50-100, class 3 100-150. Management: deliver promptly, magnesium sulfate seizure prophylaxis, blood products if active bleeding, dexamethasone is controversial (does not improve maternal outcome). Mortality 1-3 percent maternal, 10-30 percent perinatal.
This content is for educational purposes for NEET PG exam preparation. It is not a substitute for professional medical advice, diagnosis, or treatment. Clinical information has been reviewed by qualified medical professionals.
Written by: NEETPGAI Editorial Team
Reviewed by: Pending SME Review
Last reviewed: April 2026
