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Preeclampsia

1.5 Contact Hours including 1.5 Pharmacology Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Saturday, December 20, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will know about preeclampsia.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Define preeclampsia.
  2. List the risk factors for preeclampsia.
  3. Generate a plan of care for patients with preeclampsia.
  4. Identify the medications used to treat preeclampsia.
  5. State the risks of preeclampsia to the woman and the fetus.
  6. Determine the long-term consequences of preeclampsia.
  7. Describe the follow-up care that women with preeclampsia need.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Overview of Preeclampsia

Hypertensive disorders in pregnancy are one of the leading causes of maternal mortality in the world (American College of Obstetricians and Gynecologists [ACOG], 2020). Preeclampsia and elevated blood pressures are serious problems that must be treated appropriately and quickly. It is believed that 2 to 8% of all pregnancy-related complications in the world are attributed to preeclampsia (Karrar & Hong, 2022). Pregnancy-related difficulties are thought to cause over 50,000 maternal deaths and over 500,000 fetal deaths in the world every year (Karrar & Hong, 2022).

Beginning in January of 2021, The Joint Commission included a set of standards that are dedicated to improving the quality and safety of care in women with hypertension and preeclampsia (California Maternal Quality Care Collaborative [CMQCC], 2021). The goal of the standards is to reduce the likelihood of harm related to maternal severe hypertension/preeclampsia.

The Joint Commission standards include (The Joint Commission, 2019):

  1. The development of written protocols for measuring and remeasuring blood pressure (with a main goal of identifying severely elevated blood pressure).
  2. The development of written protocols for managing hypertension and preeclampsia in pregnant and postpartum patients that includes the following:
    1. The use of emergency response medications that are immediately available on the obstetric unit
    2. The use of seizure prophylaxis
    3. Guidance on when to consider transfer to a higher level of care
    4. Direction for when to employ continuous fetal monitoring
    5. Direction for when to consider emergent delivery
    6. Conditions for when a team debriefing should be done
  3. The goal of role-specific education to all staff who work with pregnant/post-partum women (including emergency department providers) regarding the hospital’s severe hypertension/preeclampsia protocols, at orientation and again every two years.
  4. A recommendation to conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills should include a team debriefing at the conclusion.
  5. A recommendation to review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.
  6. Printed education for patients and their families that includes:
    1. Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care
    2. Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care
    3. When to schedule a post-discharge follow-up appointment

Types of Hypertension in Pregnancy

When caring for pregnant women with blood pressure issues, it is important to review the different types of hypertension in pregnancy.

Chronic Hypertension

Chronic hypertension is diagnosed when a woman has systolic blood pressure (SBP) ≥ 140 or diastolic blood pressure (DBP) ≥ 90 (August & Sibai, 2023). This occurs pre-pregnancy or on at least 2 occasions before 20 weeks’ gestation (August & Sibai, 2023).

It is possible that women have chronic hypertension without knowing it because they may not routinely see a provider before they get pregnant.

Gestational Hypertension

Gestational hypertension is diagnosed with a SBP ≥ 140 or DBP ≥ 90, the patient being greater than 20 weeks gestation with previously normal blood pressures, and there being an absence of proteinuria or systemic signs and symptoms (August & Sibai, 2023).

Up to 50% of these women may go on to develop preeclampsia and require observation.

Preeclampsia

Preeclampsia is defined as a SBP ≥ 140 or DBP ≥ 90 with proteinuria and with or without signs/symptoms of end-organ dysfunction OR a SBP ≥ 140 or DBP ≥ 90 and presentation of signs/symptoms/lab abnormalities, but no proteinuria.

Proteinuria is defined as ≥ 0.3 grams of protein in a 24-hour urine specimen or a protein/creatinine ratio ≥ 0.3 (30 mg/mmol) in a random urine specimen or dipstick urine protein ≥ 2+.

Signs and symptoms of end-organ dysfunction include (August & Sibai, 2023):

  • Platelet count of less than 100,000/microliter
  • Impaired liver function as shown by abnormally elevated blood concentrations of liver enzymes (to twice the normal concentration)
  • Serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal diseases
  • Pulmonary edema
  • New-onset, persistent headache, or visual disturbances (blurred vision, flashing lights, or scotomata)

Preeclampsia with severe features (what used to be known as severe preeclampsia) is defined as ONE OR MORE of the following (August & Sibai, 2023; ACOG, 2020):

  • A systolic blood pressure of 160 mmHg or higher or a diastolic blood pressure of 110 mmHg or higher on 2 occasions while the patient is on bed rest (unless antihypertensive therapy is started before this time) with measurements at least 4 hours apart
  • Hepatic issues including severe right upper quadrant or epigastric pain that is persistent and unresponsive to medication with no alternative diagnoses and/or impaired liver function as indicated by abnormally higher blood concentrations of liver enzymes (to twice the normal concentration)
  • Thrombocytopenia (a platelet count less than 100,000/microliter)
  • Progressive renal insufficiency (a serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal diseases)
  • Pulmonary edema
  • New-onset central nervous system dysfunction which includes photopia, scotomata, cortical blindness, retinal vasospasm, and/or severe headache or headache that continues even after taking acetaminophen without an alternative diagnosis

Classic indicators of a preeclampsia headache include the headache being bilateral, progressive, pulsating or throbbing, and associated with visual changes. The headache usually is worse with physical activity, becomes worse as blood pressure increases, and is not relieved by acetaminophen (Davis, 2020).

Eclampsia is a severe form of preeclampsia. It is diagnosed if a woman with preeclampsia has a tonic-clonic, focal, or multifocal seizure without any other neurological conditions (Davis, 2020). Eclampsia is a significant cause of maternal mortality, especially in low resource areas. Patients who have seizures associated with eclampsia often have warning signs such as headache, blurred vision, and photophobia, although they can occur without any warning signs.

HELLP syndrome is considered to be a variation of preeclampsia. Sometimes, the presence of HELLP syndrome is due to an underlying disease such as antiphospholipid syndrome (an immune system disorder that results in an increased risk of blood clots).

HELLP syndrome is characterized by hemolysis (the breakdown of red blood cells), elevated liver enzymes, and low platelets. Many patients with HELLP syndrome have hypertension, and some have central nervous system or renal dysfunction. Some patients have an atypical presentation of HELLP syndrome with no other symptoms (August & Sibai, 2023).

However, the cause of hypertension is not important with severely elevated blood pressures. The following constitutes a hypertensive emergency in pregnant or postpartum women with preeclampsia/eclampsia (ACOG, 2020):

  • Acute onset
  • Persistent (lasting 15 or more minutes)
  • Severe systolic (≥ 160 mmHg) and/or severe diastolic hypertension (≥ 110 mmHg) 

Controlling blood pressure is the best possible intervention to prevent deaths due to stroke in women with preeclampsia (ACOG, 2020). Prompt treatment to lower blood pressure can decrease maternal morbidity and mortality by preventing congestive heart failure, myocardial ischemia, renal injury, and ischemic or hemorrhagic stroke (ACOG, 2020).

Preeclampsia most commonly occurs in the third trimester, but it can occur in the second trimester and can usually be more severe. It is important, too, to note that preeclampsia can also occur in the postpartum period. In fact, preeclampsia can occur 4 to 6 weeks after delivery. Nurses must educate all postpartum patients about the risks of preeclampsia and signs and symptoms to report immediately. These signs and symptoms can include any of the following:

  • Headache
  • Vision changes
  • Epigastric pain
  • Severe abdominal pain
  • Confusion
  • Shortness of breath
  • Seizures

Nurses must also emphasize to patients that they need to go to the emergency department and be sure to tell them that they recently had a baby. The emergency department (ED) should immediately treat severe range blood pressures with first-line medication (CMQCC, 2021). The emergency department should consult an obstetrician, but all emergency department nurses and providers should be educated about postpartum preeclampsia and how to treat it.

Pathophysiology

The pathophysiology of preeclampsia is complex and not completely understood. It is thought that there is abnormal placentation which leads to alteration in the placental vessels. This can lead to vascular sclerosis and abnormal arteriole remodeling of the placenta, which then causes placental ischemia (Karrar & Hong, 2022). This ischemia leads to the release of distress markers, which include antiangiogenic and pro-inflammatory factors. These markers then compete for binding sites with essential growth factors. This then leads to abnormal vessel formation and inadequate vascular accommodation for organ systems, like the heart, kidneys, and liver (Karrar & Hong, 2022).

Risk Factors

There are known risk factors for preeclampsia. Not all women with these risk factors will develop preeclampsia. And not all women with preeclampsia have had these risk factors. The risk factors may be useful in the early identification and treatment of women.

A woman who has preeclampsia in one pregnancy has eight times the risk of developing preeclampsia than a woman without a history. The severity of the preeclampsia may impact the risk as well. Women with preeclampsia with severe features in the second trimester are at the highest risk of developing preeclampsia in subsequent pregnancies (August & Sibai, 2023).

There are pre-existing medical conditions that also increase the risk of preeclampsia. Pregestational diabetes is a risk factor because of kidney or vascular complications, obesity, abnormal insulin levels, and lipid metabolism. Chronic hypertension increases a woman’s risk of developing preeclampsia five times greater than a woman without chronic hypertension. Systemic lupus erythematosus and antiphospholipid syndrome increase the risk, and this is likely due to inflammation, platelet abnormalities, and kidney dysfunction. Being overweight or obese, even without any other complications, increases the risk of preeclampsia. Chronic kidney disease and obstructive sleep apnea can also increase the risk of preeclampsia (August & Sibai, 2023).

Pregnancy conditions that can increase the risk of preeclampsia are a multifetal pregnancy or nulliparity. Prior pregnancy complications caused by placental insufficiency can increase the risk as well. A family history of preeclampsia can increase the risk, possibly indicating a hereditary condition. A woman who was born preterm, small for gestational age, or low birth weight may be at increased risk of developing preeclampsia. Gestational diabetes increases the woman’s risk of preeclampsia as well. Maternal age > 35 is an increased risk, likely due to comorbidities. Use of assisted reproductive technology is also an increased risk for preeclampsia (August & Sibai, 2023).

Presentation

Patients with preeclampsia usually will present with elevated blood pressures and/or protein in the urine. Patients may also have complaints of headaches, vision changes (scotomata, photophobia, blurred vision), abdominal pain (epigastric, upper abdominal, or retrosternal), altered mental status, or dyspnea. The patient may have a sudden weight gain or edema. The most common presentation of postpartum preeclampsia is headache (August & Sibai, 2023).

Patients who present with any symptoms or elevated blood pressures should receive further testing. The patient’s urine should be evaluated. A basic urinalysis could show if there is protein present, with 2+ or greater being abnormal. The preferred test is a urine protein to creatinine ratio. A ratio of 0.3 or greater is considered abnormal. A 24-hour urine could also be collected with 300 mg protein or greater being considered abnormal. Blood work should be drawn, and testing should include a complete blood count (CBC) to determine platelets, and a complete metabolic panel to look at liver and kidney function (Karrar & Hong, 2022).

Plan of Care

Patients with preeclampsia require close monitoring. A thorough initial assessment of the woman with possible preeclampsia should include a complete history and a complete physical exam with close attention to preeclampsia symptoms, including unremitting headaches, edema, visual changes, epigastric pain, fetal activity, and vaginal bleeding.

The nurse should review baseline blood pressures and medications or drugs taken throughout pregnancy, both illicit and those over-the-counter (OTC). The patient should have current vital signs, including O2 saturation. The nurse should also review current and past fetal assessments: fetal heart rate (FHR) monitoring results, estimated fetal weight, and recent biophysical profile. Labs that should be drawn include a CBC, platelets, lactic dehydrogenase (LDH), liver function tests, electrolytes, BUN and creatinine, and a urine sample sent for a protein/creatinine ratio (Karrar & Hong, 2022).

The nursing assessments needed vary depending on the diagnosis. Women with preeclampsia without severe features need vital signs, pulse oximetry, and lung sounds assessed every 4 hours or 8 hours if they are sleeping (CMQCC, 2021). Level of consciousness, edema and assessment for headache, visual disturbances, and epigastric pain should occur every 4 to 8 hours. Intake and output should be monitored every 4 to 8 hours, with 24-hour totals. Fetal monitoring should be done as ordered. Every shift may be appropriate for antepartum patients, but continuous monitoring should be done during labor (CMQCC, 2021).

Women with preeclampsia with severe features or women on magnesium sulfate should have 1:1 nursing care with an experienced nurse. The patient needs vital signs, including pulse oximetry every 5 to 15 minutes during the loading dose of magnesium sulfate, and then again, every 30 minutes for at least an hour, then hourly, while receiving magnesium sulfate. These women need lung sounds assessed every 2 hours. Level of consciousness, edema, and deep tendon reflexes should be assessed every 4 hours, or more as needed. Assessment for headache, visual disturbances, and epigastric pain should occur every 8 hours. Strict (hourly) intake and output should be monitored, and intake should be ≤ 125 mL/hour. Fetal monitoring should be continuous as ordered while pregnant. Once the woman is stable without severe features and no longer receiving magnesium sulfate, she may be monitored as a patient with preeclampsia without severe features (CMQCC, 2021). These women should try to remain calm and quiet in a darkened room. Patients on magnesium may have cognitive dysfunction and information may need to be reviewed more than once.

Women who are experiencing seizures with eclampsia or have magnesium toxicity need even more frequent monitoring. Blood pressure, pulse, and respirations should be monitored every 5 minutes until the patient is stable. Pulse oximetry should be monitored continuously. Level of consciousness should be monitored every 15 minutes for an hour. Continuous fetal monitoring is necessary as well (CMQCC, 2021).

When assessing a patient with suspected or diagnosed preeclampsia, the nurse should be aware that they need to report any of the following signs or symptoms immediately (CMQCC, 2021):

  • Systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 110 mmHg
  • Adventitious breath sounds
  • Altered level of consciousness (agitation, restlessness, confusion, lethargy, hallucinations)
  • Shortness of breath
  • Complaints of chest pain
  • Headache unrelieved by OTC medications
  • Oxygen saturation < 95%
  • Cough
  • Tachypnea (> 26 breaths per minute)
  • Tachycardia (> 100 beats per minute)
  • Eclamptic seizure
  • Upper abdominal pain
  • Urine output < 30 ml/hour
  • Visual disturbances (blurred vision, spots, blind spot, floaters)

Treatment

Medication

Low Dose Aspirin

Women who are at a high risk of developing preeclampsia should receive low-dose aspirin (LDA). Therapy should begin in the second trimester and continue until birth. This has been shown to reduce the risk of developing preeclampsia (August & Sibai, 2023).

LDA at doses of 60-150 mg is recommended for all women who are high risk of developing preeclampsia and should be started between 12 and 28 weeks of gestation. The most common starting point is at 16 weeks. It should be continued until delivery. In the United States, the recommended dose is 81 mg (CMQCC, 2021).

Recommendations for LDA are as follows.

LDA is recommended if the patient has one or more of any of these risk factors (CMQCC, 2021):

  • History of preeclampsia
  • Multifetal pregnancy
  • Type 1 or 2 diabetes
  • Chronic hypertension
  • Autoimmune disease
  • Renal disease
  • Combination of multiple risk factors

LDA is recommended if the patient has 2 or more of any of these risk factors (CMQCC, 2021):

  • Age ≥ 35
  • Low socioeconomic status
  • Family history of preeclampsia
  • Nulliparity
  • Black race
  • Obesity
  • Personal historical factors (low birth weight, small for gestational age, previous adverse pregnancy outcome, > 10-year pregnancy interval)
  • In-vitro conception

Antihypertensives

Early diagnosis of preeclampsia requires careful observation. If there are no severe features and the patient is managed as an outpatient, adequate blood pressure management is important. Patients are usually prescribed labetalol or nifedipine (Karrar & Hong, 2022; Norwitz, 2022).

Persistent, severe hypertension can occur antepartum, intrapartum, or postpartum. Severe blood pressure values (≥ 160/110) that persist for at least 15 minutes require treatment as soon as possible, and ideally within 30-60 minutes of severe range elevated blood pressure.

The acceptable treatments for severe blood pressure are intravenous (IV) labetalol, IV hydralazine, or oral nifedipine (ACOG, 2020). One medication should be chosen and initiated. Early treatment has been shown to decrease the chances of severe maternal morbidity due to heart failure, pulmonary edema, stroke, cerebrovascular hemorrhage, myocardial ischemia, and death (CMQCC, 2021). The goal of treating the severe range blood pressure is not to bring the blood pressure just back to normal, but to lower the mean arterial pressure (MAP) by 15-25% to decrease the risk of intracranial hemorrhage (CMQCC, 2021).

IV labetalol is one of the options to treat severe range blood pressures. It is a combined alpha and beta blocker, which dilates arterioles. The first dose starts at 20 mg and the onset of action is 2 to 5 minutes, with the peak action at 5 minutes. It should be avoided or cautiously used in patients with asthma. Labetalol can cause flushing, light headedness, and palpitations. The initial dose of 20 mg is followed by 40 mg after 10 minutes and then followed by 80 mg after another 10 minutes if there is no improvement. The maximum dose given is 140 mg (CMQCC, 2021).

IV hydralazine is an arteriole dilator. The initial dose is 5 to 10 mg, with an onset of action of 5 to 10 minutes, and a peak action at 15-30 minutes. Intravenous hydralazine may cause tachycardia, flushing, and rarely abdominal pain. The initial dose is 5 to 10 mg, followed by 10 mg after 20 minutes if no improvement. The maximum dose is 20 mg (CMQCC, 2021).

There have been no significant changes in umbilical blood flow that have been detected with the use of either labetalol or hydralazine. The outcomes of use are also similar for both drugs.

Oral immediate release nifedipine is an effective treatment of severe range blood pressure and is especially useful for patients who do not have IV access. It is a calcium channel blocker and arterial smooth muscle dilator. The first dose is 10 mg with an onset of action of 5 to 20 minutes and a peak action of 30 to 60 minutes. Nifedipine can cause reflex tachycardia, headache, flushing, nausea, and vomiting. The initial dose of 10 mg is followed by 20 mg after 20 minutes and then another 20 mg after another 20 minutes if not effective. The maximum dose is 50 mg.

There have been no significant alterations in the uteroplacental blood flow or the fetal heart that have been noted with the use of immediate-release oral nifedipine to treat severe pregnancy-induced hypertension.

If there is no improvement after a full regimen of one medication, a second line of treatment should be used. Once two agents have been used, if there is no improvement, an anesthesiologist or intensivist should be consulted. Medications like IV esmolol (beta blocker) and IV nicardipine (calcium channel blocker) may be needed. The patient may need an arterial line for invasive blood pressure monitoring as well (CMQCC, 2021).

Treating severe range blood pressures in women who are chronic abusers of cocaine or amphetamines can cause hypotension that is difficult to treat. Labetalol is a reasonable treatment option. Hydralazine can be used but it may cause tachycardia. Hypotension can be difficult to treat and may require phenylephrine, epinephrine, or norepinephrine to correct it.

Using an algorithm can help to improve treatment times and patient outcomes (CMQCC, 2021). Providers may not remember all of the treatment options and algorithms off the top of their heads. Having one readily available can improve compliance and timing, ultimately improving patient outcomes. There are electronic medical records that can also have these algorithms or order sets built in to alert the provider. For an evidence-based example of a preeclampsia treatment algorithm, check out this one created by the California Maternal Quality Care Collaborative (CMQCC) on page 2 at the following link (CMQCC, 2021): Link to CMQCC Treatment Algorithm

Seizure Prevention

Magnesium sulfate may be administered as a central nervous system depressant to decrease the risk of seizures. While magnesium may decrease blood pressure, it is not used specifically as an antihypertensive.

According to the American College of Obstetricians and Gynecologists (ACOG), magnesium sulfate should be given to patients who have preeclampsia with severe features to prevent seizures and should also be given if a seizure due to preeclampsia does occur. Both the World Health Organization (WHO) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) also recommend the use of magnesium sulfate in patients with preeclampsia without severe features. Myasthenia gravis, however, is a contraindication to administering magnesium sulfate (CMQCC, 2021).

The Institute of Safe Medication Practices (ISMP) lists magnesium sulfate as a high alert medication. Magnesium is the second most common source of medication errors in labor and delivery. Some guidelines to help prevent errors include (CMQCC, 2021):

  • Labeling magnesium sulfate as high alert
  • Labeling IV solutions, tubing, and connections in a clear manner
  • Requiring verification by two nurses of the settings for an initial magnesium sulfate IV pump infusion, rate changes, or assumption of care
  • Administering a loading dose from a bolus bag (not from the maintenance solution)
  • Using luer-lock connectors and disconnecting tubing from the main line immediately when magnesium sulfate is discontinued
  • Using a ‘smart’ infusion pump, if available, with patient safety software activated
  • Standardizing ordering, storage, preparation, and administration of magnesium sulfate (buying commercially prepared concentrations, using premixed infusions, having pharmacy prepare non-commercially prepared solutions, using a piggy-back bag for loading doses, labeling dose bags with a high-alert sticker, spelling out the full name in orders)
  • Improving access to information concerning indications, risks and benefits, and treatment of magnesium sulfate toxicity

Calcium gluconate should be readily available as a reversal agent in the event of magnesium toxicity (CMQCC, 2021).

Magnesium sulfate is usually given as a 4 to 6 gm loading dose given over 15 to 20 minutes, followed by 1 to 2 gm/hr IV maintenance dose. For a patient with a BMI > 35, a loading dose of 6 gm should be administered.

For patients with impaired renal function, a maintenance dose of 1 gm/hr should be used to prevent magnesium toxicity. This dose may be started antepartum or intrapartum and continued for 24 hours after delivery. Magnesium can also be given in the postpartum period for 24 hours to prevent seizures in patients with postpartum preeclampsia.

If there is no IV access, magnesium may be given intramuscularly. Initially, 10 g should be given as a loading dose (5 g IM in each buttock), followed by 5 g every 4 hours (ACOG, 2020). The therapeutic range is 5-9 mg/dL. Serum levels are not indicated unless there are signs and symptoms of toxicity or renal insufficiency. Before starting magnesium sulfate, a BUN and creatinine should be drawn to assess baseline renal function. Magnesium toxicity is dangerous and can cause severe complications, such as renal failure or death (CMQCC, 2021; Norwitz, 2022).

The nurse must perform proper assessments, including checking for headaches, visual changes, and altered levels of consciousness. Vital signs, reflex status, and intake and output need to be monitored as well. The infusion should be stopped, and the provider should be notified in the event that the following signs of magnesium toxicity present (CMQCC, 2021; Norwitz, 2022):

  • Depressed or absent reflexes
  • Respirations less than 12 per minute
  • Urinary output of less than 30 mL per hour or less than 120 mL in four hours of function
  • Hypotension
  • Respiratory depression
  • Respiratory arrest
  • Shortness of breath
  • Chest pain

Early signs of magnesium toxicity are (CMQCC, 2021):

  • Warm/hot “all over” flushing
  • Increased thirst
  • Diaphoresis
  • Depressed reflexes
  • Hypotension
  • Flaccidity

Late signs are (CMQCC, 2021):

  • CNS depression
  • Increased drowsiness
  • Lethargy
  • Slurring of speech
  • Respiratory paralysis
  • Circulatory collapse

The antidote for magnesium sulfate toxicity is 10% Calcium Gluconate 1-gram IV push over 3 minutes (CMQCC, 2021).

Nursing assessments are vital when caring for patients on magnesium sulfate. Nurse to patient ratio guidelines should be followed. Patients on magnesium in labor should have a 1:1 nurse to patient ratio, a patient who is antepartum receiving magnesium should have a 1:2 nurse to patient ratio, and a nurse caring for a postpartum patient on magnesium should have no more than one other couplet (CMQCC, 2021).

Nurses can help patients manage the side effects of magnesium sulfate. For flushing, sweating, malaise, and drowsiness the nurse should keep the room and the patient cool and assist the patient out of bed. For decreased contractions during the loading dose, the nurse should continue to monitor contractions and the fetal heart rate. For soreness at the IV site, the nurse can provide ice packs or warm compresses. For shortness of breath, treatment should be discontinued, and oxygen should be administered. For diuresis and monitoring for oliguria, the nurse should monitor intake and output (CMQCC, 2021).

If a patient experiences a seizure due to eclampsia, they should receive magnesium sulfate with a 4 to 6 gm loading dose given over 15 to 20 minutes, followed by a 1 to 2 gm/hr IV maintenance dose. If the patient is postpartum and had magnesium already discontinued, they should receive another 24 hours of magnesium. If there are recurrent seizures and the patient is on magnesium, they should receive an additional loading dose of magnesium sulfate 2-4 gm IV over 5 minutes. If there are recurrent seizures after the second loading dose, anti-convulsants should be given, and anesthesia and neurology should be consulted (CMQCC, 2021).

Recommended anti-convulsants include (CMQCC, 2021):

  • Midazolam: 1-2 mg IV (can repeat after 5-10 minutes) 

OR

  • Diazepam: 5-10 mg IV slowly (can repeat every 15 minutes for a maximum total of 30 mg) 

OR

  • Phenytoin: 1,250 mg IV at a rate of 50 mg/minute

Additional medications that have been used with the assistance of anesthesia providers include (CMQCC, 2021):

  • Sodium thiopental
  • Propofol
  • Sodium amobarbital

IV Fluids

Fluid management is an important part of managing a patient with preeclampsia. It is important to maintain end organ perfusion, while not causing fluid overload. The nurse must closely monitor input and output. Most women with preeclampsia have a decreased intravascular volume and can experience hypovolemia (CMQCC, 2021). However, the risk of pulmonary edema is usually greater. Fluids are usually restricted to a total of ≤ 125 mL/hr. Patients with oliguria may be given a trial of IV fluid boluses. If there is still oliguria present after 1000 mL, colloids or blood may be given to enhance renal perfusion (CMQCC, 2021).

Delivery

Ultimately, delivery of the fetus is the only way to resolve preeclampsia. The timing of delivery is dependent on the severity of preeclampsia and gestational age of the fetus.

It is important to note that regional anesthesia such as an epidural or spinal are preferred over general anesthesia if the patient requires a cesarean section (ACOG, 2020). For patients on magnesium, hypotension is a risk with regional anesthesia, but it is easily correctable. There is a risk of epidural hematoma in a patient with thrombocytopenia but in patients with platelet counts of 70x109/L or more, provided that the platelet level is stable, there is no other acquired or congenital coagulopathy, and the patient is not on any antiplatelet or anticoagulant therapy, regional anesthesia is still acceptable (ACOG, 2020). ACOG (2020) also recommends that magnesium sulfate infusion should be continued during the cesarean section.

For patients with preeclampsia without severe features who are ≥ 37 weeks gestation, delivery is recommended. For patients who have developed preeclampsia with severe features at ≥ 34 weeks gestation, immediate delivery is recommended. Patients who are less than 34 weeks gestation and experience preeclampsia with severe features may be candidates for conservative management. These patients must be admitted, and their blood pressure must be quickly controlled (CMQCC, 2021). The only exception is proteinuria > 5 grams/24 hours which used to indicate immediate delivery but is now acceptable for conservative management. Any of the following signs and symptoms present at < 34 weeks gestation may prompt delivery (CMQCC, 2021; ACOG, 2020; Norwitz, 2023):

  • Persistent maternal headache
  • Epigastric pain or right upper abdominal pain that does not respond to analgesics
  • Visual changes (blurred vision or scotomata)
  • Persistent blood pressure ≥ 160 mmHg systolic or ≥ 110 mmHg diastolic despite medical management
  • Hypoxia (O2 saturation < 95%) or pulmonary edema on clinical exam
  • Abnormal coagulation (elevated prothrombin time/partial thromboplastic time (PT/PTT) or fibrinogen < 300)
  • Thrombocytopenia (platelet count < 100 x 109/L in the absence of alternative diagnosis)
  • Evidence of renal failure (serum creatinine > 1.1 mg/dL)
  • Stroke
  • Myocardial infarction
  • Pulmonary edema
  • HELLP syndrome
  • Elevated AST or ALT > 2 times upper normal limit
  • Evidence of hemolysis (LDH > 600, bilirubin > 1.2 mg/dL or abnormal peripheral blood smear)
  • Oliguria (< 500 ml/24 hours)
  • Suspected placental abruption or unexplained vaginal bleeding
  • Abnormal fetal testing (non-stress test (NST), biophysical profile (BPP), absent or reversed end diastolic flow)

Normal fetal testing is required. Severe intrauterine growth restriction (IUGR) with reassuring fetal monitoring allows for conservative management. Patients with eclampsia, HELLP syndrome, pulmonary edema, severe thrombocytopenia, or a coagulopathy require delivery without delay. For patients with HELLP syndrome who are carrying a baby between the gestational age of fetal viability and 33 6/7 weeks of gestation, delivery may be delayed to allow the patient to complete a course of corticosteroids for fetal lung maturity.

The likelihood of success of a vaginal delivery based on cervical status, the gestational age, fetal status, and the severity of disease and rapidity of any changes in maternal or fetal status should be considered when deciding on a vaginal delivery or cesarean section delivery (CMQCC, 2021). Fetal heart tracings during seizures can show prolonged decelerations and even bradycardia due to increased uterine contractions and baseline uterine tone. Because of maternal hypoxia and hypercarbia from the seizure, the fetal heart rate tracing may show recurrent decelerations, tachycardia, and reduced variability. After maternal resuscitation, the fetal heart tracing may return to normal. Patients who have eclamptic seizures should always be hemodynamically stabilized prior to delivering the fetus (ACOG, 2020).

HELLP syndrome is progressive, and the patient’s condition can change quickly. Because of this, delivery is usually recommended right away. The woman and the fetus, especially if remote from term gestational age, may need intensive care after delivery. These patients may require transfer to a tertiary care center (ACOG, 2020).

Risks to Mom and Baby

Preeclampsia and eclampsia are dangerous diseases that can cause complications to both the woman and the fetus. Worldwide, 10-15% of maternal deaths are due to preeclampsia or eclampsia (August & Sibai, 2023). Women with preeclampsia are at increased risk for kidney damage, liver, brain, and other organs and blood systems. Central nervous system disturbances are possible (seizure, unremitting headache, visual disturbance). A woman with preeclampsia is at an increased risk of coagulopathy, stroke, pulmonary edema, thrombocytopenia, hemolysis, and oliguria.

Preeclampsia may affect the placenta. This condition could lead to placental abruption from elevated blood pressures, preterm delivery due to worsening preeclampsia, and most commonly, intrauterine growth restriction (Karrar & Hong, 2022). Uterine and placental dysfunction are thought to contribute to fetal growth restriction (Davis, 2020). Oligohydramnios and even stillbirth can occur.

Long-Term Effects

Women with preeclampsia are still at risk for difficulties after discharge. Women who had preeclampsia are four times more likely to develop hypertension and are twice as likely to develop later ischemic heart disease, a blood clot in a vein, and stroke than those who did not (ACOG, 2020).

Mothers who have preeclampsia can also experience permanent damage to their organs, such as their kidneys and liver. These women can experience fluid in the lungs and remain at increased risk for developing eclampsia and seizures. Studies show that many women do not know their risks when being discharged. Education is a vital part of care for patients with preeclampsia.

Follow-Up Care

These women need to know their risks and the signs and symptoms to look out for such as headache, visual changes, shortness of breath, or altered level of consciousness. Women must understand that they should call their provider or go to the emergency department for any of these symptoms.

Women treated with medications for elevated blood pressures should have a visit with their provider 3 to 7 days following discharge for a blood pressure follow-up check. These patients also need to know the long-term consequences of preeclampsia and the importance of being seen by their family physician.

Women with preeclampsia who are not treated with medication should see their physician within 7-14 days after delivery (CMQCC, 2021). This can be difficult for some new mothers. Education should be provided about the importance of follow-up and resources for home visits should be provided if the patient cannot get to a provider. Some hospitals are beginning to use telemedicine to follow up with these patients. Some of these women could see nephrologists in the outpatient setting. Emergency departments must also be aware of the signs and symptoms of postpartum preeclampsia.

Case Study

Scenario

Sarah is a 24-year-old G2, P0-0-1-0 at 39 weeks gestation. Her prenatal course has been unremarkable, her blood pressure has been normal throughout the prenatal period as well.

Sarah presented to the office with a complaint of regular uterine contractions and a blood pressure of 142/95. Urinalysis is negative for protein. The patient was sent to the hospital and admitted for spontaneous labor and gestational hypertension.

On admission to labor and delivery:

  • BP 133/74
  • Urinalysis negative
  • Platelet count: 187,000
  • AST 14, ALT 18

Sarah’s blood pressure remained modestly elevated throughout the labor and postpartum stay. She had a primary late-term c-section for failure to progress. The postpartum course was unremarkable. She had no documented complaints of headache, blurred vision, or epigastric pain.

On post-op day #3, Sarah complained of an “acute, crushing headache,” pain rated 8/10. Discharge orders had already been written. Sarah received hydrocodone 15 mg/acetaminophen 650 mg and was discharged 30 minutes later.

Post-op day #4: Sarah reported a worsening headache to her family.

Post-op day #5: Progressively worsening headache and new-onset visual changes.

Interventions

The family called 911. Sarah’s initial seizure occurred shortly after calling, and the family witnessed multiple seizures. She was intubated in her home and transported to the hospital, where she was started on magnesium sulfate, Ativan, Keppra, and labetalol.

Sarah was extubated shortly after admission, and her blood pressures remained elevated with max 148/98 (SBPs mostly 130’s, DBPs mostly 80’s), platelet count 370,000, AST 30, ALT 33, creatinine 0.9 mg/dl, urinalysis: negative for protein. Sarah still has a persistent, mild headache with some postural component. MRI shows “no evidence of ischemic injury.”

Discussion

Up to 26% of eclamptic seizures occur as late as 4 to 6 weeks postpartum. As many as 78% of these patients have no antepartum hypertensive diagnosis (CMQCC, 2021). The most common presenting symptom is a headache, which has occurred in about 70% of patients. Other prodromal symptoms include shortness of breath, epigastric pain, blurry vision, nausea or vomiting, edema, and neurological deficit.

Strengths and Weaknesses

Delayed onset prevented the ability to predict this outcome. Sarah’s presentation did not indicate the need for early follow-up to see her provider. Her only indicator was her headache. Sarah could have been kept in the hospital longer to evaluate the headache, especially with her history of gestational hypertension. She also may have called her doctor or gone to the emergency department sooner if she had had through discharge education.

Conclusion

Preeclampsia is a complicated disease. It can have devastating consequences for the mother or fetus if not treated promptly and correctly. All staff need to know the facts about preeclampsia. It is also important for nurses to educate the woman so that she can best advocate for her own care.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • American College of Obstetricians and Gynecologists. (ACOG). (2020). Gestational hypertension and preeclampsia. Obstetrics & Gynecology, 135(6). Visit Source.
  • August, P., & Sibai, B. M. (2023). Preeclampsia: Clinical features and diagnosis. UpToDate. Retrieved March 15, 2023. Visit Source.
  • California Maternal Quality Care Collaborative. (CMQCC). (2021). Hypertensive disorders of pregnancy toolkit. Hypertensive Disorders of Pregnancy Toolkit | California Maternal Quality Care Collaborative. Retrieved March 15, 2023. Visit Source.
  • Davis, M. (2020). Preeclampsia: Pathophysiology and clinical presentations. American College of Cardiology. Visit Source.
  • The Joint Commission. (2019). R3 report requirement, rationale, reference: Provision of care, treatment, and services standards for maternal safety. The Joint Commission. Retrieved March 18, 2023. Visit Source.
  • Karrar, S. A., & Hong, P. L. (2022). Preeclampsia. StatPearls. Retrieved March 15, 2023. Visit Source.
  • Norwitz, E. R. (2022). Preeclampsia: Intrapartum and postpartum management and long-term prognosis. UpToDate. Retrieved March 15, 2023. Visit Source.
  • Norwitz, E. R. (2023). Preeclampsia: Antepartum management and timing of delivery. UpToDate. Retrieved March 15, 2023. Visit Source.