Imagine a third-year emergency medicine resident working overnight in the intensive care unit (ICU) when a new patient arrives from an outside hospital. The patient is a 35-year-old primigravid woman, estimated to be 27 weeks pregnant with twins. Her pregnancy has otherwise been uncomplicated, and she reports no significant medical history. She was accepted to the ICU for suspected necrotizing fasciitis of her lower extremity.

Her vitals on arrival include a blood pressure (BP) of 180/110 mmHg, a heart rate of 80, respiratory rate of 26, and 94 percent on 3L/min nasal cannula. She has never required oxygen at baseline.

Her exam is significant for a headache, decreased visual acuity secondary to blurry vision, increased work of breathing with coarse lung sounds bilaterally, and grade 2+-pitting edema of the lower extremities. She also has cellulitis covering a small portion of her left leg, but without crepitus.

After reviewing imaging from the outside hospital, and after evaluation by surgery, she is diagnosed with cellulitis and receives intravenous (IV) antibiotics. However, she does not require surgery for debridement. A chest X-ray is obtained because she has a new oxygen requirement, which shows pulmonary edema.

Based on her presentation and vital signs, the patient has severe preeclampsia and obstetrics/gynecology (OB/GYN) is consulted. The patient is given IV labetalol for BP control; she is started on IV magnesium for seizure prophylaxis. Despite analgesia, the patient continues to endorse headaches. OB/GYN evaluates and determines that she needs to be transported to the operating room for emergent cesarean delivery. The patient is given a dose of steroids for fetal lung maturation.

While OB/GYN is coordinating with the neonatal ICU and preparing the operating room, the patient begins to decompensate, with increasing oxygen requirements, escalating from nasal cannula to high-flow nasal cannula, and eventually requiring bi-level positive airway pressure (BiPAP). Shortly after initiating BiPAP, she develops a tonic-clonic seizure which, fortunately, is aborted with 4 mg IV of lorazepam. She maintains her airway and does not require intubation. Her BP is eventually controlled with a nicardipine drip after multiple push doses of IV labetalol and hydralazine. The patient is successfully transported to the operating room where she undergoes surgery with successful cesarean delivery of two infants. The patient and her newborns both make a full recovery and are eventually discharged home.

Preeclampsia vs. Eclampsia^1,2

Preeclampsia and eclampsia are serious pregnancy-related conditions that fall under the umbrella of gestational hypertensive disorders and can pose significant risks to both the mother and the fetus. Preeclampsia typically occurs after the 20th week of pregnancy and is characterized by hypertension plus proteinuria or evidence of end organ dysfunction and are defined below:¹