• Hypertension
  • systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg on at least two occasions at least four hours apart after 20 weeks of gestation in a patient with a previously normal BP
  • If systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg, confirmation can be instead within minutes to facilitate timely antihypertensive therapy.
• Proteinuria
  • ≥300 mg/24-hour urine specimen or,
  • Protein:creatinine ratio of 0.3 mg/dL
• End organ dysfunction
  • renal insufficiency (serum creatinine >1.1 mg/dL or a doubling of serum creatinine in the absence of other renal disease)
  • new onset headache
  • visual disturbances
  • pulmonary edema
  • thrombocytopenia (platelet count <100,000/mm³)
  • impaired liver function (serum transaminase two times normal)
  • persistent right upper quadrant pain despite analgesia

Preeclampsia has variable presentations that range from mild to severe, and if left untreated, it can progress to eclampsia, which is a convulsive manifestation of gestational hypertensive disorders and is among the most severe form of disease. Eclampsia is defined by new-onset tonic-clonic, focal, or multifocal seizure in the absence of any additional causes of seizure such as epilepsy, intracranial hemorrhage or ischemia, or other acute causes such as severe hypoglycemia or substance use.¹ Eclampsia can occur before, during and up to six weeks after labor, and it is important to note that a significant proportion of patients (30 percent) do not present with classical signs of preeclampsia prior to a seizure episode.²

Management^3,4,5

In addition to early engagement with OB/GYN, the main objective of management of eclampsia is termination of seizure. The American College of Obstetrics and Gynecologists (ACOG) in collaboration with the ACEP developed a Guide to Obstetric Emergencies in Non-obstetric Settings that includes guidance on management of eclampsia.

First-line therapy for eclamptic seizures is magnesium sulfate. Initial treatment includes:

1. loading dose: 4-6 g IV over 20-30 minutes followed by maintenance dose
2. maintenance dose: 1-2 g/hour
   1. If IV access has not been established, magnesium sulfate can be administered intramuscularly (IM)—10 g loading dose with 5 g IM administered in each buttock.
   2. Medication can be mixed with 1 mL 2 percent Xylocaine to reduce discomfort

Persistent or recurring seizure after magnesium sulfate loading dose: Continue IV magnesium maintenance dosing, administer one of the following medications and be prepared for possible intubation.

Preferred next medication class: benzodiazepines

1. lorazepam 4 mg IV over three to five minutes or,
2. diazepam 5-10 mg IV slowly
3. If no IV access, 10 mg IM midazolam

If the patient is still seizing: