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CCS Case: Severe Preeclampsia

Case: Severe Preeclampsia

Clinical Setup

  • Presentation: 31-year-old female, G1P0 at 36 weeks gestation, with headache, visual scotomata, and RUQ pain. BP 172/114, 3+ proteinuria, platelets 98,000, elevated LFTs.
  • Location: Emergency Department / Labor and Delivery triage.

Optimal Order Pathway

  1. Immediate Orders (Minute 0–1):
    • Pulse oximetry, continuous cardiac monitoring, BP q15min.
    • IV access, Lactated Ringer’s or Normal saline @ 75 mL/hr (avoid fluid overload — pulmonary edema risk).
    • Continuous fetal monitoring (non-stress test), bed rest in left lateral position, seizure precautions.
  2. Focused Exam (Minute 1–2):
    • Neuro exam (clonus, hyperreflexia), abdominal exam (RUQ tenderness, fundal height), edema assessment.
  3. Diagnostics (Minute 2–5):
    • CBC (platelets, hemolysis), BMP (creatinine), LFTs, PT/INR, PTT, LDH.
    • Urinalysis + 24-hour urine protein or protein/creatinine ratio, urine output monitoring.
    • Obstetric ultrasound + biophysical profile if fetal status uncertain.
  4. Therapeutics & Consultation (Minute 5–12):
    • Magnesium sulfate IV loading dose + infusion for seizure prophylaxis (monitor reflexes, respiratory rate, urine output; keep calcium gluconate at bedside).
    • Antihypertensive: Hydralazine IV, Labetalol IV, or Nifedipine PO (treat SBP ≥ 160 or DBP ≥ 110 promptly).
    • OB consult stat — definitive treatment is DELIVERY (severe preeclampsia at ≥ 34 weeks: deliver; do not prolong pregnancy).
    • Corticosteroids (Betamethasone) only if < 37 weeks and delivery anticipated — do NOT delay delivery for full course in severe disease.
    • Advance clock in 15–30 min increments; re-examine BP, reflexes, fetal tracing.
  5. Disposition (Minute 12–15):
    • Transfer to Labor and Delivery for induction/C-section per OB decision; ICU if eclampsia, pulmonary edema, or DIC.
  6. Final 2 Minutes:
    • Counsel on warning signs (headache, visual changes, decreased fetal movement), need for close postpartum BP monitoring (eclampsia risk persists), future pregnancy risks.
    • Schedule OB follow-up within 1 week; arrange postpartum preeclampsia surveillance.