Obstetrics & Gynecology Emergencies

Preeclampsia with Severe Features & Eclampsia

Preeclampsia is new-onset hypertension (SBP ≥ 140 or DBP ≥ 90 mmHg) after 20 weeks of gestation plus either proteinuria (≥ 300 mg/24 hr or protein/creatinine ≥ 0.3) OR any severe feature:

Diagnostic Criteria for Severe Features

1. Severe Blood Pressure: SBP ≥ 160 mmHg or DBP ≥ 110 mmHg on 2 occasions ≥ 4 hours apart.
2. Thrombocytopenia: Platelets < 100,000/μL.
3. Renal Insufficiency: Serum creatinine > 1.1 mg/dL or doubling of baseline.
4. Hepatic Impairment: Transaminases ≥ 2 times upper limit of normal or severe persistent RUQ pain.
5. Pulmonary Edema.
6. New-onset refractory headache or visual disturbances (scotomata, cortical blindness).

Immediate Step 3 Management Triad

1. Seizure Prophylaxis: IV Magnesium Sulfate (4–6 g IV loading dose over 20 min, then 1–2 g/hr continuous infusion). Maintain throughout labor and for 24 hours postpartum.
2. Acute Antihypertensive Therapy (Mandatory if SBP ≥ 160 or DBP ≥ 110 mmHg):
   • IV Hydralazine: 5–10 mg IV push every 20 min (causes reflex tachycardia).
   • IV Labetalol: 20 mg IV push, doubling every 10 min up to 80 mg (avoid if maternal bradycardia or active asthma).
   • Oral Nifedipine: 10–20 mg PO immediate release (avoid sublingual administration).
3. Definitive Delivery Timing:
   • Preeclampsia with severe features: Delivery indicated at ≥ 34 weeks of gestation (or immediately regardless of gestational age if maternal/fetal deterioration, DIC, or eclampsia).
   • Administer IM Betamethasone (12 mg q24h × 2 doses) for fetal lung maturity if < 37 weeks.

flowchart TD
    Mg["IV Magnesium Sulfate Infusion Running"] --> Monitor["Serial Monitoring: Deep Tendon Reflexes (DTRs) + Respiratory Rate + Urine Output"]

    Monitor --> Toxicity{"Signs of Magnesium Toxicity?"}
    Toxicity -- "Loss of Deep Tendon Reflexes (Serum Mg 7-10 mEq/L)" --> StopMg["1. Stop Magnesium Infusion Immediately"]
    Toxicity -- "Respiratory Depression / Arrest (Serum Mg > 12 mEq/L)" --> Antidote["2. Administer IV Calcium Gluconate 10% (10 mL IV push stat)"]
    Antidote --> Intubate["3. Secure Airway / Mechanical Ventilation if needed"]

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Postpartum Hemorrhage (PPH) Step-Wise Protocol

Defined as cumulative blood loss ≥ 1,000 mL or bleeding accompanied by signs of hypovolemia within 24 hours post-delivery:

flowchart TD
    PPH["PPH Identified (>1000 mL or Unstable)"] --> Step1["Step 1: Fundal Assessment & Bimanual Uterine Massage"]
    Step1 --> Uterotonics["Step 2: Step-Wise Uterotonic Medications"]

    Uterotonics --> Oxy["1. IV Oxytocin (First-line for all patients)"]
    Oxy --> Methergine["2. Methylergonovine (Methergine)\n*CONTRAINDICATED in Hypertension / Preeclampsia*"]
    Methergine --> Carboprost["3. Carboprost (Hemabate / PGF2-alpha)\n*CONTRAINDICATED in Active Asthma*"]
    Carboprost --> Miso["4. Rectal / Sublingual Misoprostol (PGE1)"]

    Miso --> Tamponade["Step 3: Intrauterine Balloon Tamponade (Bakri Balloon)"]
    Tamponade --> Surgery["Step 4: Uterine Artery Embolization / B-Lynch Suture / Emergent Hysterectomy"]

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Third-Trimester Vaginal Bleeding

Key Differential Contrast

Placenta Previa vs Placental Abruption (Abruptio Placentae)

Clinical Feature	Placenta Previa	Placental Abruption	Discriminating Clue
Clinical Pain Quality	Painless bright red vaginal bleeding in 2nd/3rd trimester	Sudden-onset painful dark red vaginal bleeding with persistent severe abdominal/back pain	Painless = Previa; Painful + Tense uterus = Abruption
Uterine Tone & Palpation	Soft, nontender, relaxed uterus between contractions	Hypertonic, rock-hard ('woody'), exquisitely tender uterus with frequent high-frequency contractions	Woody, tender uterus confirms Abruption
Critical Clinical Rule	NEVER perform digital pelvic or speculum exam prior to transabdominal ultrasound (risk of catastrophic exsanguination)	Clinical diagnosis supported by ultrasound (ultrasound misses 50% of retroplacental clots)	No digital exams before ultrasound confirmation of placental location
Coagulopathy Risk	Rare unless massive unresuscitated maternal hemorrhage	High risk of rapid Disseminated Intravascular Coagulation (DIC) due to tissue factor release	Check platelet count, fibrinogen, and D-dimer in abruption
Delivery Method	Scheduled Cesarean Delivery at 36 0/7 – 37 6/7 weeks (or emergent C-section if active hemorrhage)	Emergent Cesarean delivery if maternal/fetal instability; trial of vaginal delivery permissible if stable	Vaginal delivery is strictly contraindicated in complete placenta previa