Preeclampsia & HELLP Syndrome Nursing Guide 2026
⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.
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Diagnostic criteria, magnesium sulfate protocol and toxicity monitoring, antihypertensive management, HELLP syndrome, eclampsia treatment, and nursing priorities in the obstetric patient.
1. Preeclampsia Diagnostic Criteria
Preeclampsia = hypertension + proteinuria (or end-organ damage) after 20 weeks gestation
Hypertension criteria: SBP ≥140 OR DBP ≥90 mmHg on two occasions ≥4 hours apart (while on bed rest)
Proteinuria: ≥300 mg/24-hour urine OR protein:creatinine ratio ≥0.3 OR urine dipstick ≥2+
Preeclampsia WITH severe features (any one of the following):
- SBP ≥160 OR DBP ≥110 mmHg on two occasions ≥4 hours apart
- Thrombocytopenia (platelets <100,000/mcL)
- Renal insufficiency (Cr >1.1 mg/dL or doubling of Cr)
- Impaired liver function (transaminases >2× normal)
- Pulmonary edema
- New-onset headache unresponsive to medication OR visual disturbances
- RUQ or epigastric pain (liver capsule stretching)
2. Magnesium Sulfate Protocol
Indications: Seizure prophylaxis in preeclampsia with severe features; treatment of eclamptic seizures
Standard dosing:
Loading dose: 4–6 g IV over 15–20 minutes
Maintenance: 1–2 g/hr IV continuous infusion
Duration: Continue 24–48 hours AFTER delivery (postpartum preeclampsia risk)
Magnesium Toxicity Monitoring — The Sequence
| Mg Level | Effect | Nursing Response |
|---|
| 4–7 mEq/L | THERAPEUTIC RANGE — seizure prophylaxis | Continue infusion; monitor per protocol |
| 7–10 mEq/L | Loss of deep tendon reflexes (DTRs) — FIRST sign of toxicity | Check patellar reflex before each dose assessment; if absent → hold infusion, notify provider |
| 10–13 mEq/L | Respiratory depression (<12 respirations/min) | STOP infusion; prepare calcium gluconate; support respirations |
| >15 mEq/L | Cardiac arrest | Emergency — CPR; calcium gluconate; STOP infusion |
Magnesium Toxicity Assessment — Check ALL THREE before each assessment:
- DTRs (patellar reflex) — must be present to continue infusion
- Respirations — must be ≥12/min
- Urine output — must be ≥25–30 mL/hr (magnesium excreted renally; oliguria → accumulation)
Antidote: Calcium gluconate 1 g (10 mL of 10% solution) IV push over 3–5 minutes
Keep calcium gluconate at the bedside at ALL TIMES when patient is on magnesium sulfate.
3. Antihypertensive Management
| Drug | Route/Dose | Onset | Notes |
|---|
| Labetalol | 20 mg IV; can repeat 40 mg then 80 mg q10 min; max 300 mg total | 2–5 min | First-line IV agent; avoid in asthma, bradycardia, decompensated HF |
| Hydralazine | 5–10 mg IV q20 min; max 20–30 mg | 10–20 min | Unpredictable — can cause sudden hypotension; give with maternal monitoring |
| Nifedipine (oral) | 10–20 mg PO; repeat in 30 min if needed | 15–30 min oral | Use if IV access difficult; do NOT give SL (causes rapid unpredictable drop) |
| Nicardipine | IV infusion 5–15 mg/hr | Minutes | Good for continuous infusion when BP very difficult to control |
BP target in severe preeclampsia: SBP 140–150 / DBP 90–100 mmHg — avoid over-correction to normal; uteroplacental perfusion depends on maternal BP. Sudden drops compromise fetal oxygenation.
4. HELLP Syndrome
HELLP = Hemolysis, Elevated Liver enzymes, Low Platelets
A severe variant of preeclampsia; can occur without classic hypertension or proteinuria initially.
Diagnostic criteria:
H — Hemolysis: peripheral smear with schistocytes; elevated LDH (>600 IU/L); elevated bilirubin
EL — Elevated Liver enzymes: AST >70 IU/L; LDH >600 IU/L
LP — Low Platelets: <100,000/mcL
Presentation: RUQ or epigastric pain (MOST COMMON complaint), nausea/vomiting, malaise, headache — often misdiagnosed as flu or GI illness
Complications: DIC, hepatic rupture (catastrophic), placental abruption, AKI, pulmonary edema
Treatment: Delivery is definitive treatment; corticosteroids (dexamethasone) may temporarily improve platelet count; correct coagulopathy; magnesium for seizure prophylaxis; transfuse platelets if <20k or active bleeding + <50k
5. Eclampsia
Eclampsia = new-onset grand mal (generalized tonic-clonic) seizures in a patient with preeclampsia — no other cause
During the seizure:
- Call for help; stay with patient
- Turn patient to LEFT LATERAL POSITION (reduces aortocaval compression, improves fetal perfusion)
- Protect airway; suction if needed; 100% oxygen via NRB
- Do NOT restrain; pad rails
- Time the seizure
- Fetal heart rate monitoring — bradycardia is expected during seizure and usually resolves after
After the seizure (post-ictal):
- Magnesium sulfate 4–6 g IV bolus (if not already on mag); then continue maintenance infusion
- If ALREADY on magnesium when seizure occurs: give additional 2 g IV bolus; check levels
- DO NOT use phenytoin/fosphenytoin for eclampsia — magnesium is superior and is the drug of choice
- Monitor maternal vitals; fetal heart tones; watch for placental abruption signs after seizure
- Prepare for delivery (may deliver vaginally or by C-section depending on clinical status)
6. Nursing Priorities — Preeclampsia/HELLP
- Continuous maternal and fetal monitoring; EFM (electronic fetal monitor) for fetal status
- Seizure precautions: padded rails, suction at bedside, O2 at bedside, quiet room, dim lighting
- Strict I&O with Foley catheter; UO goal ≥25–30 mL/hr
- Assess DTRs, respirations, UO before each magnesium assessment (q1–4h)
- Calcium gluconate at bedside at all times
- Restrict visitors; minimize stimulation; bed rest in left lateral position
- Lab monitoring: CBC, CMP, LFTs, LDH, uric acid, coagulation (DIC panel in HELLP)
- Position: left lateral to relieve aortocaval compression and improve uteroplacental blood flow
- Postpartum: preeclampsia/HELLP can WORSEN or develop in first 48–72 hours postpartum — continue surveillance
NCLEX High-Yield: Preeclampsia
- Preeclampsia: BP ≥140/90 + proteinuria after 20 weeks
- Severe features: BP ≥160/110, platelets <100k, Cr >1.1, headache, visual changes, epigastric pain
- Magnesium toxicity: DTR loss → respiratory depression → cardiac arrest (in that order)
- Antidote for magnesium toxicity: calcium gluconate 1 g IV — keep at bedside
- Monitor mag toxicity: DTRs present, RR ≥12/min, UO ≥25–30 mL/hr
- Eclampsia seizures: magnesium sulfate (NOT phenytoin)
- During seizure: left lateral position, airway, O2 — do NOT restrain
- HELLP: RUQ pain + hemolysis + elevated liver enzymes + low platelets
- HELLP treatment: delivery is only cure; dexamethasone may temporarily raise platelets
- Postpartum: preeclampsia can develop/worsen in first 48–72 hours after delivery
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