Preeclampsia & Eclampsia Management for NEET PG — Complete Guide 2026

Version 1.0 — Published March 2026

Preeclampsia is a multisystem hypertensive disorder of pregnancy characterised by new-onset hypertension after 20 weeks with end-organ dysfunction — and its management is a flagship NEET PG topic because it spans obstetrics, pharmacology, and medicine. The student who nails magnesium sulfate regimens, severe features, and delivery timing covers 2–3 marks across papers. Pair this guide with daily MCQ practice on the obstetrics and gynaecology subject hub, cross-reference the OBG high-yield topics overview, and revise the postpartum haemorrhage clinical case for peripartum emergency integration.

Definitions — ACOG 2020 and ISSHP 2021

Preeclampsia is a new-onset hypertensive disorder after 20 weeks of gestation in a previously normotensive woman, defined by ACOG 2020 and refined by ISSHP 2021.

ACOG 2020 criteria (both required OR first + severe feature):

ISSHP 2021 revised classification includes fetoplacental involvement (IUGR, abnormal umbilical Doppler) as a diagnostic criterion even without proteinuria. The big shift from older definitions: proteinuria is no longer mandatory if end-organ dysfunction is present.

Hypertensive disorder spectrum in pregnancy:

1. Chronic hypertension — BP >=140/90 before 20 weeks OR persisting >12 weeks postpartum
2. Gestational hypertension — new BP >=140/90 after 20 weeks WITHOUT proteinuria or severe features; ~25% progress to preeclampsia
3. Preeclampsia — gestational hypertension + proteinuria OR severe features
4. Eclampsia — preeclampsia + new-onset grand mal seizures (not attributable to other cause)
5. Chronic hypertension with superimposed preeclampsia — new proteinuria / severe features after 20 weeks in a known chronic hypertensive
6. HELLP syndrome — variant with haemolysis + elevated LFTs + low platelets

Severe features (any one qualifies as severe preeclampsia):

• BP >=160/110 on two occasions 4 hours apart (or confirmed on shorter interval)
• Platelets <100,000/microL
• Serum creatinine >=1.1 mg/dL or doubling from baseline
• AST/ALT >=2× upper limit of normal, or severe persistent RUQ/epigastric pain
• Pulmonary oedema
• New-onset headache unresponsive to medication
• Visual disturbances (scotoma, blurring, diplopia)

Pathophysiology — spiral artery, endothelial dysfunction, sFlt-1

Preeclampsia pathogenesis is a two-stage disease model involving defective placentation followed by systemic endothelial dysfunction.

Stage 1 — Defective placentation (first half of pregnancy):

• Normal pregnancy: extravillous trophoblasts invade maternal spiral arteries and convert them from high-resistance, low-capacity vessels into low-resistance, high-capacity channels (physiological conversion)
• Preeclampsia: shallow trophoblast invasion → spiral arteries retain muscular coat → placental hypoperfusion → hypoxic placenta
• Mechanisms for shallow invasion include maternal immune maladaptation, genetic predisposition, thrombophilias, obesity, and prior vascular disease

Stage 2 — Maternal syndrome (after 20 weeks):

• Hypoxic placenta releases anti-angiogenic factors into maternal circulation:
  • sFlt-1 (soluble fms-like tyrosine kinase-1) — binds and inactivates VEGF and PlGF
  • sEng (soluble endoglin) — inhibits TGF-β signalling
• Reduced bioavailability of VEGF/PlGF → endothelial dysfunction
• Downstream consequences:
  • Vasoconstriction → hypertension
  • Increased vascular permeability → oedema, pulmonary oedema, proteinuria
  • Glomerular endotheliosis (pathognomonic renal lesion) → proteinuria
  • Activation of coagulation cascade → thrombocytopenia, microangiopathic haemolysis
  • CNS endothelial dysfunction → posterior reversible encephalopathy syndrome (PRES), seizures

sFlt-1/PlGF ratio (biomarker):

• Ratio <=38 → rules out preeclampsia within 1 week (high NPV; PROGNOSIS trial)
• Ratio >85 (before 34 weeks) or >110 (after 34 weeks) → strongly suggests preeclampsia
• Adopted by NICE 2022, WHO 2021; increasingly cited in NEET PG

Risk factors (for aspirin prophylaxis):

Aspirin 75–150 mg daily from 12–16 weeks until 36 weeks reduces preeclampsia risk by ~60% (ASPRE trial, NEJM 2017).

Mild vs severe preeclampsia features

Preeclampsia severity stratification dictates inpatient admission, magnesium prophylaxis, and timing of delivery — and getting this table right is probably the single highest-yield OBG content.

Antihypertensives in pregnancy — what to use, what to avoid

Antihypertensive choice in pregnancy-induced hypertension is dictated by both maternal efficacy and fetal safety — and NEET PG routinely tests which drugs are permitted.

First-line (safe in pregnancy):

Contraindicated in pregnancy:

Target BP in severe preeclampsia: 140–150 / 90–100 mmHg. Do NOT aim for normotension — aggressive lowering reduces uteroplacental perfusion.

Treat acute severe hypertension (BP >=160/110) within 30–60 minutes to reduce maternal stroke risk.

Magnesium sulfate — Pritchard vs Zuspan regimens

Magnesium sulfate is the first-line anticonvulsant for seizure prophylaxis in severe preeclampsia and seizure treatment in eclampsia — and the Pritchard-vs-Zuspan distinction is a NEET PG staple.

Mechanism: NMDA receptor antagonist; cerebral vasodilator; membrane stabiliser; prevents calcium influx into neurons.

Pritchard regimen (intramuscular, 1955):

• Loading: 4 g IV over 3–5 minutes PLUS 10 g deep IM (5 g in each buttock, Z-track)
• Maintenance: 5 g IM every 4 hours, alternating buttocks
• Duration: 24 hours after delivery OR 24 hours after last seizure (whichever later)
• Advantage: no pump needed — ideal for low-resource settings, Indian PHC / CHC
• Disadvantage: painful injections, abscess risk

Zuspan regimen (intravenous, 1966):

• Loading: 4–6 g IV over 15–20 minutes (diluted in 100 mL saline)
• Maintenance: 1–2 g/hour continuous IV infusion
• Duration: 24 hours postpartum or 24 hours after last seizure
• Advantage: steady serum levels, more comfortable for patient
• Disadvantage: requires infusion pump, trained nursing

Sibai (modified) regimen: 6 g IV load over 20 minutes + 2 g/hour infusion. Commonly used in US.

Therapeutic serum magnesium: 4–7 mEq/L (4.8–8.4 mg/dL).

Magnesium toxicity (dose-dependent):

Clinical monitoring at each dose (before next Pritchard injection OR q1h on Zuspan):

• Deep tendon reflexes (patellar) — must be present
• Respiratory rate >=12/min
• Urine output >=30 mL/h (Mg is renally excreted)

Withhold next dose if ANY of the following:

• Absent patellar reflex
• Respiratory rate <12
• Urine output <30 mL/h in 4 hours
• Toxicity suspected

Antidote: Calcium gluconate 1 g (10 mL of 10% solution) IV over 10 minutes — reverses Mg toxicity immediately.

When MgSO4 not available: phenytoin or diazepam (inferior — Eclampsia Trial Collaborative Group, Lancet 1995 showed MgSO4 reduced recurrent seizures by 52% vs diazepam and 67% vs phenytoin).

Eclampsia — seizure management

Eclampsia is a new-onset grand mal seizure in a woman with preeclampsia, not attributable to other causes, and it is an obstetric emergency.

Immediate management (ABC first):

1. Airway — place in left lateral position; jaw thrust; suction oral secretions
2. Breathing — oxygen 8–10 L/min via face mask; pulse oximetry
3. Circulation — IV access (two wide-bore cannulae); baseline labs (CBC, LFT, RFT, coagulation, urine dipstick, type & cross)
4. Do NOT restrain during seizure — protect from injury; most seizures self-terminate within 60–90 seconds
5. Do NOT attempt intubation during the seizure

Anticonvulsant therapy:

• Magnesium sulfate loading (Pritchard or Zuspan loading dose) — give immediately
• If seizure recurs within 15 minutes of loading: additional 2 g IV bolus
• If still seizing: consider midazolam or thiopentone, intubation, ICU

Blood pressure control:

• Aggressive IV labetalol / nifedipine / hydralazine once airway secured
• Target: 140–150 / 90–100 mmHg within 30–60 minutes

Fluid management:

• Strict input/output charting — risk of pulmonary oedema and cerebral oedema
• Crystalloid restricted to 80 mL/h unless blood loss requires more
• Foley catheter for hourly urine output

Deliver after stabilisation:

• Antenatal eclampsia: stabilise mother (BP, seizures) then deliver regardless of gestational age
• Intrapartum: continue labour if progressing well and mother stable
• Mode: vaginal delivery preferred if cervix favourable; LSCS for obstetric indications or unstable mother
• Continue MgSO4 intraoperatively and for 24 hours postpartum

DDx of seizure in pregnancy:

• Eclampsia (most common cause in 3rd trimester / postpartum)
• Epilepsy (primary or breakthrough)
• Cerebral venous sinus thrombosis
• PRES (posterior reversible encephalopathy)
• Hypoglycaemia, hyponatraemia
• Stroke (ischaemic / haemorrhagic)
• Meningoencephalitis

Delivery decision — timing and mode

Delivery is the only definitive cure for preeclampsia — and gestational age at diagnosis drives the expectant-vs-immediate decision.

Mode of delivery:

• Vaginal delivery preferred when feasible (less maternal morbidity)
• Cervical ripening and induction with dinoprostone / misoprostol / Foley catheter
• LSCS for non-reassuring fetal status, unfavourable cervix at term severe preeclampsia, or obstetric indications (malpresentation, previous caesarean)
• Regional anaesthesia preferred over GA (airway oedema risk) — ensure platelets >=75,000

Antenatal corticosteroids between 24 and 34 weeks — betamethasone 12 mg IM q24h × 2 doses OR dexamethasone 6 mg IM q12h × 4 doses. Complete 48 hours ideal; incomplete still beneficial.

Magnesium for fetal neuroprotection (separate from maternal MgSO4) at <32 weeks if delivery imminent within 24 hours — reduces cerebral palsy risk.

HELLP syndrome — the pregnant woman with epigastric pain

HELLP is a microangiopathic variant of severe preeclampsia defined by Haemolysis + Elevated Liver enzymes + Low Platelets.

Tennessee criteria (all three required):

• Haemolysis: abnormal peripheral smear (schistocytes, burr cells), LDH >600 U/L, indirect bilirubin >=1.2 mg/dL, haptoglobin low
• Elevated liver enzymes: AST >=70 U/L (some use AST >=2× ULN)
• Low platelets: <100,000/microL

Mississippi classification:

Clinical presentation:

• Right upper quadrant or epigastric pain (~90%) — from hepatic capsule stretch
• Nausea, vomiting
• Headache
• Often only mildly elevated BP — 15–20% have no hypertension
• Flu-like prodrome

Complications:

• DIC
• Placental abruption
• Subcapsular liver haematoma with possible rupture (mortality >50% if ruptured)
• Acute kidney injury
• Pulmonary oedema, ARDS
• Maternal death (~1%)
• Perinatal mortality (~10–30%)

Management:

• Delivery is the only definitive treatment
• >=34 weeks: deliver promptly
• <34 weeks, stable: corticosteroids 48 hours + delivery (no consistent HELLP-specific steroid benefit, but for fetal lung maturity)
• Platelet transfusion if <20,000 (or <50,000 before LSCS)
• FFP, cryoprecipitate as needed for DIC
• LFT and platelets usually normalise within 4–7 days postpartum

DDx: acute fatty liver of pregnancy (AFLP), thrombotic thrombocytopenic purpura (TTP), haemolytic uraemic syndrome (HUS), viral hepatitis, cholestasis of pregnancy.

Postpartum monitoring and future pregnancy

Preeclampsia does not always resolve at delivery — up to 30% of eclampsia occurs postpartum, with peak within the first 48 hours.

Immediate postpartum (first 72 hours):

• Continue MgSO4 for 24 hours after delivery or last seizure
• BP check every 4 hours
• Intake-output monitoring; watch for postpartum haemorrhage (MgSO4 is a tocolytic → increased PPH risk)
• Antihypertensives continued until BP normalises (often 2–6 weeks taper)

Weeks 1–6 postpartum:

• BP check at 7–10 days
• Clinic follow-up at 2, 4, and 6 weeks
• Watch for postpartum preeclampsia (delayed/new onset) — headache, visual symptoms, BP surge
• Late postpartum eclampsia can occur up to 6 weeks

Long-term counselling (increased lifetime risk):

• Chronic hypertension: 4-fold increased risk
• Ischaemic heart disease: 2-fold
• Stroke: 1.8-fold
• End-stage renal disease: 5-fold
• Venous thromboembolism: 2-fold
• Type 2 diabetes: 2–3-fold
• All-cause mortality: 1.5-fold

Future pregnancy counselling:

• Recurrence risk: 15–20% for any preeclampsia; up to 40% for early-onset severe
• Prophylactic low-dose aspirin 75–150 mg daily from 12–16 weeks until 36 weeks
• Calcium supplementation (>=1 g/day) in low-calcium-intake populations
• Early antenatal booking; tight BP monitoring; sFlt-1/PlGF if available

Sources and references

1. American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 222 — Gestational Hypertension and Preeclampsia (June 2020, reaffirmed 2023).
2. International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations (2021 update).
3. Williams Obstetrics, 26th Edition (Cunningham, Leveno, Bloom et al., 2022) — Chapters on hypertensive disorders and HELLP syndrome.
4. DC Dutta's Textbook of Obstetrics, 9th Edition (2018) — Chapter 17: Hypertensive Disorders in Pregnancy.
5. The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995; 345:1455-1463.
6. Rolnik DL et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia (ASPRE trial). New England Journal of Medicine 2017; 377:613-622.
7. Zeisler H et al. Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia (PROGNOSIS). New England Journal of Medicine 2016; 374:13-22.

Frequently asked questions

How many preeclampsia/eclampsia questions appear in NEET PG?

Preeclampsia and eclampsia contribute 2-3 direct questions per NEET PG paper across obstetrics, pharmacology, and medicine. Magnesium sulfate regimens (Pritchard vs Zuspan), severe features per ACOG 2020, antihypertensive choice (labetalol first-line), and HELLP syndrome diagnostic criteria are the most tested subtopics based on 2019-2025 pattern analysis.

What is the ACOG 2020 definition of preeclampsia?

ACOG 2020 defines preeclampsia as new-onset hypertension (BP greater than or equal to 140/90 mmHg on two occasions at least 4 hours apart) after 20 weeks of gestation in a previously normotensive woman, PLUS either proteinuria (greater than or equal to 300 mg/24 hours or protein/creatinine ratio greater than or equal to 0.3) OR, in the absence of proteinuria, any severe feature such as thrombocytopenia, renal insufficiency, impaired liver function, pulmonary oedema, or cerebral/visual symptoms.

What is the first-line antihypertensive in pregnancy?

Labetalol is first-line for acute severe hypertension and maintenance therapy in pregnancy-induced hypertension. Oral dose: 100-400 mg two to three times daily. IV bolus: 20 mg, then 40-80 mg every 10-15 minutes (maximum 300 mg). Nifedipine (oral immediate-release 10 mg, repeated every 20 minutes up to 50 mg) is an equally good alternative. Methyldopa is the safest long-term agent but slow-acting and unsuitable for hypertensive crisis.

Which antihypertensives are contraindicated in pregnancy?

ACE inhibitors and ARBs are absolutely contraindicated in all trimesters — they cause oligohydramnios, fetal renal agenesis, skull hypoplasia, and pulmonary hypoplasia. Atenolol is avoided because it causes fetal growth restriction. Sodium nitroprusside risks cyanide toxicity with prolonged use. Diuretics are generally avoided as preeclampsia already has reduced intravascular volume.

What is the Pritchard regimen for magnesium sulfate?

Pritchard regimen (intramuscular) is loading dose 4 g IV over 3-5 minutes plus 10 g deep IM (5 g in each buttock), followed by maintenance 5 g IM every 4 hours alternating buttocks. Continued for 24 hours after delivery or the last seizure, whichever is later. Preferred in low-resource settings where IV monitoring is difficult. Therapeutic serum magnesium level is 4-7 mEq/L.

What is the Zuspan regimen for magnesium sulfate?

Zuspan regimen (intravenous) is loading dose 4-6 g IV over 15-20 minutes, followed by maintenance 1-2 g/hour as continuous IV infusion. Continued for 24 hours postpartum or 24 hours after the last seizure. Preferred in well-monitored settings with infusion pumps. Provides steadier serum levels with less fluctuation than Pritchard.

When should delivery be planned in preeclampsia?

Deliver at greater than or equal to 37 weeks for preeclampsia without severe features and at greater than or equal to 34 weeks for preeclampsia with severe features, HELLP syndrome, or eclampsia. Immediate delivery regardless of gestational age is required for uncontrollable hypertension, pulmonary oedema, placental abruption, DIC, non-reassuring fetal status, or worsening maternal organ dysfunction. Antenatal corticosteroids are given between 24 and 34 weeks if time permits.

What are the diagnostic criteria for HELLP syndrome?

HELLP requires Haemolysis (peripheral smear with schistocytes, LDH greater than 600 U/L, indirect bilirubin greater than or equal to 1.2 mg/dL), Elevated Liver enzymes (AST greater than or equal to 70 U/L or twice normal), and Low Platelets (less than 100,000/microL — Tennessee criteria). Mississippi classification stratifies severity: Class 1 platelets less than 50,000, Class 2 platelets 50,000-100,000, Class 3 platelets 100,000-150,000. Delivery is the only definitive treatment.

What is the role of sFlt-1/PlGF ratio?

Soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio is an emerging biomarker for preeclampsia prediction and diagnosis. A ratio less than or equal to 38 rules out preeclampsia in the next 1 week (high negative predictive value). A ratio greater than 85 before 34 weeks or greater than 110 after 34 weeks strongly suggests preeclampsia. Part of NICE 2022 guidance; not yet routine in Indian NACO-equivalent protocols but increasingly cited in NEET PG.

What postpartum monitoring is needed after preeclampsia?

Postpartum preeclampsia can develop up to 6 weeks after delivery. Monitor BP at 72 hours postpartum, then at 7-10 days, and every 1-2 weeks until resolution. Continue magnesium sulfate for 24 hours postpartum. Antihypertensives may need 2-6 weeks of tapering. Counsel about increased lifetime cardiovascular risk (2-4 fold higher stroke, IHD, chronic hypertension) and offer aspirin 75-150 mg daily from 12-16 weeks in future pregnancies.

Ready to convert this guide into exam marks? Revise with the OBG high-yield topics overview, drill peripartum emergencies via the postpartum haemorrhage clinical case, and use the AI tutor to map MgSO4 toxicity thresholds on demand.

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Written by: NEETPGAI Editorial Team Reviewed by: Pending SME Review Last reviewed: March 2026

This article is reviewed by qualified medical professionals for clinical accuracy and exam relevance. For corrections or updates, contact the editorial team.