Preeclampsia, Eclampsia, HELLP & Gestational Diabetes

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.

Part A — Hypertensive Disorders of Pregnancy

1. Overview and Pathophysiology

In Preeclampsia, the placenta implants with poorly remodeled spiral arteries. The under-perfused placenta releases factors that injure the lining of blood vessels (endothelial dysfunction) throughout the parent’s body. That leads to widespread vasospasm, leaky capillaries, and tiny clots, which reduce blood flow to the brain, kidneys, liver, eyes, and placenta. Delivery of the placenta is the only cure, though symptoms can persist or even begin up to 6 weeks postpartum.

Condition	Definition (ACOG, simplified)
Chronic hypertension	BP ≥ 140/90 before pregnancy or before 20 weeks
Gestational hypertension	New BP ≥ 140/90 after 20 weeks, on two readings ≥ 4 h apart, without proteinuria or organ damage
Preeclampsia	New hypertension after 20 weeks plus proteinuria or signs of organ dysfunction (even without proteinuria)
Preeclampsia with severe features	BP ≥ 160 systolic or ≥ 110 diastolic, platelets < 100,000, liver enzymes ≥ 2× normal or severe RUQ/epigastric pain, creatinine > 1.1 or doubled, pulmonary edema, new headache not relieved by meds, or visual disturbances
Eclampsia	New-onset seizures in a client with preeclampsia (no other cause)
HELLP syndrome	Hemolysis, Elevated Liver enzymes, Low Platelets. Can occur without severe hypertension or proteinuria

Risk factors: first pregnancy, history of preeclampsia, multiple gestation, chronic hypertension, pregestational diabetes, kidney disease, autoimmune disease (lupus, antiphospholipid syndrome), obesity, age > 35, IVF, family history. Low-dose aspirin (commonly 81 mg daily starting at 12–28 weeks, ideally before 16) is recommended for high-risk clients.

2. Signs and Symptoms

• Hypertension (the key sign); proteinuria (≥ 300 mg/24 h or protein/creatinine ratio ≥ 0.3)
• Brain: severe or persistent headache, visual changes (blurring, spots, flashing), Hyperreflexia, clonus, seizures
• Liver: RUQ or epigastric pain, nausea/vomiting (liver capsule swelling; can precede rupture)
• Kidneys: oliguria, rising creatinine
• Lungs: dyspnea, crackles (pulmonary edema)
• Blood: low platelets, bleeding (DIC)
• Swelling: sudden weight gain, edema of face/hands (no longer a diagnostic criterion, but a warning sign)
• Fetus: growth restriction, oligohydramnios, abnormal FHR, placental abruption

3. Diagnostics and Labs (ranges vary by lab)

Test	Concerning result
BP (correct cuff, seated, arm at heart level)	≥ 140/90 ×2; ≥ 160/110 confirmed within 15 min = treat urgently
Urine protein / protein:creatinine ratio	≥ 300 mg/24 h or ratio ≥ 0.3; dipstick 2+ if others unavailable
Platelets	< 100,000/µL
AST/ALT	≥ 2× upper limit of normal
Creatinine	> 1.1 mg/dL or doubled
LDH, bilirubin, haptoglobin, peripheral smear	Hemolysis (HELLP)
Uric acid	Often elevated (supportive, not diagnostic)
Fetal: NST, BPP, ultrasound growth, Doppler	Growth restriction, low fluid, abnormal tracing

4. Priority Nursing Care

1. Frequent BP, and report ≥ 160/110 promptly — severe-range BP should be treated within 30–60 minutes to prevent stroke
2. Neuro checks: headache, vision, LOC, deep tendon reflexes (DTRs) and clonus
3. Strict I&O (hourly with magnesium; urine output often ≥ 30 mL/h), daily weight; lung sounds (fluids are often restricted — risk of pulmonary edema)
4. Seizure precautions: padded rails per policy, suction and oxygen at the bedside, call light, low-stimulation dim room
5. Continuous or frequent FHR monitoring; watch for abruption (pain, rigid uterus, bleeding)
6. Labs trend (platelets, liver enzymes, creatinine)
7. Side-lying rest; prepare for delivery (timing based on gestational age and severity: commonly 37 weeks for gestational hypertension/preeclampsia without severe features, ~34 weeks or sooner if severe)
8. Corticosteroids for fetal lung maturity if < 34 weeks

5. Medications

Drug	Purpose	Key nursing points
Magnesium sulfate	Prevents and treats seizures (not a BP drug)	IV loading dose then maintenance via pump, usually continued ~24 h after birth. Therapeutic level often cited ~4–7 mEq/L (protocols vary). Monitor RR (≥ 12), DTRs, LOC, urine output (≥ 30 mL/h), SpO₂, lung sounds. Expected: flushing, warmth, lethargy. Toxicity: loss of patellar reflexes (first sign) → respiratory depression → cardiac arrest. Antidote: calcium gluconate IV at bedside. Kidneys clear Mg — low urine output raises levels. Increases PPH risk (uterine relaxation)
Labetalol IV/PO	Severe BP	Avoid in asthma, heart block; watch HR and BP
Hydralazine IV	Severe BP	Watch for reflex tachycardia and maternal hypotension (can drop placental flow)
Nifedipine (immediate-release PO)	Severe BP / maintenance	Headache, flushing; use caution with magnesium (hypotension)
Aspirin 81 mg	Prevention in high-risk clients	Start per provider (ideally before 16 weeks)
Avoid: ACE inhibitors/ARBs during pregnancy (fetal harm); methylergonovine postpartum (raises BP)

Eclamptic seizure — nursing actions:

1. Stay with the client; call for help. Note time and characteristics
2. Turn to the side to protect the airway and keep the uterus off the vena cava; don’t restrain or put anything in the mouth
3. After the seizure: suction, oxygen, assess FHR (often brady during seizure, then recovers)
4. Magnesium sulfate loading dose (or additional bolus) as ordered
5. Check for abruption, prepare for delivery once the client is stable

6. Education

• Measure home BP correctly; report ≥ 160/110 (or the level the provider sets), headache, vision changes, RUQ/epigastric pain, shortness of breath, sudden swelling
• Signs can start after delivery — up to 6 weeks postpartum
• Preeclampsia history raises lifelong cardiovascular risk — keep regular checkups

Part B — Gestational Diabetes (GDM)

7. Pathophysiology

Placental hormones (human placental lactogen, cortisol, progesterone) cause insulin resistance, especially in the 2nd and 3rd trimesters. If the pancreas can’t make enough extra insulin, blood glucose rises. Glucose crosses the placenta; insulin does not. The fetus responds by making its own extra insulin, which acts as a growth hormone → macrosomia, and after birth the baby’s high insulin plus loss of maternal glucose → neonatal hypoglycemia.

Risks: obesity, prior GDM or macrosomic baby, family history of type 2 diabetes, PCOS, age > 25–35, certain racial and ethnic groups, hypertension.

8. Screening and Targets (common; follow your program)

Test	Typical thresholds
Screening at 24–28 weeks (earlier if high risk)	1-h 50 g glucose challenge: positive at ≥ 130–140 mg/dL → do the 3-h test
3-h 100 g OGTT	Two or more abnormal values (Carpenter-Coustan: fasting ≥ 95, 1 h ≥ 180, 2 h ≥ 155, 3 h ≥ 140 mg/dL)
One-step 75 g 2-h OGTT (alternative)	Any one: fasting ≥ 92, 1 h ≥ 180, 2 h ≥ 153 mg/dL
Glucose targets in pregnancy	Fasting < 95; 1 h after meals < 140; 2 h after meals < 120 mg/dL

9. Management and Nursing Care

• Medical nutrition therapy first: consistent carbs, spread over 3 meals + 2–3 snacks including a bedtime snack (prevents overnight ketosis), protein with carbs
• Exercise (e.g., walking after meals) as approved
• Self-monitoring of glucose (fasting and after meals), log readings
• Medications if targets aren’t met: insulin is preferred (doesn’t cross the placenta). Metformin or glyburide are sometimes used but cross the placenta; follow the provider
• Insulin needs rise through pregnancy and drop sharply after delivery of the placenta — watch for maternal hypoglycemia postpartum; most clients with GDM stop insulin after birth
• Antenatal fetal testing (NST/BPP) as ordered, growth ultrasounds
• Intrapartum: hourly glucose checks and IV insulin/dextrose per protocol; watch for shoulder dystocia
• Newborn: glucose checks early, early feeding; watch for hypoglycemia, respiratory distress, polycythemia, jaundice, hypocalcemia

Complications: macrosomia, birth injury, cesarean, preeclampsia, polyhydramnios, stillbirth, neonatal hypoglycemia. Long-term: high risk of type 2 diabetes for the parent; obesity/diabetes risk for the child.

Education: glucose monitoring technique, hypoglycemia recognition and treatment (15 g fast carbs, recheck in 15 min), postpartum glucose test at 4–12 weeks and lifelong diabetes screening (e.g., every 1–3 years), breastfeeding lowers diabetes risk.

10. Memory Aids

• Severe features “160/110”: treat within the hour
• Magnesium checks “RUDE”: Respirations, Urine output, DTRs, Extra (LOC, SpO₂, lung sounds). “Calcium Gluconate = Get Clear of mag” — antidote at the bedside
• HELLP = Hemolysis, Elevated Liver enzymes, Low Platelets
• Preeclampsia “brain, liver, kidneys, eyes” — headache, RUQ pain, oliguria, vision changes
• GDM: “Sugar crosses, insulin doesn’t” → big baby, then low-sugar baby
• “95 / 140 / 120” — fasting / 1-h / 2-h glucose targets

11. NCLEX-Style Practice Questions

1. A client on magnesium sulfate has RR 10/min, absent patellar reflexes, and urine output of 20 mL/h for 2 hours. What is the nurse’s first action?

A. Increase the infusion to the ordered maximum
B. Stop the magnesium infusion
C. Give calcium gluconate without an order
D. Recheck the reflexes in 1 hour

Answer: B. These are signs of magnesium toxicity (worsened by poor urine output). Stop the infusion first, then notify the provider, support breathing, and anticipate calcium gluconate per order/protocol and a magnesium level.

2. A client at 35 weeks with preeclampsia reports a severe headache and “seeing spots.” BP is 168/112, repeated 15 minutes later at 166/114. Which actions does the nurse anticipate? Select all that apply.

A. Antihypertensive such as IV labetalol within 30–60 minutes
B. Magnesium sulfate infusion
C. Encourage ambulation in the hallway
D. Seizure precautions with suction and oxygen at the bedside
E. Continuous fetal monitoring

Answer: A, B, D, E. This is preeclampsia with severe features (severe-range BP plus neurologic symptoms). Treat BP promptly to prevent stroke, give magnesium for seizure prophylaxis, prepare for seizures, and monitor the fetus. Ambulation (C) increases fall and seizure risk.

3. A client’s labs show hemoglobin dropping, AST and ALT elevated, and platelets of 72,000/µL. BP is 146/94. The nurse recognizes this pattern as:

A. Gestational hypertension
B. HELLP syndrome
C. Gestational diabetes
D. Iron-deficiency anemia

Answer: B. Hemolysis, elevated liver enzymes, and low platelets = HELLP, which can occur with only mild hypertension. Watch for bleeding, RUQ pain, and DIC.

4. A client with GDM asks why she needs a snack at bedtime. Which response is best?

A. “It helps the baby grow larger.”
B. “It prevents low blood sugar and ketones overnight.”
C. “It replaces the need for insulin.”
D. “It lowers your blood pressure.”

Answer: B. A bedtime snack with protein and complex carbs prevents overnight hypoglycemia and starvation ketosis, which can harm the fetus.

5. A client with GDM managed with insulin delivered vaginally 2 hours ago. Which is most important for the nurse to monitor?

A. Maternal hyperglycemia requiring larger insulin doses
B. Maternal and newborn hypoglycemia
C. Maternal hypercalcemia
D. Newborn hypertension

Answer: B. After the placenta is delivered, insulin resistance falls quickly, so the parent may become hypoglycemic on prior doses. The newborn, used to high glucose with its own high insulin, is at risk for neonatal hypoglycemia.

References

American College of Obstetricians and Gynecologists. (n.d.). Gestational diabetes [Patient FAQ]. Retrieved October 15, 2026, from https://www.acog.org/womens-health/faqs/gestational-diabetes

American College of Obstetricians and Gynecologists. (n.d.). Preeclampsia and high blood pressure during pregnancy [Patient FAQ]. Retrieved October 15, 2026, from https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancy

Hicks, M. A., & Tyagi, A. (2023). Magnesium sulfate. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554553/

Karrar, S. A., Martingano, D. J., & Hong, P. L. (2024). Preeclampsia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570611/

Khalid, F., Mahendraker, N., & Tonismae, T. (2023). HELLP syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560615/

Kunarathnam, V., Vadakekut, E. S., & Mahdy, H. (2025). Gestational diabetes. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545196/

Magley, M., & Hinson, M. R. (2024). Eclampsia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554392/