Late-pregnancy emergencies: documentation that holds up
In the second half of pregnancy and the weeks after delivery, two patterns kill: hypertensive disease (preeclampsia → eclampsia → HELLP) and antepartum hemorrhage (abruption, previa). The defensible chart treats the mother and the fetus, and shows the dangerous diagnoses were considered even when the patient looks well.
First-trimester bleeding and ectopic pregnancy are covered in the Early-Pregnancy builder; this guide focuses on the latter half of pregnancy and the postpartum period.
01What's at stake
Preeclampsia causes roughly a fifth of US maternal deaths, and HELLP patients can "appear clinically well." Progression to eclampsia is unpredictable, and seizures can occur up to four weeks postpartum. On the bleeding side, up to 20% of abruptions have no external bleeding, and ultrasound cannot rule abruption out.
02Can't-miss diagnoses
- Preeclampsia — new hypertension + proteinuria after 20 weeks; edema is no longer a criterion.
- Eclampsia — seizure in the setting of preeclampsia; antepartum, intrapartum, or up to 4 weeks postpartum.
- HELLP — hemolysis, elevated LFTs, low platelets; may look well; screen with labs.
- Placental abruption — pain ± dark bleeding, uterine tenderness; up to 20% concealed.
- Placenta previa — painless, bright-red bleeding; no digital/instrumental cervical exam.
03History & exam red flags
- Headache, visual changes, RUQ/epigastric pain, nausea/vomiting? → severe preeclampsia / HELLP
- Severe-range BP (≥160/110)? → treat
- Vaginal bleeding with pain/uterine tenderness, or painless bright-red bleeding? → abruption / previa
- Seizure within 48h–4 weeks postpartum? → late postpartum eclampsia
- No digital or instrumental cervical exam in the second half of pregnancy — it can provoke catastrophic previa hemorrhage.
Skip the typing
Work the case in the Late-Pregnancy Pain / Bleeding Workup — it records the blood pressure, the preeclampsia/HELLP labs, Rh status, fetal assessment, and OB consultation, and assembles an MDM that documents the dangerous diagnoses were considered.
04Testing & management
- Preeclampsia labs: CBC/platelets, LFTs, LDH, peripheral smear, renal function, and proteinuria — a normal urinalysis does not exclude preeclampsia (24-hour urine is the standard).
- Severe-range BP → IV labetalol or hydralazine, goal <160/100–105.
- Eclampsia / severe preeclampsia → magnesium (4–6 g load, then 2 g/h) — superior to phenytoin/diazepam; calcium gluconate is the antidote for toxicity.
- Bleeding: transvaginal ultrasound for placental location, type & crossmatch in all, coagulation studies; abruption is a clinical diagnosis a normal US can't exclude; continuous fetal monitoring; early OB consult.
- Rh-negative → RhoGAM (300 µg); know your facility's high-risk OB capability and transfer if needed.
05What to document
06Where charts fail
- Using a normal urine dipstick to exclude preeclampsia.
- Discharging a "well-looking" preeclamptic without HELLP labs.
- Relying on a normal ultrasound to rule out abruption.
- Performing a digital cervical exam in late-pregnancy bleeding.
- Not treating severe-range BP, not giving magnesium for eclampsia, or missing Rh status/RhoGAM.
- Forgetting late postpartum eclampsia for a seizure weeks after delivery.
07Sources
- Keadey M, Houry D. Complications in pregnancy, part II: hypertensive disorders of pregnancy and vaginal bleeding. Emergency Medicine Practice (EB Medicine). 2009;11(5).
- Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. 2003;102:181-192.
- Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105:402-410.
- Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108:1005-1016.
© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.