What is the management of preeclampsia?

Management of Preeclampsia

The definitive treatment for preeclampsia is delivery of the baby and placenta, with timing based on disease severity, gestational age, maternal condition, and fetal status. 1

Definition and Classification

Preeclampsia is characterized by:

• New-onset hypertension (>140/90 mmHg) after 20 weeks of gestation
• Accompanied by at least one of:
  • Proteinuria
  • Maternal organ dysfunction
  • Uteroplacental dysfunction

Severity Classification:

• Mild preeclampsia: Hypertension with minimal organ involvement
• Severe preeclampsia: Features include:
  • Severe hypertension (≥160/110 mmHg)
  • CNS dysfunction (headache, visual disturbances)
  • Hepatocellular injury (elevated liver enzymes)
  • Thrombocytopenia (<100,000/μL)
  • Renal insufficiency
  • Pulmonary edema
  • HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
  • Severe intrauterine growth restriction

Management Approach

1. Initial Assessment and Hospitalization

• All women with suspected severe preeclampsia must be hospitalized for:
  • Confirmation of diagnosis
  • Assessment of disease severity
  • Monitoring of disease progression
  • Stabilization

2. Blood Pressure Management

• Target: Keep BP <160/110 mmHg to prevent cerebral hemorrhage

• Medications for acute severe hypertension 1:

  Medication	Dosage
  Hydralazine	5 mg IV bolus, then 10 mg every 20-30 min to max 25 mg
  Labetalol	20 mg IV bolus, then 40 mg after 10 min, followed by 80 mg every 10 min to max 220 mg
  Nifedipine	10 mg PO, repeat every 20 min to max 30 mg (caution with magnesium sulfate)

• For chronic management:

  • Methyldopa: 750 mg to 4 g per day in 3-4 divided doses
  • Labetalol: 100 mg twice daily up to 2400 mg per day
  • Calcium channel blockers (avoid sublingual administration)

3. Seizure Prevention and Management

• Magnesium sulfate is the anticonvulsant of choice 2:
  • Loading dose: 4-5 g IV in 250 mL of fluid over 15-20 minutes
  • Maintenance: 1-2 g/hour continuous IV infusion
  • Continue for 24-48 hours postpartum
  • Monitor for toxicity: loss of deep tendon reflexes, respiratory depression
  • Therapeutic serum level: 4-7 mEq/L

4. Fluid Management

• Avoid aggressive fluid administration or restriction
• Maintain urine output >0.5 mL/kg/hour
• IV fluid rate of 60-80 mL/hour to avoid pulmonary edema 1

5. Timing of Delivery

• Immediate delivery indicated for:

  • Gestational age ≥37 weeks
  • Eclampsia
  • Pulmonary edema
  • DIC
  • Abruptio placentae
  • Uncontrollable severe hypertension
  • Progressive renal insufficiency
  • HELLP syndrome
  • Fetal distress or demise

• Expectant management may be considered for:

  • Preterm preeclampsia (<34 weeks) with stable maternal and fetal condition
  • Goal: prolong pregnancy for fetal maturation
  • Requires close maternal and fetal monitoring

6. Antenatal Corticosteroids

• Administer if gestational age <34 weeks to accelerate fetal lung maturity 1
• Complete course (48 hours) if possible before delivery

7. Mode of Delivery

• Vaginal delivery preferred when feasible 1
• Cesarean delivery for standard obstetric indications or when rapid delivery is needed

8. Postpartum Management

• Continue antihypertensive therapy
• Monitor BP at least every 4-6 hours for minimum 72 hours 1
• Taper antihypertensives slowly after days 3-6 postpartum
• Avoid NSAIDs if possible, especially with renal dysfunction 1
• Follow-up within 1 week if still on antihypertensives at discharge

Long-term Follow-up

• All women with preeclampsia require lifelong follow-up due to increased cardiovascular risk 1
• Advise about:
  • 15% risk of recurrence in future pregnancies
  • Increased risk of cardiovascular disease, stroke, diabetes, and chronic kidney disease
  • Recommendation for low-dose aspirin in future pregnancies
  • Regular BP monitoring and periodic metabolic screening
  • Healthy lifestyle with ideal weight maintenance and regular exercise

Common Pitfalls and Caveats

1. Delayed recognition of severe features leading to maternal or fetal complications
2. Inadequate BP control - both under-treatment (risking stroke) and over-treatment (risking placental hypoperfusion)
3. Fluid overload leading to pulmonary edema
4. Magnesium toxicity - requires careful monitoring of reflexes, respiratory rate, and urine output
5. Premature discontinuation of postpartum monitoring - preeclampsia can develop or worsen postpartum
6. Failure to provide long-term cardiovascular risk counseling and follow-up

Remember that preeclampsia is a progressive disorder, and the only definitive cure is delivery of the placenta. Management decisions should balance maternal safety against the risks of prematurity for the fetus.