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, and maternal/fetal condition. 1

Definition and Classification

Preeclampsia is characterized by:

• New-onset hypertension (>140/90 mmHg) after 20 weeks of gestation
• Accompanied by proteinuria and/or maternal organ dysfunction and/or uteroplacental dysfunction

Severity classification:

• Mild preeclampsia: Hypertension with proteinuria without severe features
• Severe preeclampsia: Features include severe hypertension, CNS dysfunction, hepatocellular injury, thrombocytopenia, oliguria, pulmonary edema, or severe intrauterine growth restriction 2

Management Algorithm

1. Initial Assessment and Hospitalization

• All women with severe preeclampsia must be hospitalized for:
  • Diagnosis confirmation
  • Disease severity assessment
  • Monitoring of disease progression
  • Stabilization attempts 2

2. Blood Pressure Management

• Acute severe hypertension treatment (Table for IV medications):

  Medication	Dosage
  Hydralazine	5 mg IV bolus, then 10 mg every 20-30 minutes to maximum 25 mg
  Labetalol (second-line)	20 mg IV bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes for 2 additional doses to maximum 220 mg
  Nifedipine	10 mg PO, repeat every 20 minutes to maximum 30 mg (caution with magnesium sulfate)
  Sodium nitroprusside (rarely)	0.25μg/kg/min to maximum 5μg/kg/min (only when others fail)

  1

• Chronic hypertension management:

  • First-line: Methyldopa (750 mg to 4 g daily in 3-4 divided doses)
  • Alternative: Labetalol (100 mg twice daily up to 2400 mg daily) 1

3. Seizure Prevention and Management

• Magnesium sulfate is the anticonvulsant of choice:
  • Initial dose: 4-5 g IV in 250 mL of 5% Dextrose or 0.9% Sodium Chloride over 3-4 minutes
  • Maintenance: 1-2 g/hour by continuous IV infusion
  • Target serum level: 6 mg/100 mL for seizure control
  • Maximum daily dose: 30-40 g/24 hours
  • Duration: Until paroxysms cease, typically 24-48 hours postpartum 3
  • Monitor for toxicity: Loss of deep tendon reflexes, respiratory depression, heart block

4. Fluid Management

• Avoid "running dry" as patients are at risk of acute kidney injury
• Recommended IV fluid rate: 60-80 mL/hr to avoid pulmonary edema risk 1
• Replace fluid losses as needed

5. Corticosteroid Administration

• For pregnancies <34 weeks: Administer steroids for 48 hours to accelerate fetal lung maturation 1

6. Delivery Planning

• Timing of delivery is based on:

  • Gestational age
  • Severity of preeclampsia
  • Maternal and fetal risks 2

• Indications for immediate delivery:

  • Severe uncontrolled hypertension
  • Eclampsia
  • Pulmonary edema
  • Abruptio placentae
  • Disseminated intravascular coagulation
  • Worsening maternal organ dysfunction
  • Fetal distress
  • Intrauterine growth restriction with abnormal testing 1

• Mode of delivery:

  • Vaginal delivery is preferable when possible
  • Cesarean delivery for standard obstetric indications 1

7. Expectant Management (Selected Cases)

• May be considered for severe preeclampsia <34 weeks if:
  • Stable maternal condition
  • Reassuring fetal status
  • No evidence of end-organ damage progression
  • Close monitoring available 2

8. Postpartum Management

• Monitor BP at least every 4-6 hours for minimum 3 days
• Continue antihypertensives and taper slowly after days 3-6
• Avoid NSAIDs if possible, especially with renal dysfunction
• Laboratory monitoring: Repeat Hb, platelets, creatinine, liver enzymes the day after delivery and then every second day until stable 1

Follow-up Care

Short-term (3 months)

• Review within 1 week if still on antihypertensives at discharge
• Complete assessment at 3 months postpartum:
  • BP, urinalysis, laboratory tests should normalize
  • Screen for depression, anxiety, and PTSD 1

Long-term

• Counsel women about increased lifetime risks:
  • Cardiovascular disease
  • Stroke
  • Diabetes mellitus
  • Venous thromboembolism
  • Chronic kidney disease
  • Recurrent preeclampsia (15%) or gestational hypertension (15%) in future pregnancies
• Recommend regular follow-up with primary care for BP monitoring and periodic metabolic screening
• Advise healthy lifestyle with ideal weight maintenance and regular exercise 1

Common Pitfalls and Caveats

1. Delayed recognition: Preeclampsia can develop rapidly; regular monitoring of at-risk women is essential

2. Inadequate BP control: Untreated severe hypertension can lead to stroke and other complications

3. Magnesium sulfate toxicity: Monitor respiratory rate, deep tendon reflexes, and urine output; have calcium gluconate available as antidote

4. Fluid overload: Excessive IV fluids can precipitate pulmonary edema in preeclamptic women

5. Premature discontinuation of monitoring: Preeclampsia can develop de novo in the postpartum period; continue vigilance for at least 72 hours after delivery 1

6. Prolonged magnesium sulfate use: Continuous administration beyond 5-7 days can cause fetal abnormalities 3

7. Overlooking long-term cardiovascular risks: Women with history of preeclampsia require lifelong cardiovascular risk monitoring 1