From the Guidelines
Pre-eclampsia should be managed with urgent treatment in a monitored setting when severe (>160/110 mm Hg), and delivery is recommended if the patient has reached 37 weeks’ gestation or develops any of the following: repeated episodes of severe hypertension, progressive thrombocytopenia, progressively abnormal renal or liver enzyme tests, pulmonary edema, abnormal neurological features, or nonreassuring fetal status, as stated in the ISSHP classification, diagnosis, and management recommendations for international practice 1.
Diagnosis and Management
The diagnosis of pre-eclampsia is based on the presence of high blood pressure and organ damage, typically occurring after 20 weeks of gestation. The management of pre-eclampsia depends on the severity of the condition and the gestational age of the fetus.
- For mild pre-eclampsia, close monitoring with frequent blood pressure checks, urine protein tests, and blood work is recommended.
- Antihypertensive medications like labetalol, nifedipine, or methyldopa are used to keep blood pressure below 160/110 mmHg.
- For severe pre-eclampsia, especially with features like severe hypertension, neurological symptoms, or HELLP syndrome, immediate hospitalization is necessary.
- Magnesium sulfate is given to prevent seizures in women with severe pre-eclampsia or eclampsia.
Key Management Points
The ISSHP recommends the following key management points for pre-eclampsia:
- BP requires urgent treatment in a monitored setting when ≥ 160/110 mm Hg; acceptable agents for this include oral nifedipine or intravenous labetalol or hydralazine.
- BPs consistently at or > 140/90 mm Hg should be treated aiming for a target diastolic BP of 85 mm Hg (and systolic BP at least < 160 mm Hg) to reduce the likelihood of developing severe maternal hypertension and possibly other complications.
- Women with preeclampsia should be assessed in hospital when first diagnosed; thereafter, some may be managed as outpatients once it is established that their condition is stable and they can be relied on to report problems and monitor their BP.
- Women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms, should receive magnesium sulfate for convulsion prophylaxis, as recommended by the ISSHP 1.
Fetal and Maternal Monitoring
Fetal monitoring in preeclampsia should include an initial assessment to confirm fetal well-being, and serial fetal surveillance with ultrasound should be performed at 2-week intervals if the initial assessment was normal, and more frequent if there is fetal growth restriction.
- Maternal monitoring in preeclampsia should include BP monitoring, repeated assessments for proteinuria if not already present, clinical assessment including clonus, and twice weekly blood tests for hemoglobin, platelet count, liver transaminases, creatinine, and uric acid.
- Blood test evaluation should be performed at least twice weekly (and again in response to a change in clinical status) in most women with preeclampsia, as stated in the ISSHP recommendations 1.
From the Research
Diagnosis of Pre-eclampsia
- Pre-eclampsia is defined as the association of pregnancy-induced hypertension and proteinuria of 300 mg/24h or more after 20 weeks gestation 2
- Hypertensive disorders of pregnancy are one of the leading causes of peripartum morbidity and mortality globally 3
- Pre-eclampsia is characterized by blood pressure greater than 140/90 mmHg in the second half of pregnancy 4
Management of Pre-eclampsia
- The mainstay of the management of severe pre-eclampsia is early referral, stabilization of the mother with antihypertensive therapy and anticonvulsants if required, full assessment of the mother and the baby, and delivery on the best day in the best way 5
- Management of severe pre-eclampsia includes identification of high-risk patients, optimisation of antenatal care, early intervention and the identification and early management of complications 3
- Oral anti-hypertensive agents, including labetalol, nifedipine and methyldopa, should be tried first, and if they fail to adequately control blood pressure, intravenous anti-hypertensives such as labetalol, hydralazine and glyceryl trinitrate should be considered 3
- Magnesium sulphate should be considered early to prevent seizures 3, 2
- Delivery of the baby is the definitive management of severe pre-eclampsia 3, 5
Expectant Management of Pre-eclampsia
- Expectant management of early onset, severe pre-eclampsia can diminish and limit the impact of serious maternal complications, and valuable time to prolong the pregnancy and improve neonatal outcome can be gained 6
- Careful noninvasive management of early onset, severe pre-eclampsia in a tertiary centre can prolong pregnancies by a mean of 11 days before delivery 6
Prevention of Pre-eclampsia
- Preventive treatment of preeclampsia consists essentially of low dose aspirin, which decreases the risk of recurrence of preeclampsia by 10 to 15%, of prematurity by 8% and of perinatal mortality by 14% 2