Management of Preeclampsia
The management of preeclampsia requires immediate hospitalization for assessment, blood pressure control, seizure prophylaxis with magnesium sulfate, and delivery timing based on disease severity and gestational age, with delivery being the only definitive treatment. 1
Initial Assessment and Monitoring
Maternal Monitoring
- Blood pressure monitoring (target: diastolic BP of 85 mmHg, systolic BP 110-140 mmHg)
- Clinical assessment including evaluation for clonus
- Laboratory tests at least twice weekly:
- Complete blood count with platelets
- Liver function tests
- Renal function tests
- Uric acid levels 1
Fetal Monitoring
- Initial assessment to confirm fetal well-being
- Ultrasound for fetal biometry, amniotic fluid, and umbilical artery Doppler
- More frequent monitoring if fetal growth restriction is present 1
Blood Pressure Management
Severe Hypertension (≥160/110 mmHg)
Requires urgent treatment in a monitored setting with:
- Oral nifedipine OR
- IV labetalol OR
- IV hydralazine 1
Non-Severe Hypertension (≥140/90 mmHg)
- Target diastolic BP of 85 mmHg and systolic BP 110-140 mmHg
- First-line agents:
- Methyldopa (750mg-4g/day in 3-4 divided doses)
- Labetalol
- Nifedipine
- Oxprenolol
- Second/third-line agents:
Caution: Reduce or cease antihypertensives if diastolic BP falls below 80 mmHg to maintain uteroplacental perfusion 1
Seizure Prophylaxis
Magnesium sulfate is indicated for women with:
- Proteinuria and severe hypertension
- Hypertension with neurological signs or symptoms 1
Dosing of Magnesium Sulfate
- Initial dose: 4-5g IV over 15-20 minutes
- Maintenance: 1-2g/hour by continuous IV infusion
- Continue for at least 24 hours postpartum
- Target serum magnesium level: 4-7 mEq/L 1, 3
Warning: Monitor for magnesium toxicity (loss of deep tendon reflexes occurs at levels >10 mEq/L, respiratory depression may occur at this level) 3
Delivery Planning
Delivery is the only definitive treatment for preeclampsia. Timing depends on:
Immediate Delivery Indicated
- ≥37 weeks gestation
- Any of the following regardless of gestational age:
- Repeated episodes of severe hypertension despite treatment with 3 classes of antihypertensives
- Progressive thrombocytopenia
- Progressively abnormal renal or liver enzyme tests
- Pulmonary edema
- Abnormal neurological features (severe headache, visual scotomata, convulsions)
- Non-reassuring fetal status 1
Expectant Management Considerations
- Between 34-37 weeks with preeclampsia without severe features:
- Consider immediate delivery as 41% of expectantly managed patients develop severe features within 72 hours 4
- Between 24-34 weeks with severe preeclampsia:
- Conservative management may be considered in selected patients at centers with appropriate maternal and fetal care capabilities
- Administer corticosteroids for fetal lung maturity 1
- <24 weeks with severe preeclampsia:
- Termination of pregnancy should be discussed due to high maternal morbidity with limited perinatal benefit 5
Mode of Delivery
- Vaginal delivery should be considered for all hypertensive disorders unless cesarean delivery is required for obstetric indications 1
- Continue antihypertensive treatment during labor and delivery to keep SBP <160 mmHg and DBP <110 mmHg 1
Postpartum Management
- Continue magnesium sulfate for at least 24 hours postpartum
- Continue antihypertensive therapy as needed
- Check blood pressure and urine at 6 weeks postpartum
- Confirm persistent hypertension with 24-hour ambulatory monitoring
- Consider assessment for secondary causes of hypertension in women under 40 with persistent hypertension 1
Prevention in High-Risk Women
- Low-dose aspirin (100-150 mg daily) from week 12 to weeks 36-37 for women at high or moderate risk 1, 2
- Calcium supplementation (≥1 g/day) for women with low calcium intake 1
Important: All women with preeclampsia should be counseled about increased risk in future pregnancies and long-term cardiovascular risk 2