What is the management of preeclampsia?

Management of Preeclampsia

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

Diagnosis and Classification

• Preeclampsia is defined as hypertension (≥140/90 mmHg) after 20 weeks gestation with either:

  • Proteinuria, or
  • End-organ dysfunction (thrombocytopenia, renal insufficiency, liver dysfunction, pulmonary edema, cerebral/visual symptoms)

• Severe features include:

  • Blood pressure ≥160/110 mmHg
  • Platelet count <100×10³/μL
  • Liver transaminases >2× normal
  • Serum creatinine >1.1 mg/dL or doubling
  • Pulmonary edema
  • Cerebral/visual disturbances
  • Severe persistent right upper quadrant pain

Antihypertensive Management

Non-Severe Hypertension (140-159/90-109 mmHg)

• Oral medications:
  • Labetalol: First-line option
  • Nifedipine: Alternative option
  • Methyldopa: Safe option during pregnancy 1

Severe Hypertension (≥160/110 mmHg)

• Requires urgent treatment in monitored setting:
  • IV labetalol: 10-20 mg initially, then 20-80 mg every 10-30 minutes (maximum 220 mg) 1
  • IV hydralazine: 5-10 mg every 15-30 minutes 1
  • IV nicardipine: Start at 5 mg/h, increase by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h) 2, 1

Seizure Prophylaxis with Magnesium Sulfate

• Indicated for all women with preeclampsia with severe features

• Dosing regimen:

  • Loading dose: 4-5g IV over 15-20 minutes
  • Maintenance: 1-2g/hour continuous infusion
  • Continue for at least 24 hours postpartum 1, 3

• Monitor for magnesium toxicity:

  • Loss of deep tendon reflexes (serum level >4 mEq/L)
  • Respiratory depression (serum level approaches 10 mEq/L)
  • Heart block or cardiac arrest (serum level >12 mEq/L) 3

Timing of Delivery

• ≥37 weeks gestation: Immediate delivery

• 34-37 weeks gestation: Delivery generally recommended for preeclampsia with severe features

• <34 weeks gestation: Consider expectant management at centers with maternal-fetal medicine expertise 1

• Indications for immediate delivery regardless of gestational age:

  • Uncontrolled severe hypertension
  • Eclampsia
  • Pulmonary edema
  • Placental abruption
  • Disseminated intravascular coagulation
  • Non-reassuring fetal status 2, 1

Corticosteroids for Fetal Lung Maturity

• Administer to women with preeclampsia at ≤34 weeks gestation
• Consider for women with gestational hypertension at ≤34 weeks only if delivery anticipated within 7 days 2

Intrapartum Management

• Continue antihypertensive medications during labor
• Maintain blood pressure <160/110 mmHg
• Limit total fluid intake to 60-80 mL/h to avoid pulmonary edema 2
• Vaginal delivery preferred unless cesarean indicated for obstetric reasons 2

Postpartum Care

• Monitor blood pressure every 4-6 hours for at least 3 days 2
• Continue antihypertensive medications and taper slowly after days 3-6
• Avoid NSAIDs if possible, especially with renal dysfunction 2
• Follow up within 1 week if still requiring antihypertensives at discharge
• All women should be reviewed at 3 months postpartum 2

Prevention in High-Risk Women

• Low-dose aspirin (100-150 mg daily) from 12 weeks until 36-37 weeks gestation 2, 1
• Calcium supplementation (≥1 g/day) for women with low calcium intake 2, 1

Long-term Follow-up

• All women with preeclampsia require lifelong follow-up due to increased cardiovascular risk
• Annual medical review recommended 1

Common Pitfalls and Caveats

1. Failure to recognize severe features requiring immediate intervention
2. Inadequate blood pressure control during and after delivery
3. Overlooking postpartum preeclampsia (can develop de novo up to 4 weeks postpartum)
4. Insufficient magnesium sulfate monitoring leading to toxicity
5. Prolonged use of magnesium sulfate (>5-7 days) can cause fetal abnormalities 3
6. Underestimating fluid balance - aim for euvolemia, not "running dry" 2

Remember that preeclampsia is a multisystem disorder with risks beyond hypertension alone. Careful monitoring of maternal and fetal status is essential throughout management.