Management of Pre-eclampsia Without Severe Features
Women with pre-eclampsia without severe features should be managed with outpatient observation including weekly visits, laboratory monitoring, and twice-weekly non-stress tests, with delivery recommended at ≥37 weeks gestation. 1, 2
Diagnostic Criteria and Initial Assessment
Pre-eclampsia without severe features is characterized by:
- New-onset hypertension (≥140/90 mmHg) after 20 weeks gestation
- With or without proteinuria
- Without evidence of end-organ damage or severe features
Outpatient Management Protocol
Blood Pressure Monitoring
- Prescribe automated home blood pressure monitoring devices 1
- Instruct patients on proper technique and appropriate cuff size
- Patients should report elevated readings promptly for triage
- Treat blood pressures consistently ≥140/90 mmHg with a target diastolic BP of 85 mmHg 1
- Reduce or discontinue antihypertensive medications if diastolic BP falls <80 mmHg 1
Medication Options
- First-line agents: oral methyldopa, labetalol, oxprenolol, nifedipine
- Second/third-line agents: hydralazine, prazosin 1
Laboratory Monitoring
- Perform twice weekly blood tests including:
- Repeat assessments for proteinuria if not already present
Fetal Surveillance
- Initial ultrasound assessment of fetal biometry and amniotic fluid
- Umbilical artery Doppler evaluation
- Repeat ultrasound every 2 weeks if initial assessment normal
- Perform twice-weekly non-stress tests (NSTs) 1
- More frequent monitoring if fetal growth restriction is detected
Clinical Assessment
- Weekly in-person visits
- Evaluate for neurological symptoms, headache, visual changes
- Check for clonus and hyperreflexia
- Assess for right upper quadrant/epigastric pain
- Monitor for sudden weight gain or increased edema 1, 2
Important Considerations
Timing of Delivery
- Deliver at 37 weeks gestation for pre-eclampsia without severe features 1, 2
- Earlier delivery may be indicated if condition progresses to severe features or fetal compromise develops
Magnesium Sulfate
- Not routinely required for pre-eclampsia without severe features
- Should be administered if progression to severe features occurs 1, 2
Progression Monitoring
- Approximately 25% of women with gestational hypertension will progress to pre-eclampsia 1
- Risk is highest among those diagnosed before 34 weeks
- Immediate hospital assessment is required if:
- Development of severe hypertension (≥160/110 mmHg)
- New-onset symptoms (headache, visual changes, epigastric pain)
- Abnormal laboratory values
- Decreased fetal movement
Post-Delivery Management
- Continue blood pressure monitoring every 4-6 hours for at least 3 days postpartum
- Taper antihypertensive medications slowly after days 3-6
- Follow-up within 1 week if still requiring antihypertensives at discharge
- Review at 3 months postpartum
- Annual medical review recommended lifelong due to increased future cardiovascular risk 2
Pitfalls to Avoid
- Do not attempt to distinguish between "mild" and "severe" pre-eclampsia clinically, as all cases can rapidly progress to emergencies 1
- Do not discontinue close monitoring even if condition appears stable
- Avoid volume expansion as it is not recommended routinely in women with pre-eclampsia 1
- Do not delay delivery beyond 37 weeks in women with pre-eclampsia without severe features 1, 2
By following this structured approach to the management of pre-eclampsia without severe features, clinicians can optimize maternal and fetal outcomes while minimizing the risk of progression to more severe disease.