Management Guidelines for Preeclampsia
Preeclampsia management requires early identification of risk factors, regular monitoring, and timely intervention with delivery being the definitive treatment when indicated by maternal or fetal status.
Definition and Diagnosis
Preeclampsia is defined as:
- New-onset hypertension (≥140/90 mmHg) after 20 weeks gestation
- With or without proteinuria (≥300 mg/24 hours or ≥1+ on dipstick)
- May include end-organ dysfunction 1
Risk Assessment and Prevention
Risk Factors
- First pregnancy (RR 2.91)
- Previous preeclampsia (RR 7.19)
- Multiple pregnancy (RR 2.93)
- Pre-existing diabetes (RR 3.56)
- Pre-existing hypertension or renal disease
- Antiphospholipid antibodies (RR 9.72)
- Family history of preeclampsia (RR 2.90)
- Age ≥40 years (RR 1.68-1.96)
- BMI ≥35 (RR 1.55)
- Pregnancy interval ≥10 years 2
Preventive Measures
- Low-dose aspirin (81 mg/day) should be initiated between 12-16 weeks gestation for high-risk women 1
- Calcium supplementation (1.0-1.5g daily) for women with low calcium intake 1
- Regular exercise following ACOG guidelines 2
- Vitamin C and E supplements are NOT recommended 2
Monitoring Schedule
For Women with Risk Factors
- Before 32 weeks: visits every 3 weeks
- After 32 weeks: visits every 2 weeks until delivery 2
For Women Without Risk Factors
- Regular assessments at weeks 16,28,34,36,38,40, and 41 2
- Patient education about symptoms requiring immediate medical attention 2
Assessment at Each Visit
Maternal Assessment
- Blood pressure measurement (using proper technique)
- Proteinuria testing
- Assessment for symptoms:
- Headache
- Visual disturbances
- Epigastric pain
- Reduced fetal movements 2
Laboratory Tests
- Complete blood count with platelets
- Liver function tests
- Renal function tests
- Uric acid
- Fibrinogen (if DIC suspected) 1
Management Based on Severity
Non-Severe Preeclampsia
- If ≥37 weeks: delivery is recommended 1
- If <37 weeks: expectant management with close monitoring
- Antihypertensive treatment options:
- First-line: oral methyldopa, labetalol, oxprenolol, or nifedipine
- Second/third-line: hydralazine, prazosin 1
Severe Preeclampsia
Defined by any of the following:
- Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg
- New proteinuria ≥1+ with symptoms
- End-organ dysfunction
Management:
- Immediate hospital admission 2
- Urgent treatment of severe hypertension:
- IV labetalol: 10-20 mg initially, then 20-80 mg every 10-30 minutes
- IV hydralazine: 5-10 mg every 15-30 minutes
- IV nicardipine: starting at 5 mg/h, increasing by 2.5 mg/h every 5-15 minutes 1
- Magnesium sulfate for seizure prophylaxis:
- Corticosteroids for fetal lung maturation if <34 weeks 2, 1
- Delivery timing:
- ≥34 weeks: immediate delivery
- <34 weeks: consider expectant management at centers with maternal-fetal medicine expertise 1
Fetal Monitoring
- Initial assessment: fetal biometry, amniotic fluid volume, and umbilical artery Doppler 2
- Serial evaluation of fetal growth every 2 weeks
- More frequent monitoring if abnormal Doppler findings 2
Postpartum Management
- Continue blood pressure monitoring every 4-6 hours for at least 3 days
- Taper antihypertensive medications slowly after days 3-6
- Follow-up within 1 week if still on antihypertensives at discharge
- Review at 3 months postpartum
- Annual medical review recommended lifelong 1
Common Pitfalls to Avoid
- Do not attempt to distinguish between "mild" and "severe" preeclampsia clinically, as all cases can rapidly progress 1
- Do not discontinue close monitoring even if condition appears stable 1
- Do not use volume expansion routinely 1
- Do not delay delivery beyond 37 weeks in women with preeclampsia without severe features 1
- Do not use magnesium sulfate beyond 5-7 days due to risk of fetal abnormalities 3
- Do not use ACE inhibitors during second and third trimesters 1
- Do not use diuretics in preeclampsia with fetal growth restriction 1
By following these evidence-based guidelines, clinicians can optimize outcomes for both mother and baby in the management of preeclampsia.