What is the initial management for a 25-week pregnant patient with suspected preeclampsia and hypertension?

Initial Management for Suspected Preeclampsia at 25 Weeks Gestation

For a 25-week pregnant patient with suspected preeclampsia presenting with chest pain, hypertension (164/79 mmHg), and tachycardia (99 bpm), immediate IV labetalol should be administered as first-line therapy to reduce blood pressure within 30-60 minutes of confirmed severe hypertension. 1, 2, 3

Initial Assessment and Monitoring

• Establish continuous maternal monitoring:

  • Vital signs every 15 minutes until stabilized
  • Continuous fetal heart rate monitoring
  • Place on left lateral position to improve uteroplacental perfusion

• Laboratory tests to order immediately:

  • Complete blood count with platelets
  • Comprehensive metabolic panel (liver enzymes, renal function)
  • Uric acid level
  • Urinalysis with protein/creatinine ratio
  • Coagulation studies (fibrinogen, PT/PTT)
  • Chest X-ray (if chest pain is concerning for pulmonary edema)

Antihypertensive Management

• Target blood pressure: Reduce mean BP by 15-25% with goal SBP 140-150 mmHg and DBP 90-100 mmHg 4
• First-line medication options:
  1. IV labetalol: 10-20 mg initially, then 20-80 mg every 10-30 minutes (maximum 300 mg) 4, 1
  2. IV hydralazine: 5-10 mg every 15-30 minutes (maximum 30 mg) 4, 1
  3. Oral nifedipine (immediate release): 10-20 mg, can repeat in 30 minutes if needed 1, 2

Note: While hydralazine is commonly used in North America, it has been associated with more adverse effects including maternal hypotension, increased risk of cesarean section, placental abruption, and fetal tachycardia 4. Labetalol is considered safer and equally effective.

Seizure Prophylaxis

• If severe features of preeclampsia are present (severe hypertension with proteinuria or neurological symptoms):
  • Administer magnesium sulfate:
    • Loading dose: 4-5g IV over 15-20 minutes
    • Maintenance: 1-2g/hour continuous infusion 1
  • Monitor for magnesium toxicity (respiratory depression, loss of deep tendon reflexes)

Fetal Assessment

• Ultrasound for fetal growth assessment
• Amniotic fluid volume assessment
• Doppler studies if growth restriction is suspected
• Continuous fetal heart rate monitoring

Delivery Considerations

• At 25 weeks, the goal is to stabilize the mother and prolong pregnancy if possible
• Administer antenatal corticosteroids for fetal lung maturity
• Consider delivery only if:
  • Uncontrollable severe hypertension despite treatment
  • Progressive thrombocytopenia
  • Worsening liver or renal function
  • Pulmonary edema
  • Neurological symptoms
  • Non-reassuring fetal status 1

Common Pitfalls to Avoid

1. Delayed treatment: Treatment should occur within 30-60 minutes of confirmed severe hypertension to reduce maternal stroke risk 2, 3

2. Excessive BP reduction: Too rapid or excessive lowering of blood pressure can compromise uteroplacental perfusion and cause fetal distress

3. Failure to recognize pulmonary edema: Chest pain in preeclampsia may indicate pulmonary edema, which requires immediate treatment with IV nitroglycerin (5 mg/min, gradually increased) 4

4. Overlooking magnesium sulfate: Essential for seizure prophylaxis in severe preeclampsia

5. Inappropriate use of diuretics: Generally avoided in preeclampsia as these patients are often volume depleted despite edema

The management of preeclampsia at 25 weeks requires a multidisciplinary approach involving emergency medicine, obstetrics, maternal-fetal medicine, and potentially critical care. The primary goal is maternal stabilization while optimizing conditions for fetal development.