Management of Pre-eclampsia
The definitive treatment for pre-eclampsia is delivery of the baby and placenta, with timing based on gestational age, disease severity, and maternal/fetal condition. 1, 2
Diagnosis and Risk Assessment
- Pre-eclampsia is diagnosed by hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with proteinuria (≥30 mg/mmol protein/creatinine ratio) 1
- All pregnant women should be screened for pre-eclampsia with blood pressure measurements at each prenatal visit 3
- Risk factors include:
Laboratory Monitoring
- Regular monitoring should include:
- Complete blood count with platelets
- Liver function tests
- Renal function tests
- Uric acid levels 1
- Evaluate for microangiopathic hemolytic anemia and potential DIC with fibrinogen levels 1
Blood Pressure Management
Severe Hypertension (≥160/110 mmHg)
- Requires immediate treatment to prevent maternal stroke
- First-line IV medications:
- Labetalol: 20 mg IV bolus, then 40 mg after 10 minutes, 80 mg every 10 minutes for 2 additional doses (maximum 220 mg) 3
- Hydralazine: 5 mg IV bolus, then 10 mg every 20-30 minutes (maximum 25 mg) 3
- Nifedipine: 10 mg PO, repeat every 20 minutes (maximum 30 mg) - caution when used with magnesium sulfate 3
- Target BP reduction: 15-25% with goal systolic 140-150 mmHg and diastolic 90-100 mmHg 1
Mild to Moderate Hypertension
- First-line oral agents:
- Target diastolic BP of 85 mmHg (systolic 110-140 mmHg) 1
- ACE inhibitors are contraindicated during pregnancy 3
Seizure Prevention and Management
- Magnesium sulfate is the drug of choice for seizure prophylaxis in severe pre-eclampsia and eclampsia 4, 5
- Dosing regimen:
- Loading dose: 4-5 g IV in 250 mL of fluid over 15-20 minutes
- Maintenance: 1-2 g/hour continuous IV infusion
- Alternative regimen: 4-5 g IV loading dose followed by 4-5 g IM every 4 hours 4
- Continue for at least 24 hours postpartum 6
- Monitor for toxicity: assess deep tendon reflexes, respiratory rate, and urine output
- Therapeutic serum levels: 4-7 mEq/L 4
- Maximum daily dose: 30-40 g/24 hours; reduce to 20 g/48 hours in severe renal insufficiency 4
Delivery Planning
- Delivery indications:
- Gestational age ≥37 weeks
- Severe features at 34-37 weeks
- Any gestational age with:
- Repeated episodes of severe hypertension despite treatment
- Progressive thrombocytopenia
- Progressive abnormal renal or liver function
- Pulmonary edema
- Neurological complications
- Non-reassuring fetal status 1
- Expectant management may be considered for severe pre-eclampsia <34 weeks at centers with maternal-fetal medicine expertise 1, 7
- Administer corticosteroids for fetal lung maturation if delivery anticipated between 24-34 weeks 3, 6
Fetal Monitoring
- Continuous fetal heart rate monitoring in patients with pre-eclampsia
- Ultrasound for fetal growth assessment
- Amniotic fluid volume assessment
- Doppler studies if growth restriction is suspected 1
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 1
- Continue magnesium sulfate for at least 24 hours postpartum 6
Prevention Strategies
- Low-dose aspirin (81 mg/day) initiated between 12-16 weeks gestation for high-risk women 3, 1
- Calcium supplementation (1.0-1.5g daily) for women with low calcium intake 1
- Regular prenatal care with blood pressure monitoring at each visit 3
Pre-eclampsia remains a significant cause of maternal and fetal morbidity and mortality worldwide, with delivery being the only definitive treatment. Early identification, close monitoring, and appropriate management can significantly improve outcomes for both mother and baby.