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, 2

Diagnosis and Risk Assessment

• Preeclampsia is diagnosed by hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with proteinuria (≥30 mg/mmol or 0.3 mg/mg protein/creatinine ratio) 1
• Risk factors include:
  • History of preeclampsia
  • Previous adverse pregnancy outcomes
  • Maternal comorbidities
  • Multifetal gestation
  • Nulliparity
  • Obesity
  • African American race
  • Advanced maternal age 1

Management Algorithm

Mild Preeclampsia (≥37 weeks)

• Proceed with delivery (similar outcomes to normotensive pregnancy) 2

Mild Preeclampsia (<37 weeks)

• Close maternal and fetal monitoring
• Blood pressure control with first-line oral agents
• Delivery at 37 weeks or earlier if condition worsens 1

Severe Preeclampsia (≥34 weeks)

• Immediate delivery is indicated 1, 2

Severe Preeclampsia (<34 weeks)

1. Administer corticosteroids for fetal lung maturation 1
2. Magnesium sulfate for seizure prophylaxis 1, 3
3. Antihypertensive therapy for blood pressure control 1
4. Consider expectant management for 24-48 hours to allow corticosteroids to take effect 2
5. Immediate delivery if:
   • Uncontrolled severe hypertension
   • Eclampsia
   • Pulmonary edema
   • Placental abruption
   • DIC
   • Non-reassuring fetal testing
   • HELLP syndrome 1, 4

Pharmacological Management

Seizure Prophylaxis

• Magnesium sulfate is the drug of choice 1, 3
• Initial dose: 4-5g IV over 15-20 minutes
• Maintenance: 1-2g/hour continuous IV infusion
• Continue for 24 hours postpartum
• Target serum level: 6 mg/100 mL 3
• Maximum daily dose: 30-40g/24 hours 3
• Monitor for toxicity: loss of deep tendon reflexes, respiratory depression, heart block 3

Antihypertensive Therapy

Severe Hypertension (BP ≥160/110 mmHg)

• First-line IV medications:
  • Labetalol: 10-20 mg IV initially, then 20-80 mg every 10-30 minutes (maximum 300 mg) 1
  • Hydralazine: 5-10 mg IV every 15-30 minutes (maximum 30 mg) 1
  • Nifedipine: 10-20 mg orally 1
• Target BP: 140-150/90-100 mmHg 1

Chronic Hypertension Management

• First-line oral agents:
  • Methyldopa
  • Labetalol 1
• Target diastolic BP: 85 mmHg (systolic 110-140 mmHg) 1
• ACE inhibitors are contraindicated during pregnancy 1, 5

Laboratory Monitoring

• Complete blood count with platelets
• Liver function tests
• Renal function
• Uric acid
• Fibrinogen levels (to evaluate for DIC) 1

Fetal Monitoring

• Continuous fetal heart rate monitoring in patients with preeclampsia
• Ultrasound for fetal growth assessment
• Amniotic fluid volume assessment
• Doppler studies if growth restriction is suspected 1

Prevention Strategies

• Low-dose aspirin (81 mg/day) between 12-16 weeks of gestation for high-risk women 1
• Calcium supplementation (1.0-1.5g daily) for women with low calcium intake 1
• Healthy diet focusing on fruits, vegetables, and whole grains 1

Postpartum Care

• 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
• Home blood pressure monitoring with proper technique and appropriate cuff size 1

Important Caveats

• Magnesium sulfate should not be used beyond 5-7 days in pregnancy as it can cause fetal abnormalities 3
• Diuretics are controversial and generally not recommended as first-line therapy as they reduce plasma volume expansion 5
• Calcium antagonism can partially reverse magnesium toxicity 3
• Women with history of preeclampsia have increased risk of cardiovascular disease later in life and require long-term follow-up 6