What is the management of preeclampsia?

Management of Preeclampsia

The definitive management of preeclampsia involves antihypertensive treatment for severe hypertension (SBP ≥160 mmHg and/or DBP ≥110 mmHg), magnesium sulfate for seizure prophylaxis in severe cases, and delivery timing based on disease severity and gestational age. 1, 2

Diagnostic Criteria

Preeclampsia is defined as gestational hypertension accompanied by ≥1 of the following new-onset conditions at or after 20 weeks' gestation:

• Proteinuria (present in ~75% of cases but not required for diagnosis)
• End-organ dysfunction:
  • Renal insufficiency
  • Liver involvement
  • Neurological complications
  • Hematological complications (thrombocytopenia)
  • Uteroplacental dysfunction (fetal growth restriction) 2

Initial Evaluation

• Blood pressure monitoring
• Laboratory assessment:
  • Complete blood count with platelets
  • Liver function tests
  • Renal function tests (creatinine, electrolytes, uric acid)
  • Urinalysis with protein/creatinine ratio
• Fetal assessment:
  • Continuous fetal heart rate monitoring
  • Ultrasound for fetal growth
  • Amniotic fluid volume assessment
  • Doppler studies if growth restriction is suspected 2

Management Algorithm

1. Antihypertensive Treatment

• Severe hypertension (SBP ≥160 mmHg and/or DBP ≥110 mmHg):
  • Immediate treatment is recommended to reduce maternal complications
  • First-line IV medications:
    • Labetalol
    • Hydralazine
    • Oral nifedipine
  • Target BP: Diastolic 85 mmHg, Systolic 110-140 mmHg 1, 2

2. Seizure Prophylaxis

• Magnesium sulfate is recommended for:
  • Women with severe preeclampsia
  • Those with neurological signs/symptoms
  • Should be continued during labor and for at least 24 hours postpartum 2, 3

3. Corticosteroids

• Administer for fetal lung maturation if delivery is anticipated between 24-34 weeks 2

4. Delivery Decision-Making

Immediate delivery is indicated for:

• Gestational age ≥37 weeks with preeclampsia
• Severe preeclampsia at ≥34 weeks
• Any gestational age with:
  • Repeated episodes of severe hypertension despite treatment
  • Progressive thrombocytopenia
  • Progressive abnormal renal or liver function
  • Pulmonary edema
  • Abnormal neurological features
  • Non-reassuring fetal status
  • HELLP syndrome 2, 4

Expectant management may be considered for:

• Select cases of severe preeclampsia between 24-34 weeks
• Only in tertiary care centers with close maternal and fetal monitoring
• Average prolongation of pregnancy: 7-15 days 5, 6

Contraindications to expectant management:

• Imminent eclampsia
• Multi-organ dysfunction
• Severe fetal growth restriction
• Suspected placental abruption
• Non-reassuring fetal testing 4, 7

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
• Prescribe home blood pressure monitoring devices 2

Prevention Strategies

For high-risk women in future pregnancies:

• Low-dose aspirin (81 mg/day) initiated between 12-16 weeks of gestation
• Calcium supplements (1.0-1.5g elemental calcium daily), particularly for those with low calcium intake 2

Common Pitfalls and Caveats

• Underestimating severity: Any new headache with hypertension should be considered preeclampsia until proven otherwise
• Delayed treatment: Severe hypertension requires immediate treatment to prevent cerebrovascular complications
• Inadequate monitoring: Patients with severe preeclampsia require intensive inpatient monitoring
• Inappropriate expectant management: Should only be attempted in tertiary care centers with experienced teams
• Premature discontinuation of magnesium sulfate: Should be continued for at least 24 hours postpartum 1, 2, 4

Remember that while delivery is always appropriate therapy for the mother, timing must balance maternal safety against fetal maturity when remote from term.