What is the management of preeclampsia?

Management of Preeclampsia

The definitive management of preeclampsia involves antihypertensive treatment for severe hypertension, magnesium sulfate for seizure prophylaxis in severe cases, and delivery timing based on disease severity and gestational age. 1

Diagnosis and Definition

Preeclampsia is defined as gestational hypertension (BP ≥140/90 mmHg) after 20 weeks of gestation accompanied by one or more of the following new-onset conditions:

• Proteinuria (>0.3 g/24h or ACR ≥30 mg/mmol)
• Evidence of maternal organ dysfunction
• Uteroplacental dysfunction 2, 1

Important clinical features include:

• Right upper quadrant/epigastric pain
• Headache and visual disturbances
• Hyperreflexia
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) 2

Risk Assessment and Prevention

Risk Factors

• History of preeclampsia (particularly early-onset)
• Previous adverse pregnancy outcomes
• Maternal comorbidities (diabetes, chronic hypertension, renal disease, autoimmune diseases)
• Multifetal gestation
• Nulliparity, obesity, African American race, advanced maternal age 2, 1

Prevention Strategies

• Low-dose aspirin (81 mg/day) should be initiated between 12-16 weeks of gestation for high-risk women and continued until delivery 1
• Calcium supplements (1.0-1.5g daily) are recommended for pregnant women with low calcium intake 1
• Regular blood pressure monitoring at each prenatal visit 2, 1

Management Protocol

Antihypertensive Treatment

1. Severe hypertension (SBP ≥160 mmHg and/or DBP ≥110 mmHg) requires immediate treatment with first-line IV medications:

   • Labetalol
   • Hydralazine
   • Oral nifedipine 1, 3
   • Target BP: diastolic 85 mmHg, systolic 110-140 mmHg 1

2. Mild to moderate hypertension (140-159/90-109 mmHg):

   • Initiate drug treatment in all hypertensive women with BP persistently ≥150/95 mmHg
   • Start treatment at ≥140/90 mmHg in women with:
     • Gestational hypertension
     • Pre-existing hypertension with superimposed gestational hypertension
     • Hypertension with subclinical organ damage or symptoms 2

Seizure Prophylaxis with Magnesium Sulfate

• Indication: Severe preeclampsia or eclampsia 1, 4
• Initial dosing: 4-5g IV in 250mL of 5% Dextrose or 0.9% Sodium Chloride over 3-4 minutes
• Maintenance: 1-2g/hour by continuous IV infusion
• Duration: Continue for at least 24 hours postpartum
• Monitoring: Check for patellar reflexes, respiratory rate, and urine output
• Maximum dose: Total daily dose should not exceed 30-40g
• Caution: In severe renal insufficiency, maximum dosage is 20g/48 hours 4

Delivery Timing

Delivery is recommended for women with preeclampsia who have:

• Reached 37 weeks' gestation
• Repeated episodes of severe hypertension despite treatment
• Progressive thrombocytopenia
• Progressively abnormal renal or liver enzyme tests
• Pulmonary edema
• Abnormal neurological features
• Non-reassuring fetal status 1

For severe preeclampsia before 34 weeks, consider antenatal corticosteroids to promote fetal lung maturity 5

Monitoring

Maternal Monitoring

• Blood pressure every 4-6 hours during hospitalization
• Laboratory monitoring: complete blood count with platelets, liver function tests, renal function
• Assess for symptoms of severe preeclampsia (headache, visual changes, epigastric pain)
• Continue monitoring for at least 72 hours postpartum 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

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
• Long-term follow-up is important as preeclampsia increases risk for future cardiovascular disease 5

Important Caveats

• Continuous use of magnesium sulfate beyond 5-7 days can cause fetal abnormalities 4
• Magnesium toxicity can occur with renal insufficiency; monitor serum levels
• Therapeutic serum magnesium levels range from 2.5 to 7.5 mEq/L; levels above 12 mEq/L may be fatal 4
• Calcium can antagonize magnesium toxicity effects if needed 4

Remember that delivery is the definitive treatment for preeclampsia, and management decisions should balance maternal safety and fetal maturity 3, 6.