What is the management of pre eclampsia (preeclampsia) with severe features?

Management of Preeclampsia with Severe Features

Patients with preeclampsia with severe features require urgent treatment with antihypertensive medications, magnesium sulfate for seizure prophylaxis, and timely delivery based on gestational age and maternal/fetal status. 1

Initial Assessment and Stabilization

• All women with preeclampsia should be initially assessed in a hospital setting when first diagnosed 1
• Blood pressure (BP) requires urgent treatment in a monitored setting when ≥160/110 mmHg 1
• First-line antihypertensive agents include:
  • Oral nifedipine (10-20 mg, repeat in 30 minutes if needed) 1
  • Intravenous labetalol 1
  • Intravenous hydralazine (5 mg, then 5-10 mg every 30 minutes) 1
• Target diastolic BP of 85 mmHg and systolic BP <160 mmHg (some units target 110-140 mmHg) 1
• Reduce or cease antihypertensive drugs if diastolic BP falls <80 mmHg 1

Seizure Prophylaxis

• Administer magnesium sulfate to all women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs/symptoms 1
• Dosing regimen for magnesium sulfate 2:
  • Loading dose: 4-5 g IV in 250 mL of 5% Dextrose or 0.9% Sodium Chloride over 15-20 minutes
  • Maintenance: 1-2 g/hour by continuous IV infusion
  • Alternative regimen: After IV loading dose, 4-5 g IM into alternate buttocks every 4 hours
  • Continue until 24 hours postpartum or paroxysms cease
  • Monitor for signs of magnesium toxicity (loss of patellar reflexes, respiratory depression)
  • Do not exceed total daily dose of 30-40 g 2

Maternal Monitoring

• Blood pressure monitoring 1
• Repeated assessments for proteinuria if not already present 1
• Clinical assessment including clonus 1
• Laboratory tests twice weekly (or more frequently with clinical changes) 1:
  • Hemoglobin
  • Platelet count
  • Liver transaminases
  • Creatinine
  • Uric acid

Fetal Monitoring

• Initial assessment with ultrasound for 1:
  • Fetal biometry
  • Amniotic fluid volume
  • Umbilical artery Doppler
• Repeat assessment every 2 weeks if initial assessment normal 1
• More frequent monitoring of amniotic fluid and Doppler if fetal growth restriction present 1

Timing of Delivery

Delivery timing depends on gestational age and maternal/fetal status 1:

1. ≥37 weeks' gestation: Immediate delivery 1
2. 34-37 weeks' gestation: Expectant management with close monitoring 1
3. <34 weeks' gestation: Conservative management at a center with Maternal-Fetal Medicine expertise 1
4. Near viability (<24 weeks): Counsel regarding possible need for pregnancy termination 1, 3

Indications for Immediate Delivery Regardless of Gestational Age

• Inability to control maternal BP despite using ≥3 classes of antihypertensives in appropriate doses 1
• Maternal pulse oximetry <90% 1
• Progressive deterioration in liver function, creatinine, hemolysis, or platelet count 1
• Ongoing neurological features (severe intractable headache, repeated visual scotomata, eclampsia) 1
• Placental abruption 1
• Reversed end-diastolic flow in umbilical artery Doppler, non-reassuring cardiotocograph, or stillbirth 1

Mode of Delivery

• Vaginal delivery should be considered for women with any hypertensive disorders unless cesarean delivery is required for obstetric indications 1
• For women with severe preeclampsia, especially with HELLP syndrome and unripe cervix, cesarean section may be preferred 4

Transport Considerations

• Medicalised transport should be systematically considered for patients with severe preeclampsia 1
• The decision to initiate and determine modalities of antihypertensive treatment should involve discussion between obstetric and anesthetic-intensivist teams of the receiving specialized facility 1

Additional Management Considerations

• Corticosteroids for fetal lung maturity should be considered for all women with preeclampsia at ≤34 weeks of gestation 1
• Plasma volume expansion is not recommended routinely 1
• For women with HELLP syndrome, fresh frozen plasma may be needed for coagulation disorders 4

Important Caveats

• There should be no attempt to diagnose mild versus severe preeclampsia clinically as all cases may become emergencies, often rapidly 1
• Neither serum uric acid nor level of proteinuria should be used as an indication for delivery 1
• The level of BP itself is not a reliable way to stratify immediate risk, as some women may develop serious organ dysfunction at relatively mild levels of hypertension 1
• Continuous maternal administration of magnesium sulfate beyond 5-7 days can cause fetal abnormalities 2