What are the management options for pre-eclampsia?

Management of Pre-eclampsia

The management of pre-eclampsia requires urgent hospitalization for assessment, close maternal and fetal monitoring, blood pressure control, seizure prophylaxis, and timely delivery based on disease severity and gestational age. 1

Diagnosis and Initial Assessment

• Pre-eclampsia is diagnosed by new-onset hypertension (≥140/90 mmHg) after 20 weeks of gestation with proteinuria or evidence of end-organ damage 1, 2
• All women with pre-eclampsia should be hospitalized initially to confirm diagnosis, assess severity, and monitor progression 1, 3
• Maternal monitoring should include:
  • Blood pressure measurements every 4 hours (more frequently if severe) 1
  • Clinical assessment including evaluation for clonus and neurological symptoms 1
  • At least twice weekly blood tests for hemoglobin, platelet count, liver enzymes, and renal function including uric acid 1, 4
  • Repeated assessment for proteinuria if not already present 1

Blood Pressure Management

• Severe hypertension (>160/110 mmHg) requires urgent treatment in a monitored setting using: 1

  • Oral nifedipine (10 mg, repeat every 20 minutes to maximum 30 mg) 1
  • IV labetalol (20 mg bolus, then 40 mg if needed after 10 minutes, followed by 80 mg every 10 minutes to maximum 220 mg) 1
  • IV hydralazine (5 mg bolus, then 10 mg every 20-30 minutes to maximum 25 mg) 1

• For non-severe hypertension (≥140/90 mmHg), treat with oral antihypertensives aiming for target diastolic BP of 85 mmHg and systolic BP between 110-140 mmHg 1

  • First-line agents include methyldopa, labetalol, oxprenolol, and nifedipine 1
  • Reduce or cease antihypertensives if diastolic BP falls below 80 mmHg 1

Seizure Prevention with Magnesium Sulfate

• Magnesium sulfate should be administered for convulsion prophylaxis in women with: 1

  • Pre-eclampsia with severe hypertension 1
  • Hypertension with neurological signs or symptoms 1, 4

• Magnesium sulfate dosing for pre-eclampsia/eclampsia: 5

  • Initial dose: 4-5g IV over 15-20 minutes 5
  • Maintenance: 1-2g/hour continuous IV infusion 5
  • Continue for 24 hours postpartum 1, 4
  • Monitor for magnesium toxicity by checking deep tendon reflexes, respiratory rate, and urine output 5

Fluid Management

• Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema 1, 4
• Aim for euvolemia; avoid "running dry" as this increases risk of acute kidney injury 1
• Avoid NSAIDs for postpartum analgesia, especially with renal dysfunction 1

Fetal Monitoring

• Initial assessment should confirm fetal well-being 1
• Serial ultrasound surveillance including fetal biometry, amniotic fluid assessment, and umbilical artery Doppler 1, 4
• More frequent monitoring if fetal growth restriction is present 4

Timing of Delivery

• Delivery is the definitive treatment for pre-eclampsia 2, 3

• Deliver at 37 weeks' gestation or earlier if any of the following develop: 1

  • Repeated episodes of severe hypertension despite treatment with 3 classes of antihypertensives 1
  • Progressive thrombocytopenia 1
  • Progressively abnormal renal or liver enzyme tests 1
  • Pulmonary edema 1
  • Abnormal neurological features (severe headache, visual scotomata, convulsions) 1
  • Non-reassuring fetal status 1

• For severe pre-eclampsia between 24-34 weeks:

  • Consider expectant management in selected cases to improve neonatal outcomes 3
  • Administer antenatal corticosteroids for fetal lung maturity 2, 3

Postpartum Management

• Continue close monitoring for at least 3 days postpartum as eclampsia can still develop 1
• Monitor BP at least every 4 hours while awake 1
• Continue antihypertensives and taper slowly after days 3-6 postpartum 1
• Avoid abrupt cessation of antihypertensive therapy 1
• Review at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 1

Prevention Strategies for High-Risk Women

• Low-dose aspirin (75-162 mg/day) before 16 weeks' gestation (definitely before 20 weeks) for women with strong clinical risk factors: 1

  • Prior pre-eclampsia
  • Chronic hypertension
  • Pre-gestational diabetes
  • BMI >30 kg/m²
  • Antiphospholipid syndrome
  • Assisted reproduction

• Supplemental calcium (1.2-2.5 g/day) if intake is likely low (<600 mg/day) 1

Special Considerations

• Home BP monitoring is useful for managing chronic hypertension in pregnancy 1
• Avoid low molecular weight heparin for pre-eclampsia prevention 1
• Women with pre-eclampsia should be counseled about increased lifetime cardiovascular risk 1
• Regular exercise during pregnancy may help reduce the likelihood of hypertension 1