What are the initial management orders for pre-eclampsia in the Emergency Department (ED)?

Initial Management Orders for Pre-eclampsia in the Emergency Department

The initial management of pre-eclampsia in the ED requires urgent blood pressure control when severe hypertension is present (>160/110 mmHg), administration of magnesium sulfate for seizure prophylaxis in severe cases, comprehensive maternal and fetal monitoring, and preparation for possible delivery depending on gestational age and clinical severity. 1

Blood Pressure Management

• Urgent treatment of severe hypertension (≥160/110 mmHg) in a monitored setting using oral nifedipine, intravenous labetalol, or intravenous hydralazine 1
• Target diastolic BP of 85 mmHg and systolic BP between 110-140 mmHg to reduce the risk of developing severe maternal complications 1
• Reduce or discontinue antihypertensive medications if diastolic BP falls below 80 mmHg 1
• For non-severe hypertension (140-159/90-109 mmHg), initiate oral antihypertensives including methyldopa, labetalol, oxprenolol, or nifedipine 1

Seizure Prophylaxis

• Administer magnesium sulfate for seizure prophylaxis in women with pre-eclampsia who have proteinuria with severe hypertension or any hypertension with neurological signs/symptoms 1
• Initial IV dose: 4-5g in 250mL of 5% Dextrose or 0.9% Sodium Chloride infused over 15-20 minutes 2
• Maintenance: Either 1-2g/hour by continuous IV infusion or 4-5g IM every 4 hours 2
• Monitor for magnesium toxicity: assess deep tendon reflexes, respiratory rate, and urine output 2

Laboratory Assessment

• Complete blood count with focus on hemoglobin and platelet count 1
• Comprehensive metabolic panel including liver enzymes, creatinine, and uric acid 1
• Urinalysis and urine protein/creatinine ratio (≥30 mg/mmol or 0.3 mg/mg is abnormal) 1
• Coagulation studies if platelet count is low or if liver enzymes are elevated 3

Maternal Monitoring

• Continuous blood pressure monitoring 1
• Assessment for proteinuria if not already documented 1
• Clinical assessment including deep tendon reflexes and clonus 1
• Evaluation for signs of end-organ damage: headache, visual disturbances, epigastric pain, pulmonary edema 1
• Pulse oximetry monitoring 1

Fetal Assessment

• Initial ultrasound to assess fetal biometry, amniotic fluid volume, and umbilical artery Doppler 1
• Electronic fetal monitoring to assess fetal heart rate and variability 1, 4
• More frequent monitoring if fetal growth restriction is present 1

Delivery Considerations

• Immediate delivery is indicated for women with pre-eclampsia at ≥37 weeks' gestation 1, 4
• For women between 34-37 weeks, expectant management with close monitoring is appropriate in the absence of severe features 4
• For women <34 weeks, conservative management at a center with Maternal-Fetal Medicine expertise is recommended 1, 4
• Regardless of gestational age, delivery is necessary for:
  • Uncontrolled severe hypertension despite ≥3 antihypertensive medications 1, 4
  • Oxygen saturation <90% 1, 4
  • Progressive deterioration in liver function, renal function, hemolysis, or platelet count 1, 4
  • Neurological complications (severe headache, visual scotomata, eclampsia) 1, 4
  • Pulmonary edema or placental abruption 1, 4
  • Non-reassuring fetal status 1, 4

Important Caveats

• All cases of pre-eclampsia should be considered potentially severe as they can rapidly progress to emergencies 1, 4
• Blood pressure alone is not a reliable indicator of disease severity as serious organ dysfunction can develop at relatively mild levels of hypertension 1, 4
• Neither serum uric acid nor the level of proteinuria should be used as an indication for delivery 1
• Plasma volume expansion is not recommended routinely 1
• Obstetric consultation should be obtained immediately upon diagnosis 5