What is the management and treatment for preeclampsia?

Management and Treatment of Preeclampsia

Delivery is the only definitive treatment for preeclampsia, with management focused on controlling blood pressure, preventing seizures, and monitoring for maternal and fetal complications until appropriate timing for delivery. 1, 2

Diagnosis and Initial Assessment

• Preeclampsia is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks' gestation with either proteinuria or evidence of end-organ damage 3, 1
• All women with preeclampsia should be hospitalized initially to confirm diagnosis, assess severity, and monitor progression 1
• Maternal monitoring should include blood pressure measurements every 4 hours (more frequently if severe) and clinical assessment for clonus and neurological symptoms 1
• Laboratory tests should include hemoglobin, platelet count, liver enzymes, and renal function tests at least twice weekly 1

Blood Pressure Management

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

  • 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 (alternative option) 4, 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 oral antihypertensives include methyldopa, labetalol, and nifedipine 1

• ACE inhibitors are contraindicated during pregnancy 4, 1

Seizure Prevention with Magnesium Sulfate

• Magnesium sulfate should be administered for convulsion prophylaxis in women with preeclampsia and severe hypertension 1, 5
• For severe preeclampsia or eclampsia, the total initial dose is 10-14 g of magnesium sulfate 5
• IV administration: 4-5 g in 250 mL of 5% Dextrose or 0.9% Sodium Chloride Injection may be infused 5
• Simultaneously, IM doses of up to 10 g (5 g in each buttock) can be given 5
• Alternatively, after initial IV dose, some clinicians administer 1-2 g/hour by constant IV infusion 5
• Continue magnesium sulfate for 24 hours postpartum 1, 5
• A serum magnesium level of 6 mg/100 mL is considered optimal for seizure control 5

Fluid Management

• Total fluid intake should be limited to 60-80 mL/hour to avoid pulmonary edema 1, 6
• Aim for euvolemia; avoid "running dry" as this increases risk of acute kidney injury 6
• Plasma volume expansion is not recommended routinely 6
• Avoid NSAIDs if possible, especially with renal dysfunction 3, 6

Fetal Monitoring

• Initial assessment should confirm fetal well-being 1
• Serial ultrasound surveillance including fetal biometry, amniotic fluid assessment, and umbilical artery Doppler should be performed 1
• More frequent monitoring is needed if fetal growth restriction is present 6

Timing of Delivery

• Delivery is the definitive treatment for preeclampsia 4, 1, 2

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

  • 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 1
  • Non-reassuring fetal status 1

• Steroids should be given for 48 hours to accelerate lung maturation if gestation is <34 weeks 4, 1

Postpartum Management

• Blood pressure should be monitored at least every 4-6 hours for at least 3 days postpartum 3, 1
• Continue antihypertensives and taper slowly after days 3-6 postpartum unless blood pressure becomes low (<110/70 mmHg) 3, 1
• Laboratory tests that were abnormal before delivery should be repeated the day after delivery and then every second day until stable 3
• Eclampsia can still occur postpartum, so continued vigilance is necessary 3, 1
• Women still requiring antihypertensives at discharge should be reviewed within 1 week 3
• All women with preeclampsia should be reviewed at 3 months postpartum 3

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
• A Cochrane review showed a 15% reduction in the incidence of preeclampsia and a 7% fall in deliveries before 37 weeks with aspirin use 4

Long-term Implications

• Women with a history of preeclampsia require lifelong follow-up due to increased risk of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease 3
• By 3 months postpartum, blood pressure, urinalysis, and all laboratory tests should have normalized; persistent abnormalities require further investigation 3
• Assessment should include checking for depression, anxiety, or post-traumatic stress disorder symptoms 3

Common Pitfalls and Caveats

• Do not attempt to classify preeclampsia as mild versus severe as all cases can rapidly deteriorate 6
• The combination of calcium channel blockers with intravenous magnesium may cause myocardial depression, requiring close cardiac monitoring 4, 6
• Diuretics are controversial in preeclampsia as they reduce plasma volume expansion 4
• A total daily (24 hr) dose of 30-40 g of magnesium sulfate should not be exceeded 5
• In the presence of severe renal insufficiency, the maximum dosage of magnesium sulfate is 20 grams/48 hours 5