What is the management and treatment for preeclampsia?

Management and Treatment of Preeclampsia

The definitive treatment for preeclampsia is delivery of the placenta and fetus, with timing based on gestational age, maternal condition, and fetal status. 1, 2

Diagnosis and Initial Assessment

• Preeclampsia is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks of gestation with proteinuria or evidence of end-organ damage 3
• All women with preeclampsia should be hospitalized initially to confirm diagnosis, assess severity, and monitor progression 2
• Maternal monitoring should include:
  • Blood pressure measurements every 4 hours (more frequently if severe) 2
  • Clinical assessment including evaluation for clonus and neurological symptoms 2
  • At least twice weekly blood tests for hemoglobin, platelet count, liver enzymes, and renal function 1

Blood Pressure Management

• Severe hypertension (≥160/110 mmHg) requires urgent treatment in a monitored setting using: 1, 2
  • Oral nifedipine (10 mg, repeat every 20 minutes to maximum 30 mg), or
  • IV labetalol (20 mg bolus, then 40 mg if needed after 10 minutes, followed by 80 mg every 10 minutes to maximum 220 mg), or
  • IV hydralazine
• For non-severe hypertension (≥140/90 mmHg), treat with oral antihypertensives aiming for: 1
  • Target diastolic BP of 85 mmHg
  • Systolic BP between 110-140 mmHg
• Acceptable oral agents include methyldopa, labetalol, oxprenolol, and nifedipine 1
• Antihypertensive drugs should be reduced or ceased if diastolic BP falls <80 mmHg 1

Seizure Prevention with Magnesium Sulfate

• All women with preeclampsia should receive magnesium sulfate for convulsion prophylaxis, especially those with severe hypertension or neurological symptoms 1, 2
• Dosing regimen: 1, 4
  • Loading dose: 4 g IV or 10 g IM
  • Maintenance: 5 g IM every 4 hours or IV infusion of 1 g/hour
  • Continue until delivery and for at least 24 hours postpartum
• In severe preeclampsia or eclampsia, the total initial dose is 10-14 g of magnesium sulfate 4
• A serum magnesium level of 6 mg/100 mL is considered optimal for seizure control 4

Fluid Management

• Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema 2
• Plasma volume expansion is not recommended routinely 1

Fetal Monitoring

• Initial assessment should confirm fetal well-being 2
• Serial ultrasound surveillance including: 1, 2
  • Fetal biometry
  • Amniotic fluid assessment
  • Umbilical artery Doppler
• Perform at first diagnosis and thereafter at 2-week intervals if initial assessment was normal 1
• More frequent monitoring in the presence of fetal growth restriction 1

Timing of Delivery

• Deliver at 37 weeks' gestation or earlier if any of the following develop: 1, 2
  • Repeated episodes of severe hypertension despite treatment with 3 classes of antihypertensives
  • Progressive thrombocytopenia
  • Progressively abnormal renal or liver enzyme tests
  • Pulmonary edema
  • Abnormal neurological features (severe headache, visual disturbances, convulsions)
  • Non-reassuring fetal status
• Women with onset of preeclampsia at ≥37 weeks' gestation should be delivered 1
• For preeclampsia between 34-37 weeks, expectant management may be considered 1
• Steroids should be given for 48 hours to accelerate lung maturation if gestation is <34 weeks 1, 5

Postpartum Management

• Continue close monitoring for at least 3 days postpartum as eclampsia can still develop 6, 2
• Monitor BP at least every 4-6 hours 6, 2
• Continue antihypertensives and taper slowly after days 3-6 postpartum 6
• Laboratory tests that were abnormal before delivery should be repeated the day after delivery and then every second day until stable 6
• NSAIDs should be avoided for pain relief, especially in women with renal disease or acute kidney injury 6, 2

Long-term Follow-up

• Women still requiring antihypertensives at discharge should be reviewed within 1 week 6
• All women with preeclampsia should be reviewed at 3 months postpartum 6
• By 3 months, blood pressure, urinalysis, and all laboratory tests should have normalized; persistent abnormalities require further investigation 6
• Women with a history of preeclampsia have increased lifetime risks of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease 6, 3, 2

Prevention Strategies for High-Risk Women

• Low-dose aspirin (75-162 mg/day) before 16 weeks' gestation for women with strong clinical risk factors 2
• Supplemental calcium if dietary intake is likely low 2

Common Pitfalls and 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 the level of proteinuria should be used as an indication for delivery 1
• Continuous maternal administration of magnesium sulfate in pregnancy beyond 5-7 days can cause fetal abnormalities 4
• In the presence of severe renal insufficiency, the maximum dosage of magnesium sulfate is 20 grams/48 hours with frequent monitoring of serum magnesium concentrations 4