What are the symptoms and treatment options for preeclampsia?

Symptoms and Treatment Options for Preeclampsia

Preeclampsia is characterized by new-onset hypertension after 20 weeks of gestation with proteinuria or evidence of end-organ damage, and the definitive treatment is delivery of the placenta and fetus, with timing based on gestational age, maternal condition, and fetal status. 1, 2

Symptoms of Preeclampsia

Common Symptoms and Signs

• New-onset hypertension (≥140/90 mmHg) developing after 20 weeks of gestation 3, 2
• Proteinuria (≥0.3 g/24 h in a 24-hour urine collection) 3, 2
• Right upper quadrant/epigastric pain due to liver edema and hepatic hemorrhage 3
• Headache and visual disturbances due to cerebral edema 3, 2
• Hyperreflexia and clonus 3, 4
• Occipital lobe blindness 3
• Convulsions (cerebral edema) 3, 5

Severe Preeclampsia Signs

• HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelet count 3, 6
• Severe hypertension (≥160/110 mmHg) 3, 1
• Progressive thrombocytopenia (<100,000/μL) 3, 6
• Liver dysfunction with elevated transaminases 3, 6
• Renal insufficiency 2, 6
• Pulmonary edema 3, 1

Treatment Options for Preeclampsia

Definitive Treatment

• Delivery of the placenta and fetus is the only curative treatment for preeclampsia 1, 6
• Timing of delivery depends on gestational age, maternal condition, and fetal status 1, 7

Blood Pressure Management

• Severe hypertension (≥160/110 mmHg) requires urgent treatment in a monitored setting using: 3, 1
  • Hydralazine: 5 mg IV bolus, then 10 mg every 20-30 minutes to maximum 25 mg 3
  • Labetalol: 20 mg IV bolus, then 40 mg 10 minutes later, 80 mg every 10 minutes for 2 additional doses to maximum 220 mg 3
  • Nifedipine: 10 mg orally, repeat every 20 minutes to maximum 30 mg 3

Seizure Prevention

• Magnesium sulfate is the drug of choice for prevention and treatment of eclamptic seizures 1, 5
• Dosing regimen: 8
  • 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
• Monitor for magnesium toxicity: assess patellar reflexes, respiratory rate, and serum magnesium levels 8

Delivery Considerations

• Deliver at 37 weeks' gestation or earlier if any of the following develop: 3, 1
  • Repeated episodes of severe hypertension despite treatment
  • Progressive thrombocytopenia
  • Progressively abnormal renal or liver enzyme tests
  • Pulmonary edema
  • Abnormal neurological features
  • Non-reassuring fetal status
• Between 24-34 weeks, conservative management may be considered in selected patients 1, 6
• Antenatal corticosteroids should be administered to women <34 weeks' gestation to promote fetal lung maturity 6

Postpartum Management

• Monitor blood pressure at least every 4 hours for at least 3 days postpartum 4, 1
• Continue antihypertensive medications and taper slowly after days 3-6 postpartum 4, 1
• Avoid NSAIDs for postpartum analgesia, especially with renal disease, placental abruption, or acute kidney injury 3, 4
• All women with preeclampsia should be reviewed at 3 months postpartum 4, 1

Prevention in High-Risk Women

• Low-dose aspirin (75-162 mg/day) before 16 weeks' gestation for women with strong clinical risk factors 3, 1
• Supplemental calcium (1.2-2.5 g/day) if dietary intake is likely low 3

Important Considerations and Pitfalls

• Do not attempt to distinguish between mild and severe preeclampsia clinically, as all cases may rapidly progress to emergencies 1
• Women with a history of preeclampsia have increased lifetime risks of cardiovascular disease, stroke, diabetes mellitus, and chronic kidney disease 4, 1
• Fluid intake should be limited to 60-80 mL/hour to avoid pulmonary edema 1
• Maternal monitoring should include blood pressure measurements, repeated assessments for proteinuria, clinical assessment including clonus, and blood tests for hemoglobin, platelet count, and liver and renal function 3, 1