What is the management for preeclampsia?

Management of Preeclampsia

Deliver the fetus and placenta at 37 weeks' gestation or earlier if severe features develop, as this is the only definitive treatment for preeclampsia. 1, 2

Initial Assessment and Hospitalization

• All women with newly diagnosed preeclampsia require initial hospital assessment to confirm diagnosis, assess severity, and establish monitoring protocols 1, 2
• After stabilization, selected patients with preeclampsia without severe features may transition to outpatient management if their condition remains stable and they can reliably report symptoms and monitor blood pressure 1
• Preeclampsia is diagnosed by new-onset hypertension (≥140/90 mmHg) after 20 weeks' gestation with either proteinuria or evidence of end-organ damage 2

Blood Pressure Management

Severe Hypertension (≥160/110 mmHg)

Severe hypertension requires urgent treatment in a monitored setting to reduce risk of maternal stroke and other complications 1, 2:

• First-line oral agent: Nifedipine 10 mg orally, repeat every 20 minutes to maximum 30 mg 2
• First-line IV agent: Labetalol 20 mg IV bolus, then 40 mg after 10 minutes if needed, followed by 80 mg every 10 minutes to maximum 220 mg 2
• Alternative IV agent: Hydralazine (though found inferior to other agents in some studies) 1

Non-Severe Hypertension (≥140/90 mmHg)

• Treat persistently elevated blood pressure ≥140/90 mmHg to reduce progression to severe hypertension and complications 1, 2
• Target diastolic BP of 85 mmHg and systolic BP 110-140 mmHg (at minimum keep systolic <160 mmHg) 1, 2
• Acceptable oral agents include methyldopa, labetalol, oxprenolol, or nifedipine as first-line; hydralazine and prazosin as second or third-line 1
• Reduce or discontinue antihypertensives if diastolic BP falls below 80 mmHg 1

Seizure Prophylaxis with Magnesium Sulfate

Administer magnesium sulfate for convulsion prophylaxis in women with preeclampsia who have severe hypertension, proteinuria with severe hypertension, or any severe clinical features 1, 2:

• Loading dose: 4-5 g IV over 3-4 minutes or infused in 250 mL fluid, with simultaneous IM doses of up to 10 g (5 g in each buttock) 3
• Maintenance: 4-5 g IM into alternate buttocks every 4 hours as needed, OR 1-2 g/hour by continuous IV infusion 3
• Continue for 24 hours postpartum 2, 3
• Monitor patellar reflexes and respiratory function before each dose; discontinue if reflexes absent or respirations <12/minute 3
• Therapeutic serum magnesium level is 4-7.5 mEq/L (optimal for seizure control is 6 mg/100 mL) 3
• Do not exceed 30-40 g total in 24 hours (20 g/48 hours in severe renal insufficiency) 3
• Calcium gluconate should be available as antidote for magnesium toxicity 3

Fluid Management

• Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema 2
• Aim for euvolemia; avoid excessive fluid restriction as this increases acute kidney injury risk 2
• Plasma volume expansion is not recommended routinely 1

Maternal Monitoring

• Blood pressure measurements every 4 hours (more frequently if severe features present) 2, 4
• Clinical assessment including evaluation for clonus, neurological symptoms (headache, visual changes), and right upper quadrant pain 1, 2
• Laboratory testing at least twice weekly: hemoglobin, platelet count, liver transaminases, creatinine, and uric acid 1, 2
• Repeat laboratory evaluation immediately if clinical status changes 1
• Do not attempt to classify as "mild" versus "severe" preeclampsia as all cases may rapidly become emergencies 1

Fetal Monitoring

• Initial assessment: fetal biometry, amniotic fluid volume, and umbilical artery Doppler ultrasound 1, 2
• If initial assessment normal: repeat ultrasound surveillance every 2 weeks 1, 2
• If fetal growth restriction present: more frequent amniotic fluid and Doppler assessments 1
• Non-stress testing and biophysical profile as clinically indicated 5

Timing and Indications for Delivery

Delivery at 37 Weeks or Beyond

Women with preeclampsia onset at ≥37 weeks' gestation should be delivered 1, 2, 5

Delivery Between 34-37 Weeks

• Manage expectantly with close monitoring unless severe features develop 1
• Consider delivery if maternal or fetal condition deteriorates 1

Delivery Before 34 Weeks

Manage conservatively at a center with Maternal-Fetal Medicine expertise unless immediate delivery indications emerge 1:

• Inability to control BP despite 3 classes of antihypertensives in appropriate doses 1, 2
• Progressive thrombocytopenia or progressively abnormal liver or renal function tests 1
• Pulmonary edema 1
• Severe intractable headache, repeated visual scotomata, or eclamptic seizures 1
• Non-reassuring fetal status 1
• Suspected placental abruption 5

Corticosteroids for Fetal Lung Maturity

Administer corticosteroids if gestational age <34 weeks and delivery anticipated within 7 days 1, 6

Important Caveats

• Neither serum uric acid level nor degree of proteinuria should be used as isolated indications for delivery 1
• For pregnancies at limits of viability (generally <24 weeks), counsel that termination may be required 1
• Expectant management before 24 weeks is associated with high maternal morbidity and limited perinatal benefit 5

Postpartum Management

• Continue close monitoring for at least 72 hours postpartum as eclampsia can still develop 2, 6
• Monitor blood pressure at least every 4 hours while awake 2
• Continue antihypertensive medications and taper slowly after days 3-6 postpartum 2
• Magnesium sulfate should continue for 24 hours after delivery if used for seizure prophylaxis 2, 3

Mode of Delivery

• Vaginal delivery is generally preferred unless obstetric indications for cesarean section exist 1
• Consider cesarean delivery for unripe cervix with full-blown HELLP syndrome 7
• Epidural anesthesia is favored but requires adequate platelet count 1

Prevention in High-Risk Women

Low-dose aspirin (75-162 mg/day) should be initiated before 16 weeks' gestation (definitely before 20 weeks) in women with strong clinical risk factors 2:

• History of preeclampsia, especially with adverse outcome
• Multifetal gestation
• Chronic hypertension
• Diabetes mellitus
• Renal disease
• Autoimmune disease

Supplemental calcium (1.2-2.5 g/day) if dietary intake likely <600 mg/day 2

Long-Term Counseling

Women with preeclampsia should be counseled about increased lifetime cardiovascular risk and need for long-term cardiovascular risk factor modification 2