What is the management approach for preeclampsia and eclampsia?

Management of Preeclampsia and Eclampsia

Delivery is the only definitive treatment for preeclampsia, but immediate management focuses on preventing maternal seizures with magnesium sulfate, urgently controlling severe hypertension to prevent stroke, and carefully timing delivery based on gestational age and disease severity. 1, 2, 3

Initial Assessment and Hospitalization

All women with newly diagnosed preeclampsia require immediate hospitalization to confirm diagnosis, assess severity, and establish baseline maternal and fetal status. 1, 2

Maternal monitoring includes:

• Blood pressure measurements every 4 hours (more frequently if severe features present) 1, 2
• Baseline laboratory tests: complete blood count with platelets, liver transaminases (AST/ALT), serum creatinine, and uric acid 1, 2, 3
• Clinical neurological assessment including evaluation for clonus, visual disturbances, and severe headache 2, 3
• Repeat laboratory testing at least twice weekly to detect progression 2

Fetal assessment includes:

• Ultrasound evaluation of fetal biometry, amniotic fluid volume, and umbilical artery Doppler 1, 3
• Electronic fetal heart rate monitoring 3

Blood Pressure Management

Severe Hypertension (≥160/110 mmHg)

Severe hypertension requires urgent treatment in a monitored setting to prevent maternal stroke. 2, 3

First-line options:

• Oral nifedipine 10 mg, repeat every 20 minutes to maximum 30 mg 1, 2
• IV labetalol 20 mg bolus, then 40 mg after 10 minutes if needed, followed by 80 mg every 10 minutes to maximum total dose of 220 mg 2
• IV hydralazine (alternative option) 3

Critical caveat: Sublingual or rapid IV administration of calcium channel blockers can cause excessive blood pressure reduction leading to myocardial infarction or fetal distress. 4 Avoid combining calcium blockers with IV magnesium due to risk of myocardial depression. 4

Non-Severe Hypertension (140-159/90-109 mmHg)

Initiate oral antihypertensive therapy targeting diastolic BP of 85 mmHg and systolic BP between 110-140 mmHg. 1, 2, 3

Magnesium Sulfate for Seizure Prophylaxis

Administer magnesium sulfate to all women with severe hypertension (≥160/110 mmHg) or any neurological signs/symptoms to prevent eclamptic seizures. 1, 2, 5

Dosing regimen:

• Loading dose: 4-5 g IV over 20 minutes OR 10 g IM (5 g in each buttock) 5
• Maintenance: 4-5 g IM into alternate buttocks every 4 hours OR 1-2 g/hour continuous IV infusion 5
• Continue for 24 hours postpartum 2, 5
• Monitor patellar reflexes and respiratory function before each dose 5

Therapeutic serum level: 2.5-7.5 mEq/L (optimal for seizure control is 6 mg/100 mL) 5

Important safety considerations:

• Deep tendon reflexes disappear at plasma levels approaching 10 mEq/L 5
• Respiratory paralysis may occur at 10 mEq/L 5
• Maximum total daily dose should not exceed 30-40 g 5
• In severe renal insufficiency, maximum dose is 20 g/48 hours with frequent serum level monitoring 5
• Do not use continuously beyond 5-7 days as this can cause fetal abnormalities 5

Magnesium sulfate is more effective than diazepam or phenytoin for eclampsia treatment and prevention. 6

Fluid Management

Strictly limit total fluid intake to 60-80 mL/hour to prevent pulmonary edema. 1, 2

Aim for euvolemia; avoid "running dry" as this increases acute kidney injury risk, but remember that uteroplacental perfusion is already reduced in preeclampsia. 4, 2 Diuretics are contraindicated in preeclampsia as they further reduce plasma volume. 4

Timing of Delivery by Gestational Age

≥37 Weeks

Deliver immediately regardless of severity. 2, 3

34-37 Weeks

• Deliver at 37 weeks for preeclampsia without severe features 2
• Deliver after 34 weeks for severe preeclampsia 1
• Expectant management with close monitoring is appropriate between 34-37 weeks in absence of severe features 3

24-34 Weeks

• Expectant management with aggressive monitoring at a perinatal center is recommended for women ≥24 weeks 1
• Administer corticosteroids for 48 hours to accelerate fetal lung maturation if gestation <34 weeks 4, 1
• Transfer to tertiary perinatal center with maternal-fetal medicine expertise is mandatory if <24 weeks and expectant management is attempted 1

<24 Weeks

Termination of pregnancy should be discussed given extremely poor prognosis. 1

Mandatory Immediate Delivery Indications (Regardless of Gestational Age)

Deliver immediately if any of the following develop: 1, 2, 3

• Repeated episodes of severe hypertension despite treatment with 3 classes of antihypertensives
• Progressive thrombocytopenia (especially <100,000/μL)
• Progressively abnormal liver function tests (transaminases >2x normal) or renal function
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
• Pulmonary edema or oxygen saturation <90%
• Eclamptic seizures
• Severe intractable headache or repeated visual scotomata
• Persistent epigastric or right upper quadrant pain
• Placental abruption
• Non-reassuring fetal status

Critical principle: All cases of preeclampsia should be considered potentially severe as they can rapidly progress to emergencies. Blood pressure alone is not a reliable indicator of disease severity. 3

Postpartum Management

Continue close monitoring for at least 3 days postpartum as eclampsia can still develop after delivery. 1, 2

• Monitor blood pressure at least every 4 hours while awake 2
• Continue antihypertensive medications and taper slowly only after days 3-6 postpartum unless BP falls below 110/70 mmHg 1, 2
• Maintain magnesium sulfate for 24 hours postpartum 2, 5

Anesthetic Considerations

Neuraxial analgesia and anesthesia are strongly preferred as first-line techniques in the absence of thrombocytopenia. 7 General anesthesia carries significant risks including airway edema and dangerous blood pressure elevation during intubation. 7

Long-Term Counseling and Prevention

Counsel all women about significantly increased lifetime cardiovascular risk, including stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease. 1, 2

For future pregnancies:

• Low-dose aspirin 75-162 mg daily started before 16 weeks gestation (definitely before 20 weeks) for women with history of preeclampsia 1, 2
• Supplemental calcium 1.2-2.5 g/day if dietary intake is low (<600 mg/day) 2

Key Clinical Pitfalls to Avoid

• Never use serum uric acid or level of proteinuria as indications for delivery 3
• Plasma volume expansion is not recommended routinely 3
• ACE inhibitors are absolutely contraindicated during second and third trimesters due to renal dysgenesis 4
• Avoid sublingual nifedipine due to risk of precipitous blood pressure drops 4
• Do not combine IV magnesium with calcium channel blockers due to myocardial depression risk 4