What is the management and treatment for preeclampsia?

Management and Treatment of Preeclampsia

Immediate Hospitalization and Assessment

All women with preeclampsia require immediate hospitalization to confirm diagnosis, assess severity, and monitor disease progression. 1, 2

Initial assessment must include:

• Blood pressure monitoring every 4 hours (more frequently if severe hypertension present) 1, 2
• Clinical neurological examination including assessment for clonus and visual disturbances 1
• Laboratory testing at least twice weekly: complete blood count with platelets, liver enzymes (AST/ALT), renal function tests including creatinine and uric acid 1, 2
• Fetal well-being confirmation with ultrasound including biometry, amniotic fluid assessment, and umbilical artery Doppler 1, 2

Blood Pressure Management

Severe Hypertension (≥160/110 mmHg)

Severe hypertension requires urgent treatment in a monitored setting with first-line options: 1, 2

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

Critical caveat: Avoid sublingual nifedipine due to risk of precipitous blood pressure drops that can cause myocardial infarction or fetal distress. 1 Never combine calcium channel blockers with IV magnesium sulfate due to myocardial depression risk. 1

Non-Severe Hypertension (≥140/90 mmHg)

Target blood pressure: Diastolic 85 mmHg and systolic 110-140 mmHg using oral antihypertensives 1, 2

Absolutely contraindicated: ACE inhibitors during second and third trimesters due to fetal renal dysgenesis 1

Seizure Prevention with Magnesium Sulfate

Magnesium sulfate is mandatory for all women with preeclampsia and severe hypertension or neurological symptoms. 1, 2, 3

Dosing Protocol

Loading dose: 3

• 4-5 g IV in 250 mL of 5% dextrose or 0.9% saline infused over 3-4 minutes
• Simultaneously, 10 g IM (5 g in each buttock) may be given

Maintenance dose: 3

• 4-5 g IM into alternate buttocks every 4 hours, OR
• 1-2 g/hour by continuous IV infusion

Duration: Continue until delivery and for 24 hours postpartum 1, 3

Target therapeutic level: 6 mg/100 mL (2.5-7.5 mEq/L) 3

Critical monitoring: 3

• Check patellar reflexes before each dose (reflexes disappear at ~10 mEq/L)
• Monitor respiratory rate (respiratory paralysis may occur at 10 mEq/L)
• Maximum daily dose: 30-40 g in 24 hours
• In severe renal insufficiency: maximum 20 g/48 hours with frequent serum magnesium monitoring

Important warning: Continuous maternal administration beyond 5-7 days can cause fetal abnormalities. 3

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 1
• Diuretics are contraindicated as they further reduce plasma volume 1
• Plasma volume expansion is not recommended routinely 2

Timing of Delivery

Delivery is the only definitive treatment for preeclampsia. 2, 4

Delivery Timing Algorithm

At ≥37 weeks: Deliver all women with preeclampsia 1, 2

At 34-37 weeks: Deliver if severe preeclampsia or any severity criteria present 2

At 24-34 weeks: 1

• Administer corticosteroids for 48 hours to accelerate fetal lung maturation
• Consider expectant management only in highly selected cases without severe features
• Deliver if severe preeclampsia with deterioration

At <24 weeks: Discuss termination of pregnancy 5

Mandatory Immediate Delivery Indications (at any gestational age)

Deliver immediately if any of the following occur: 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 (persistent headache, visual disturbances)
• Placental abruption
• Non-reassuring fetal status

Postpartum Management

Close monitoring must continue for at least 3 days postpartum as eclampsia can still develop. 1, 2

• Monitor blood pressure every 4-6 hours while awake 1, 2
• Continue magnesium sulfate for 24 hours postpartum 1
• Continue antihypertensives and taper slowly after days 3-6 postpartum 1, 2

Long-term Follow-up

• Review within 1 week if still requiring antihypertensives at discharge 2
• Review at 3 months postpartum for all women with preeclampsia 2
• By 3 months, blood pressure, urinalysis, and laboratory tests should normalize; persistent abnormalities require further investigation 2
• Counsel about increased lifetime cardiovascular risk: Women with preeclampsia history have elevated risks of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease 1, 2, 4

Prevention for 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. 1, 2

Supplemental calcium (1.2-2.5 g/day) if dietary intake is likely low (<600 mg/day) 1, 2

Critical Pitfalls to Avoid

• Do not attempt to classify as "mild" versus "severe" preeclampsia clinically as all cases may become emergencies rapidly 2
• Neither serum uric acid nor level of proteinuria should be used as an indication for delivery 2
• Never use sublingual or rapid IV calcium channel blockers 1
• Never combine magnesium sulfate with calcium channel blockers 1
• Do not exceed maximum magnesium sulfate dosing limits 3
• Do not continue magnesium sulfate beyond 5-7 days due to fetal risks 3