What are the management criteria for preeclampsia (high blood pressure during pregnancy) at 22 weeks gestation?

Management of Preeclampsia at 22 Weeks Gestation

At 22 weeks gestation with preeclampsia, immediate hospitalization at a tertiary care center with maternal-fetal medicine, neonatology, and intensive care capabilities is mandatory, with expectant management possible only in carefully selected cases without severe features, while severe preeclampsia requires urgent blood pressure control, magnesium sulfate for seizure prophylaxis, and preparation for delivery if maternal or fetal deterioration occurs. 1, 2

Diagnostic Confirmation and Severity Assessment

Confirm the diagnosis by documenting blood pressure ≥140/90 mmHg on repeat measurements and assess for proteinuria using urine protein/creatinine ratio (≥30 mg/mmol is abnormal). 1

Immediately evaluate for severe features, which include:

• Severe hypertension (≥160/110 mmHg) 1
• Pulmonary edema 1
• Severe persistent headache or visual disturbances 1
• Epigastric or right upper quadrant pain 1
• Thrombocytopenia, elevated liver enzymes, or renal dysfunction on laboratory testing 1

Obtain baseline laboratory tests including complete blood count with hemoglobin and platelets, liver enzymes, creatinine, and uric acid. 1 These tests must be repeated at least twice weekly or more frequently if clinical deterioration occurs. 1

Blood Pressure Management

For severe hypertension (≥160/110 mmHg), initiate urgent antihypertensive therapy within 15 minutes to prevent maternal stroke. 1 The target is systolic BP 110-140 mmHg and diastolic BP 85 mmHg. 1

First-line medication is oral nifedipine. 1 Alternative options include intravenous labetalol or methyldopa. 3

Critical contraindications:

• Never use ACE inhibitors, ARBs, or direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis. 1
• Avoid diuretics as they further reduce plasma volume, which is already compromised in preeclampsia and worsens uteroplacental perfusion. 1
• Do not use intravenous hydralazine as it is associated with more perinatal adverse effects than other drugs. 3

Magnesium Sulfate for Seizure Prophylaxis

Administer magnesium sulfate if severe features are present to prevent eclamptic seizures. 1 This intervention more than halves the risk of eclampsia and probably reduces maternal death. 4

Maternal Monitoring Protocol

Monitor blood pressure continuously or every 4 hours while awake. 1

Perform clinical assessments including:

• Deep tendon reflexes and clonus evaluation 1
• Assessment for symptoms of cerebral involvement (headache, visual changes) 1
• Evaluation for signs of end-organ damage 1

Repeat laboratory tests at least twice weekly or more frequently if clinical deterioration occurs. 1

Fetal Surveillance

Initiate serial ultrasound assessments for fetal biometry, amniotic fluid volume, and umbilical artery Doppler to monitor for intrauterine growth restriction. 1

Perform electronic fetal heart rate monitoring to assess fetal well-being. 1

Expectant Management Considerations at 22 Weeks

At 22 weeks gestation, expectant management may be considered in the absence of severe features, though this represents periviable gestation with significant challenges. 5

Recent data shows that expectant management of preeclampsia with severe features at <24 weeks can achieve 30% perinatal survival with acceptable maternal morbidity (7% acute kidney injury, 7% pericardial/pleural effusions). 5 The median latency period at 22 weeks is 7 days. 5

However, preeclampsia rarely occurs before 20 weeks except in the presence of trophoblast diseases such as hydatidiform mole, so alternative diagnoses must be considered. 3

Absolute Indications for Immediate Delivery

Deliver immediately if any of the following develop:

• Repeated episodes of severe hypertension despite treatment 1
• Progressive thrombocytopenia 1
• Progressively abnormal liver or renal function tests 1
• Pulmonary edema 1
• Severe intractable headache 1
• Repeated visual scotomata 1
• Eclamptic seizures 1
• Non-reassuring fetal status 1

Critical Management Pitfalls to Avoid

Do not use blood pressure level alone to determine disease severity, as serious organ dysfunction can develop at relatively mild blood pressure elevations. 1, 6

Do not use serum uric acid level or degree of proteinuria as indications for delivery. 1, 6 Changes in proteinuria are not predictive of disease severity or maternal or fetal complications. 6

Do not administer NSAIDs for analgesia if delivery occurs, as they can worsen renal function in preeclampsia. 1

Do not use low molecular weight heparin for prevention, as it is not indicated even with prior early-onset preeclampsia. 1

Do not perform plasma volume expansion routinely. 4

Hospital Setting Requirements

Management must occur in a hospital with appropriate obstetrical care facilities, maternal intensive care capabilities, and neonatal intensive care unit for extremely premature infants. 1, 2 Coordination of care with maternal-fetal medicine specialists, neonatology, and anesthesiology teams is essential. 1

Preeclampsia with severe features at <24 weeks should be managed only at tertiary care centers. 2