What is the management approach for a pregnant female with preeclampsia?

Management of Preeclampsia

All women with preeclampsia at ≥37 weeks' gestation should be delivered immediately after maternal stabilization, while those with severe features at any gestational age require urgent blood pressure control with IV labetalol or oral nifedipine, magnesium sulfate for seizure prophylaxis, and delivery planning based on specific maternal and fetal indications. 1

Initial Assessment and Risk Stratification

When preeclampsia is diagnosed (new-onset hypertension ≥140/90 mmHg after 20 weeks' gestation), immediately assess for severe features rather than treating all cases as mild. 1 Proteinuria is no longer mandatory for diagnosis, though when present it is confirmed by spot urine protein/creatinine ratio ≥30 mg/mmol, ≥300 mg/24 hours, or ≥1+ on dipstick. 2, 1

Critical pitfall: Do not underestimate disease severity based on blood pressure alone—serious organ dysfunction including HELLP syndrome can develop at relatively mild hypertension levels. 1 All preeclampsia can rapidly progress to life-threatening complications. 1

Severe Features Requiring Immediate Action

Identify any of the following severe features immediately: 1

• Severe hypertension: BP ≥160/110 mmHg on two occasions at least 15 minutes apart
• Thrombocytopenia: Platelets <100,000/μL
• Renal dysfunction: Creatinine >1.1 mg/dL or doubling of baseline
• Liver dysfunction: AST/ALT ≥2× upper limit of normal
• Pulmonary edema
• Neurological symptoms: Severe persistent headache, visual scotomata, or cortical blindness

Immediate Stabilization for Severe Hypertension

When BP ≥160/110 mmHg persists for >15 minutes, initiate urgent antihypertensive therapy immediately to prevent maternal cerebral hemorrhage. 1

First-Line Antihypertensive Options

• IV labetalol: 20 mg IV bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes (maximum cumulative dose 220 mg) 1
• Oral nifedipine 2, 1
• IV hydralazine: 5-10 mg IV every 20 minutes as needed 2, 1

Target blood pressure: Systolic 110-140 mmHg and diastolic 85 mmHg (or at minimum <160/105 mmHg). 2, 1 Do not reduce antihypertensives if diastolic BP falls <80 mmHg. 2

For non-severe hypertension (BP consistently ≥140/90 mmHg), acceptable oral agents include methyldopa, labetalol, oxprenolol, and nifedipine. 2 Second or third-line agents include hydralazine and prazosin. 2

Critical contraindications: Never use ACE inhibitors, ARBs, or direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis. 3 Avoid diuretics routinely as they further reduce plasma volume, which is already contracted in preeclampsia. 2, 3

Seizure Prophylaxis with Magnesium Sulfate

Administer magnesium sulfate immediately to all patients with: 2, 1

• Severe preeclampsia with any severe feature
• Proteinuria plus severe hypertension
• Any hypertension with neurological symptoms

Dosing: 1

• Loading dose: 4-5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline)
• Maintenance: 1-2 g/hour continuous IV infusion

Comprehensive Laboratory and Monitoring Protocol

Initial Laboratory Workup

Obtain the following tests at diagnosis: 1

• Complete blood count with focus on hemoglobin and platelet count
• Comprehensive metabolic panel: liver transaminases (AST/ALT), creatinine, uric acid
• Spot urine protein/creatinine ratio

Ongoing Maternal Monitoring

• Blood pressure: Monitor at least twice weekly or continuously if severe features present 2, 1
• Laboratory tests: Repeat at least twice weekly—hemoglobin, platelet count, liver enzymes, creatinine, and uric acid 2, 1
• Clinical assessment: Evaluate for clonus, deep tendon reflexes, symptoms of end-organ damage 2, 1

Important caveat: Do not use serum uric acid level or degree of proteinuria as indications for delivery—these are monitoring parameters only. 1, 3 However, uric acid correlates with disease severity and complications like hepatic dysfunction. 1

Fetal Surveillance

• Initial ultrasound: Confirm fetal well-being, assess biometry, amniotic fluid volume, and umbilical artery Doppler 2, 1
• Serial monitoring: In the presence of fetal growth restriction, perform scheduled ultrasound surveillance 2, 1
• Electronic fetal monitoring: Assess fetal heart rate and variability 1

Delivery Timing: Gestational Age-Based Algorithm

At ≥37 Weeks' Gestation

Deliver immediately after maternal stabilization regardless of severity or laboratory values. 2, 1 Do not delay delivery based on non-reactive NST—delivery is indicated regardless of fetal testing results. 1

At 34-37 Weeks' Gestation

• Without severe features: Expectant management with close monitoring is appropriate 1
• With severe features: Deliver after maternal stabilization 1

At <34 Weeks' Gestation

Expectant management may be considered in select cases without absolute indications for delivery, but this requires tertiary care facilities with maternal-fetal medicine specialists and NICU capabilities. 3

Absolute Indications for Immediate Delivery (Any Gestational Age)

Deliver immediately regardless of gestational age if any of the following develop: 2, 1

• Uncontrolled severe hypertension: Repeated episodes of BP ≥160/110 mmHg despite treatment with ≥3 classes of antihypertensives in appropriate doses
• Progressive thrombocytopenia: Declining platelet counts on serial measurements
• Progressively abnormal liver or renal function tests: Worsening trends, not static elevations
• Pulmonary edema
• Neurological complications: Severe intractable headache, repeated visual scotomata, or eclamptic seizures
• Placental abruption
• Non-reassuring fetal status on continuous monitoring
• Maternal oxygen saturation deterioration (<90%)

The distinction between "progressively abnormal" versus simply "elevated" laboratory values is crucial—static elevations warrant close monitoring, while worsening trends mandate delivery. 1

HELLP Syndrome: Special Considerations

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is part of the preeclampsia spectrum with a maternal mortality rate of 3.4%. 1 Key management points:

• Hallmark symptom: Epigastric or right upper quadrant pain 1
• Intraoperative monitoring: Monitor glucose closely as severe hypoglycemia can occur 1
• Management approach: Treat as severe preeclampsia with all features sought and addressed 1

Management of Pulmonary Edema

If pulmonary edema develops: 1

• Drug of choice: IV nitroglycerin (glycerol trinitrate) starting at 5 mcg/min, gradually increased every 3-5 minutes to maximum 100 mcg/min
• Avoid: Plasma volume expansion is NOT recommended routinely 2, 1

Postpartum Management

Preeclampsia can worsen or initially present after delivery. 4

• Monitoring: Check BP and clinical condition at least every 4 hours while awake 1
• Continue antihypertensives: Maintain medications administered antenatally 1
• Analgesia: Avoid NSAIDs for postpartum pain unless other analgesics are ineffective, especially if renal disease or placental abruption are present 1
• Duration: Monitor as inpatient or closely at home for 72 hours postpartum 4

Follow-Up and Long-Term Considerations

• 3-month postpartum review: Ensure BP, urinalysis, and laboratory abnormalities have normalized; initiate appropriate referral if proteinuria or hypertension persists 1
• Long-term cardiovascular risk: Women with preeclampsia have significant cardiovascular risks requiring annual medical review lifelong 1

Setting of Care

Women with preeclampsia should be assessed in hospital when first diagnosed. 2 Thereafter, some with stable disease may be managed as outpatients once stability is established and they can reliably report problems and monitor their BP. 2 However, any severe features mandate inpatient management in facilities with appropriate obstetrical care, maternal intensive care capabilities, and NICU for premature infants. 3