What is the management plan for a pregnant woman with pre-eclampsia?

Management of Preeclampsia

All women with preeclampsia at ≥37 weeks' gestation should be delivered immediately after maternal stabilization, and severe hypertension (≥160/110 mmHg) requires urgent antihypertensive treatment within 15 minutes plus magnesium sulfate for seizure prophylaxis. 1, 2

Initial Assessment and Hospital Admission

• All women with newly diagnosed preeclampsia must be hospitalized initially to confirm diagnosis, assess severity, and establish monitoring protocols 1, 3
• Preeclampsia is diagnosed by new-onset hypertension (≥140/90 mmHg) after 20 weeks' gestation; proteinuria is no longer mandatory for diagnosis but when present is confirmed by spot urine protein/creatinine ratio ≥30 mg/mmol (0.3 mg/mg), ≥300 mg/24 hours, or ≥1+ on dipstick 1, 2
• After initial stabilization, selected women with non-severe preeclampsia may be managed as outpatients if their condition is stable and they can reliably report symptoms and monitor blood pressure 1

Immediate Severity Assessment: Identify Severe Features

Critical pitfall: Blood pressure level alone does not determine disease severity—serious organ dysfunction can develop at relatively mild blood pressure elevations. 2

Severe features requiring urgent intervention include:

• Severe hypertension: BP ≥160/110 mmHg on two occasions at least 15 minutes apart 2
• Thrombocytopenia: platelets <100,000/μL 2
• Renal dysfunction: creatinine >1.1 mg/dL or doubling of baseline 2
• Liver involvement: transaminases ≥2× upper limit of normal 2, 4
• Pulmonary edema 2
• Neurological symptoms: severe persistent headache, visual disturbances (scotomata, cortical blindness), or altered mental status 1, 2
• Persistent epigastric or right upper quadrant pain (hallmark of HELLP syndrome) 2

Urgent Management of Severe Hypertension

When BP ≥160/110 mmHg persists for >15 minutes, initiate urgent antihypertensive therapy immediately in a monitored setting to prevent maternal cerebral hemorrhage. 1, 2

First-Line Antihypertensive Options:

• Oral nifedipine: 10 mg, repeat every 20 minutes to maximum 30 mg 3
• IV labetalol: 20 mg bolus, then 40 mg after 10 minutes if needed, followed by 80 mg every 10 minutes (maximum cumulative dose 220 mg) 1, 2
• IV hydralazine: 5-10 mg every 20 minutes as needed 1, 2
• Oral labetalol may be used if the above are unavailable 1

Target blood pressure: Systolic 110-140 mmHg and diastolic 85 mmHg (or at minimum <160/105 mmHg). 1, 2

Critical contraindications: Never use ACE inhibitors, ARBs, or direct renin inhibitors—these cause severe fetotoxicity and renal dysgenesis 3, 5. Avoid sublingual nifedipine due to risk of precipitous blood pressure drops 3. Do not combine IV magnesium with calcium channel blockers due to myocardial depression risk 3.

Management of Non-Severe Hypertension

For BP consistently ≥140/90 mmHg in clinic (or ≥135/85 mmHg at home):

• Initiate oral antihypertensives targeting diastolic BP of 85 mmHg and systolic BP 110-140 mmHg 1
• First-line agents: methyldopa, labetalol, oxprenolol, or nifedipine 1, 3
• Second/third-line agents: hydralazine or prazosin 1, 3
• Reduce or cease antihypertensives if diastolic BP falls <80 mmHg 1

Magnesium Sulfate for Seizure Prophylaxis

Administer magnesium sulfate immediately to all patients with:

• Severe preeclampsia (any severe feature present) 1, 2
• Proteinuria plus severe hypertension 1, 2
• Any hypertension with neurological symptoms 1, 2

Dosing Protocol (FDA-approved): 6

• Loading dose: 4-5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline) 2, 6
• Maintenance: 1-2 g/hour continuous IV infusion 2, 6
• Alternative regimen: 4 g IV loading dose, then 4-5 g IM into alternate buttocks every 4 hours as needed 6
• Continue for 24 hours postpartum 3, 6
• Therapeutic serum magnesium level: 2.5-7.5 mEq/L (optimal for seizure control is 6 mg/100 mL) 6

Monitoring during magnesium therapy:

• Deep tendon reflexes disappear at plasma levels approaching 10 mEq/L 6
• Respiratory paralysis may occur at 10 mEq/L 6
• Heart block may occur at this or lower levels 6
• Serum magnesium >12 mEq/L may be fatal 6
• Discontinue if patellar reflex absent or respiratory depression occurs 6

Critical warning: Do not administer magnesium sulfate continuously beyond 5-7 days in pregnancy as it can cause fetal abnormalities 6. In severe renal insufficiency, maximum dose is 20 grams/48 hours with frequent serum level monitoring 6.

Comprehensive Maternal Monitoring Protocol

Blood Pressure and Clinical Assessment:

• Monitor BP at least every 4 hours while awake (more frequently if severe features present) 1, 3
• Perform clinical assessment including evaluation for clonus and neurological symptoms 1, 3
• Assess for new-onset symptoms: headache, visual changes, epigastric/RUQ pain 1, 2

Laboratory Monitoring:

• At least twice weekly: complete blood count (hemoglobin, platelets), liver enzymes (AST/ALT), creatinine, uric acid 1, 2, 3
• More frequent testing if clinical deterioration or abnormal values 2
• Reassess for proteinuria if not already present 1

Important note: Uric acid levels correlate with disease severity and worse maternal/fetal outcomes but should NOT be used as an indication for delivery 1, 2. Similarly, degree of proteinuria should not determine delivery timing 2.

Fetal Surveillance

• Initial assessment: Confirm fetal well-being immediately upon diagnosis 1, 2
• Serial ultrasound surveillance: Fetal biometry, amniotic fluid volume, and umbilical artery Doppler to monitor for intrauterine growth restriction 1, 2, 3
• Electronic fetal heart rate monitoring to assess fetal status 5

Fluid Management

Strictly limit total fluid intake to 60-80 mL/hour to prevent pulmonary edema. 1, 3

• Aim for euvolemia; avoid "running dry" as preeclamptic women are already at risk for acute kidney injury 1, 3
• Replace anticipated urinary losses at 0.5-1 mL/kg per hour 1
• Diuretics are contraindicated—they further reduce plasma volume which is already contracted in preeclampsia and worsen uteroplacental perfusion 2, 3
• For pulmonary edema, use IV nitroglycerin starting at 5 mcg/min, gradually increased every 3-5 minutes to maximum 100 mcg/min 2
• Plasma volume expansion is NOT recommended routinely 2

Delivery Timing: Gestational Age-Based Algorithm

Delivery is the definitive treatment for preeclampsia. 3, 4

At ≥37 Weeks' Gestation:

• Deliver all women with preeclampsia immediately after maternal stabilization, regardless of severity or laboratory values 1, 2, 3

At 34-37 Weeks' Gestation:

• Without severe features: Expectant management with close monitoring is appropriate 2
• With severe features: Deliver after maternal stabilization 2, 3

At <34 Weeks' Gestation:

• Administer corticosteroids for 48 hours to accelerate fetal lung maturation 3, 7
• Expectant management may be considered in highly selected patients with severe preeclampsia between 24-34 weeks in facilities with appropriate maternal intensive care and NICU capabilities 7
• Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks' gestation 4

Absolute Indications for Immediate Delivery (Any Gestational Age)

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

• Repeated episodes of severe hypertension despite maintenance treatment with 3 classes of antihypertensive agents 1, 2, 3
• Progressive thrombocytopenia (declining platelet counts on serial measurements) 1, 2
• Progressively abnormal renal or liver function tests (worsening trends, not static elevations) 1, 2
• Pulmonary edema 1, 2, 3
• Abnormal neurological features: severe intractable headache, repeated visual scotomata, or eclamptic seizures 1, 2
• Placental abruption 3
• Non-reassuring fetal status on continuous monitoring 1, 2, 3
• Maternal oxygen saturation deterioration (<90%) 2

HELLP Syndrome: Special Considerations

• HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is part of the preeclampsia spectrum and should be managed as severe preeclampsia 2, 4
• Maternal mortality rate is 3.4% in HELLP syndrome 2
• Epigastric or right upper quadrant pain is a hallmark symptom 2
• Monitor glucose intraoperatively as severe hypoglycemia can occur 2
• Delivery is indicated when HELLP syndrome is diagnosed 4

Postpartum Management

Preeclampsia may develop de novo intra- or early postpartum; eclampsia can occur postpartum. 1, 3

• Monitor BP at least every 4 hours while awake for at least 3 days postpartum 1, 3
• Continue monitoring general well-being and neurological status 1
• Repeat hemoglobin, platelets, creatinine, liver transaminases the day after delivery and then every other day until stable if any were abnormal before delivery 1
• Continue antihypertensives administered antenatally and taper slowly only after days 3-6 postpartum unless BP becomes low (<110/70 mmHg) or woman becomes symptomatic 1, 3
• Avoid NSAIDs for postpartum analgesia in women with preeclampsia, especially in the setting of acute kidney injury or placental abruption; use alternative pain relief 1, 3
• Most women can be discharged by day 5 postpartum, especially when able to monitor BP at home 1

Short-Term Follow-Up

• Review within 1 week if still requiring antihypertensives at hospital discharge 1
• All women should be reviewed 3 months postpartum by which time BP, urinalysis, and all laboratory tests should have normalized 1, 3
• Further investigation required for persistent abnormalities, including work-up for secondary causes of persistent severe hypertension or underlying renal disease with persistent proteinuria 1
• Assessment should include clinical check for depression, anxiety, or posttraumatic stress disorder symptoms 1

Long-Term Follow-Up and Cardiovascular Risk Counseling

Women with preeclampsia have significantly increased lifetime cardiovascular risk requiring lifelong follow-up. 1, 3, 4

• Advise women they have increased risks of cardiovascular disease, death, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease compared with women who had normotensive pregnancies 1
• Approximately 15% risk for developing preeclampsia again and further 15% risk for gestational hypertension in future pregnancy 1
• Low-dose aspirin (75-162 mg/day) should be given in another pregnancy, started before 16 weeks' gestation (definitely before 20 weeks) 1, 3
• Regular follow-up with general practitioner to monitor BP and periodic measurement of fasting lipids and blood sugar 1
• Adopt healthy lifestyle with maintenance of ideal weight and regular aerobic exercise 1, 3

Critical Pitfalls to Avoid

• Do not underestimate disease severity based on "mild" classification—all preeclampsia can rapidly progress to life-threatening complications 2, 4
• Do not use serum uric acid level or degree of proteinuria as indications for delivery 1, 2
• Do not delay delivery at ≥37 weeks based on non-reactive NST—delivery is indicated regardless of fetal testing results 2
• Do not reduce antihypertensives if diastolic BP falls <80 mmHg—this is the target threshold 1
• Do not use diuretics routinely—they further reduce plasma volume which is already contracted in preeclampsia 2, 3
• Recognize that preeclampsia rarely occurs before 20 weeks except with trophoblastic disease (hydatidiform mole); consider alternative diagnoses 5

Setting of Care Requirements

• Management must occur in hospital with appropriate obstetrical care facilities, maternal intensive care capabilities, and NICU for premature infants 3, 5
• Coordinate care with maternal-fetal medicine specialists, neonatology, and anesthesiology teams 5
• All units managing hypertensive pregnant women should maintain uniform departmental management protocols and conduct regular audits of maternal and fetal outcomes 1