Management of Preeclampsia

Deliver all women with preeclampsia at ≥37 weeks' gestation immediately after maternal stabilization, regardless of disease severity or laboratory values. 1, 2

Initial Assessment and Diagnosis

Confirm the diagnosis by documenting blood pressure ≥140/90 mmHg on repeat measurements after 20 weeks' gestation. 1 Proteinuria is no longer mandatory for diagnosis, but when present is confirmed by spot urine protein/creatinine ratio ≥30 mg/mmol (or 0.3 mg/mg), ≥300 mg/24 hours, or ≥1+ on dipstick. 3, 1

All preeclampsia should be treated as potentially severe because rapid progression to life-threatening complications can occur even with initially mild presentations. 1 Blood pressure level alone is not a reliable indicator of disease severity—serious organ dysfunction can develop at relatively mild blood pressure elevations. 1, 4

Severity Assessment: Identify Severe Features Immediately

Severe features requiring urgent intervention include:

Severe hypertension: BP ≥160/110 mmHg on two occasions at least 15 minutes apart 1
Thrombocytopenia: Platelets <100,000/μL 1
Renal dysfunction: Creatinine >1.1 mg/dL or doubling of baseline 1
Elevated liver enzymes: AST/ALT ≥2× upper limit of normal 1
Pulmonary edema 1
Neurological symptoms: Severe persistent headache, visual disturbances (scotomata, cortical blindness), or epigastric/right upper quadrant pain 1

Immediate Stabilization for Severe Hypertension

Initiate urgent antihypertensive therapy within 15 minutes when BP ≥160/110 mmHg persists to prevent maternal cerebral hemorrhage. 1, 4

First-Line IV 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
IV hydralazine: 5-10 mg IV every 20 minutes as needed 1
Oral nifedipine is also acceptable as first-line 4, 2

Target blood pressure: Systolic 110-140 mmHg and diastolic 85 mmHg (or at minimum <160/105 mmHg). 3, 1, 2

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

Acceptable oral agents include methyldopa, labetalol, oxprenolol, and nifedipine, with second or third-line agents including hydralazine and prazosin. 1

Critical contraindications: Avoid ACE inhibitors, ARBs, and direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis. 4 Do not use diuretics routinely—they further reduce plasma volume which is already contracted in preeclampsia and can worsen uteroplacental perfusion. 3, 4

Seizure Prophylaxis with Magnesium Sulfate

Administer magnesium sulfate immediately to all patients with severe preeclampsia, proteinuria plus severe hypertension (≥160/110 mmHg), or any hypertension with neurological symptoms. 1, 5

Dosing Protocol:

Loading dose: 4-5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline) 1, 5
Maintenance: 1-2 g/hour continuous IV infusion 1, 5
Alternative regimen: 4-5 g (8-10 mL of 50% solution) IM into alternate buttocks every 4 hours as needed, depending on presence of patellar reflex and adequate respiratory function 5

Therapeutic serum magnesium level: 2.5-7.5 mEq/L (optimal for seizure control is 6 mg/100 mL). 5 Monitor deep tendon reflexes—they disappear as plasma level approaches 10 mEq/L, at which point respiratory paralysis may occur. 5

Maximum dosing: Total daily (24-hour) dose should not exceed 30-40 g. 5 In severe renal insufficiency, maximum dosage is 20 g/48 hours with frequent serum magnesium monitoring. 5 Do not use magnesium sulfate continuously beyond 5-7 days as it can cause fetal abnormalities. 5

Comprehensive Laboratory and Fetal Assessment

Initial Laboratory Workup:

Complete blood count with focus on hemoglobin and platelet count 1, 2
Comprehensive metabolic panel: liver transaminases (AST/ALT), creatinine, uric acid 1, 2
Spot urine protein/creatinine ratio 1

Repeat laboratory tests at least twice weekly (hemoglobin, platelets, liver enzymes, creatinine, uric acid) or more frequently if clinical deterioration occurs. 3, 1

Fetal Surveillance:

Serial ultrasound assessments for fetal biometry, amniotic fluid volume, and umbilical artery Doppler to monitor for intrauterine growth restriction 1, 4
Electronic fetal heart rate monitoring to assess fetal well-being 4, 2
Biophysical profile including fetal breathing movements, body movements, and tone 2

Delivery Timing: Gestational Age-Based Algorithm

≥37 Weeks' Gestation:

Deliver immediately after maternal stabilization regardless of severity, laboratory values, or fetal testing results. 3, 1, 2 Do not delay delivery based solely on non-reactive NST—at 37 weeks with preeclampsia, delivery is indicated regardless of fetal testing. 2

34-37 Weeks' Gestation:

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

<34 Weeks' Gestation:

Expectant management is possible in a select group with severe preeclampsia between 24-32 weeks in a suitable hospital setting, which may improve neonatal outcomes by allowing 7-10 days of prolongation. 6 However, at <24 weeks, expectant treatment is associated with high maternal morbidity with limited perinatal benefit. 6

Absolute Indications for Immediate Delivery (Any Gestational Age)

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

Inability to control BP despite ≥3 classes of antihypertensives in appropriate doses 1
Repeated episodes of severe hypertension despite treatment 1, 4
Progressive thrombocytopenia (declining platelet counts on serial measurements) 1
Progressively abnormal liver or renal function tests (worsening trends, not static elevations) 1
Pulmonary edema 1, 4
Severe intractable headache, repeated visual scotomata, or eclamptic seizures 1, 4
Placental abruption 1
Non-reassuring fetal status on continuous monitoring 1, 4, 2
Maternal oxygen saturation deterioration (<90%) 1

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. 1 Maternal mortality rate is 3.4% in HELLP syndrome. 1

Hallmark symptom: Epigastric or right upper quadrant pain. 1

Critical management point: Monitor glucose intraoperatively as severe hypoglycemia can occur in HELLP syndrome. 1

Fluid Management

Maintain fluid balance at 60-80 mL/hour to avoid risks of pulmonary edema. 3 There is no rationale to "run dry" a preeclamptic woman as she is already at risk of acute kidney injury. 3

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

Postpartum Management

Monitor BP at least 4-6 hourly during the day for at least 3 days postpartum 3, 1
Continue antihypertensives administered antenatally and taper slowly only after days 3-6 postpartum unless BP becomes low (<110/70 mmHg) or the woman becomes symptomatic 3, 1
Repeat hemoglobin, platelets, creatinine, liver transaminases the day after delivery and then every other day until stable if any were abnormal before delivery 3
Avoid NSAIDs in women with preeclampsia if possible, especially in the setting of acute kidney injury, renal disease, or placental abruption—use alternative pain relief 3, 1
Preeclampsia may develop de novo intra- or early postpartum; such cases should be managed as above with careful assessment for retained products 3
Monitor general well-being and neurological status as eclampsia may occur postpartum 3

Follow-Up

Short-Term (Within 3 Months):

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

Long-Term (Lifelong):

Women with preeclampsia have significant long-term cardiovascular risks requiring annual medical review lifelong. 1 Counsel patients about:

Increased risks of cardiovascular disease, death, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease compared with women who had normotensive pregnancies 3
Approximately 15% risk for developing preeclampsia again and further 15% risk for gestational hypertension in future pregnancy 3
Should receive low-dose aspirin in another pregnancy 3
Increased risks of small for gestational age babies in another pregnancy even if preeclampsia does not recur 3
Regular follow-up with general practitioner to monitor BP and periodic measurement of fasting lipids and blood sugar 3
Adopt healthy lifestyle with maintenance of ideal weight and regular aerobic exercise 3

Setting of Care Requirements

Management must occur in a hospital with:

Appropriate obstetrical care facilities 1, 4
Maternal intensive care capabilities 1, 4
Neonatal intensive care unit for premature infants 1, 4
Coordination with maternal-fetal medicine specialists, neonatology, and anesthesiology teams 4

Critical Pitfalls to Avoid

Do not underestimate disease severity based on "mild" classification—all preeclampsia can rapidly progress to emergencies 1, 2
Do not use serum uric acid level or degree of proteinuria as indications for delivery 1, 4
Do not delay delivery at ≥37 weeks based on non-reactive NST—delivery is indicated regardless of fetal testing results 1, 2
Do not reduce antihypertensives if diastolic BP falls <80 mmHg 1
Before 20 weeks' gestation, consider alternative diagnoses such as trophoblast diseases (hydatidiform mole), as preeclampsia rarely occurs this early 4

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