What is the recommended management for a 26‑week pregnant woman with pre‑eclampsia with severe features?

Management of Preeclampsia with Severe Features at 26 Weeks Gestation

At 26 weeks gestation with preeclampsia with severe features, you should immediately stabilize the mother with IV magnesium sulfate for seizure prophylaxis and aggressive blood pressure control, then pursue conservative expectant management at a tertiary center with Maternal-Fetal Medicine expertise, delivering only when maternal or fetal deterioration occurs. 1, 2

Immediate Stabilization (First 30-60 Minutes)

Magnesium Sulfate Administration

• Administer magnesium sulfate immediately for seizure prophylaxis with a loading dose of 4-5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline), followed by maintenance infusion of 1-2 g/hour. 2, 3, 4
• Magnesium sulfate is superior to all other anticonvulsants (phenytoin, diazepam) for preventing eclamptic seizures and reducing maternal mortality. 3, 5
• Continue magnesium sulfate throughout the expectant management period and for 24 hours postpartum if delivery occurs. 2

Blood Pressure Control

• Initiate IV antihypertensive therapy immediately if BP ≥160/110 mmHg persists for more than 15 minutes. 1, 2
• First-line agent: IV labetalol starting with 20 mg IV bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes up to maximum cumulative dose of 220 mg. 1, 2
• Alternative agents include IV hydralazine (5-10 mg every 20 minutes) or oral immediate-release nifedipine. 1, 2
• Target blood pressure: systolic 110-140 mmHg and diastolic 85 mmHg (absolute minimum goal <160/105 mmHg). 1, 2
• Critical safety warning: Never combine magnesium sulfate with IV or sublingual nifedipine, as this causes severe myocardial depression and precipitous hypotension. 2, 3

Conservative Expectant Management Strategy

Rationale for Expectant Management at 26 Weeks

• Women with preeclampsia onset at <34 weeks' gestation should be managed with conservative expectant approach at a center with Maternal-Fetal Medicine expertise. 1
• At 26 weeks, the goal is to prolong pregnancy safely to improve neonatal outcomes, as delivery at this gestational age carries significant neonatal morbidity and mortality. 1, 6
• However, temporization beyond 72 hours is often not possible due to rapid maternal or fetal deterioration (occurs in approximately 90% of cases). 6

Maternal Monitoring Protocol

• Blood pressure monitoring: Continuous or at minimum every 4 hours while awake. 2, 7
• Clinical assessment twice daily: Check for clonus, severe headache, visual scotomata, epigastric or right upper quadrant pain. 1, 2
• Laboratory tests at least twice weekly (more frequently with clinical deterioration): complete blood count with platelets, liver transaminases (AST/ALT), serum creatinine, uric acid. 1, 2
• Magnesium sulfate monitoring: Hourly urine output via Foley catheter (target ≥100 mL/4 hours or >30 mL/hour), respiratory rate (hold if <12 breaths/minute), deep tendon reflexes before each dose, oxygen saturation >90%. 2, 3
• Fluid restriction: Limit total intake to 60-80 mL/hour to prevent pulmonary edema. 2

Fetal Monitoring Protocol

• Initial ultrasound assessment: Fetal biometry, amniotic fluid volume, umbilical artery Doppler velocimetry. 1, 2
• Repeat ultrasound every 2 weeks if initial assessment normal; more frequently if fetal growth restriction present. 1, 2
• Continuous fetal heart rate monitoring or at minimum daily non-stress tests. 2

Absolute Indications for Immediate Delivery (Any Gestational Age)

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

Maternal Indications

• Inability to control BP despite using ≥3 classes of antihypertensives in appropriate doses 1, 2
• Progressive thrombocytopenia (declining platelet counts on serial measurements) 1, 2
• Progressively abnormal liver function tests (worsening trends, not static elevations) 1, 2
• Progressive renal dysfunction (rising creatinine) 1, 2
• Pulmonary edema or maternal oxygen saturation <90% 1, 2
• Severe intractable headache, repeated visual scotomata, or eclamptic seizures 1, 2
• Placental abruption 1, 2
• HELLP syndrome with clinical deterioration 2, 7

Fetal Indications

• Non-reassuring fetal heart rate pattern 1, 2
• Reversed end-diastolic flow on umbilical artery Doppler 1
• Stillbirth 1

Critical Pitfalls to Avoid

• Do not attempt to classify as "mild versus severe" preeclampsia—all cases may become emergencies rapidly, often within hours. 1, 2
• Do not use serum uric acid level or degree of proteinuria as indications for delivery—these do not predict outcomes. 1, 2
• Do not use plasma volume expansion routinely—preeclamptic women already have contracted plasma volume. 1, 2
• Do not reduce antihypertensives if diastolic BP falls <80 mmHg—maintain therapy to prevent rebound hypertension. 1, 2
• Do not continue magnesium sulfate beyond 5-7 days as continuous maternal administration can cause fetal abnormalities. 4
• Blood pressure alone is not a reliable indicator of disease severity—serious organ dysfunction can develop at relatively mild BP levels. 1, 7

Special Considerations at 26 Weeks

• Antenatal corticosteroids should be administered to promote fetal lung maturity. 8
• Transfer to tertiary center with Level III/IV NICU capabilities should occur immediately if not already at such a facility. 2, 7
• Counsel the patient that at 26 weeks, neonatal outcomes are significantly compromised compared to term delivery, but expectant management may improve outcomes if maternal/fetal status remains stable. 1, 6
• Realistic expectations: The average interval from diagnosis to delivery in severe preeclampsia at <32 weeks is only 14 days, with many requiring delivery within 72 hours. 6
• Neonatal outcomes at 26 weeks with severe preeclampsia are worse than gestational age-matched controls due to preexisting fetal compromise, with higher rates of respiratory distress syndrome and perinatal death. 6

HELLP Syndrome Recognition

Watch specifically for: 2, 7

• Epigastric or right upper quadrant pain (hallmark symptom suggesting hepatic capsule distension)
• Hemolysis on peripheral smear
• Elevated liver enzymes (AST/ALT ≥2x upper limit of normal)
• Platelets <100,000/μL
• Severe hypoglycemia (monitor glucose intraoperatively if delivery occurs)
• Maternal mortality rate with HELLP syndrome is 3.4%