What is the recommended management for a pregnant woman with a prior history of pre‑eclampsia?

Management of Pregnant Women with Prior History of Preeclampsia

Women with a history of preeclampsia should receive low-dose aspirin (75-162 mg daily) starting before 16 weeks' gestation, combined with calcium supplementation if dietary intake is low, along with enhanced antenatal surveillance including more frequent prenatal visits and serial fetal monitoring. 1, 2, 3

Preconception and Early Pregnancy Counseling

Risk stratification is essential at the first prenatal visit. Women with prior preeclampsia face approximately 15% risk of recurrent preeclampsia and an additional 15% risk of gestational hypertension in subsequent pregnancies. 1 The magnitude of recurrence risk depends critically on:

• Gestational age at onset of prior preeclampsia (earlier onset = higher recurrence risk) 3
• Severity of prior disease (severe features increase recurrence) 3
• Presence of underlying medical conditions (chronic hypertension, diabetes, renal disease, autoimmune disorders) 1, 3

Counsel patients that they also face increased lifetime cardiovascular risks, including stroke, cardiovascular disease, diabetes mellitus, venous thromboembolism, and chronic kidney disease compared to women with normotensive pregnancies. 1, 2, 4

Prevention Strategies

Low-Dose Aspirin (Primary Prevention)

Initiate aspirin 75-162 mg daily before 16 weeks' gestation (ideally by 12 weeks) in all women with prior preeclampsia. 1, 2 This intervention has the strongest evidence base for preventing recurrent preterm preeclampsia. 4

Calcium Supplementation

Prescribe 1.2-2.5 g elemental calcium daily if dietary calcium intake is likely <600-800 mg/day. 1, 2 This is particularly important in populations with low baseline calcium intake.

Ineffective Interventions to Avoid

Do not recommend fish oil, vitamin C and E supplementation, or prophylactic antihypertensives, as these have been proven ineffective for preventing recurrent preeclampsia. 3

Enhanced Antenatal Surveillance Protocol

First Trimester

Obtain accurate dating ultrasound and establish fetal number, as this is essential for subsequent management decisions. 3

Establish baseline laboratory values including:

• Complete blood count (hemoglobin, platelets) 3
• Comprehensive metabolic panel (creatinine, liver transaminases) 3
• Uric acid 3
• Urinalysis for proteinuria 3

Ongoing Monitoring Throughout Pregnancy

Schedule more frequent prenatal visits than standard care (exact frequency depends on severity of prior disease and presence of comorbidities). 3 This may include:

• Home blood pressure monitoring between visits 1, 3
• Nursing telephone contacts for symptom assessment 3
• Blood pressure checks at every visit with careful attention to trends 2

Repeat laboratory studies at least twice weekly (or more frequently if clinical deterioration occurs) to monitor for:

• Thrombocytopenia (HELLP syndrome) 2
• Rising liver enzymes 2
• Worsening renal function 2

Fetal Surveillance

For women whose prior pregnancy was complicated by fetal growth restriction, implement serial ultrasound surveillance including:

• Fetal biometry every 2-4 weeks 2, 3
• Amniotic fluid assessment 2, 3
• Umbilical artery Doppler studies 2, 3

Perform initial fetal assessment at diagnosis of any hypertension or concerning symptoms, then repeat based on findings and clinical course. 2

Management of Recurrent Preeclampsia

Blood Pressure Control

Treat severe hypertension (≥160/110 mmHg) urgently within 30-60 minutes to prevent maternal stroke. 5, 2

First-line agents for acute severe hypertension:

• IV labetalol: 20 mg bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes (maximum 220 mg) 5, 2
• Oral immediate-release nifedipine: 10 mg, repeat every 20 minutes (maximum 30 mg) 2
• IV hydralazine as alternative 5

Target blood pressure: systolic 110-140 mmHg and diastolic ≈85 mmHg (minimum goal <160/105 mmHg). 5, 2

For non-severe hypertension (140-159/90-109 mmHg), use oral antihypertensives targeting the same blood pressure goals. 2

Seizure Prophylaxis

Administer magnesium sulfate immediately for any woman with severe hypertension (≥160/110 mmHg) and preeclampsia or those with neurological symptoms (severe headache, visual changes, hyperreflexia). 6, 5, 2

Dosing regimen:

• Loading dose: 4-5 grams IV over 5-20 minutes 6, 7
• Maintenance: 1-2 grams/hour continuous IV infusion 6, 7
• Continue for 24 hours postpartum 1, 6, 2

Monitor clinically (not with routine serum levels) for toxicity:

• Deep tendon reflexes before each dose 5
• Respiratory rate (toxicity causes depression) 1, 5
• Urine output ≥30 mL/hour (oliguria increases toxicity risk) 6, 5

Critical safety warning: Never combine magnesium sulfate with calcium channel blockers (especially IV or sublingual nifedipine), as this causes severe myocardial depression and precipitous hypotension. 6, 5, 2

Fluid Management

Strictly limit total fluid intake to 60-80 mL/hour to prevent pulmonary edema, as preeclamptic women have capillary leak. 1, 2 Aim for euvolemia—do not "run dry" as this increases acute kidney injury risk. 1, 2

Delivery Timing

Deliver immediately after maternal stabilization if:

• Gestational age ≥37 weeks 5, 2
• Inability to control blood pressure despite ≥3 antihypertensive classes 5, 2
• Progressive thrombocytopenia or worsening liver/renal function 5
• Pulmonary edema 5
• Severe intractable headache, visual scotomata, or convulsions 5
• Non-reassuring fetal status 5, 2
• Placental abruption 5, 2

For gestational age 34-37 weeks with stable maternal and fetal status, expectant management with close monitoring is appropriate, but deliver if any deterioration occurs. 5, 8

For gestational age <34 weeks, expectant management at a tertiary center with Maternal-Fetal Medicine expertise may be considered if maternal condition is stable and fetal status reassuring, but this requires intensive monitoring. 5, 8 Administer corticosteroids for fetal lung maturation. 2

For gestational age <24 weeks, expectant management carries high maternal morbidity with limited perinatal benefit—counsel regarding pregnancy termination. 5, 8

Postpartum Management

Monitor blood pressure at least every 4-6 hours while awake for minimum 3 days postpartum, as preeclampsia may develop de novo postpartum and eclampsia can occur after delivery. 1, 2

Continue or restart antihypertensives after delivery and taper slowly only after days 3-6 postpartum unless blood pressure becomes low (<110/70 mmHg). 1

Avoid NSAIDs in women with preeclampsia, especially with acute kidney injury, and use alternative analgesia. 1

Review within 1 week if still requiring antihypertensives at discharge. 1 All women should be reviewed at 3 months postpartum, by which time blood pressure, urinalysis, and laboratory tests should have normalized. 1 Further investigation is required for persistent abnormalities. 1

Screen for postpartum depression, anxiety, and post-traumatic stress disorder symptoms. 1

Long-Term Follow-Up

Establish lifelong cardiovascular risk monitoring with regular primary care follow-up including:

• Periodic blood pressure monitoring 1
• Fasting lipids and blood glucose screening 1
• Maintenance of ideal weight and regular aerobic exercise 1, 2

Women who survive preeclampsia have reduced life expectancy with increased risks of stroke, cardiovascular disease, and diabetes requiring ongoing risk factor modification. 4