How should a pregnant woman with severe preeclampsia (24‑hour urine protein 6 g and hypertension) be managed?

Management of Severe Preeclampsia with Massive Proteinuria

This patient requires immediate delivery after maternal stabilization, given the combination of severe proteinuria (6 g/24h) and hypertension, which represents severe preeclampsia with high-risk features. 1

Immediate Assessment and Stabilization

Blood Pressure Management

• Measure blood pressure immediately and confirm the severity. If BP ≥160/110 mmHg (severe range), initiate urgent treatment with oral nifedipine or IV labetalol/hydralazine in a monitored setting, with confirmation within 15 minutes. 1
• For BP 140-159/90-109 mmHg (mild-moderate range), start oral methyldopa, labetalol, or nifedipine, targeting diastolic 85 mmHg and systolic 110-140 mmHg. 1
• The rate of IV magnesium sulfate should generally not exceed 150 mg/minute except in severe eclampsia with seizures. 2

Seizure Prophylaxis

• Strongly consider magnesium sulfate given the massive proteinuria (6 g/24h). The combination of elevated uric acid and protein/creatinine ratio >4.9 dramatically increases eclampsia risk. 1
• Standard dosing: 4-5 g IV loading dose over 3-4 minutes, followed by 1-2 g/hour continuous infusion, or 4-5 g IM into alternate buttocks every 4 hours. 2
• Continue therapy until paroxysms cease, targeting serum magnesium level of 6 mg/100 mL for seizure control. 2
• Critical warning: Do not exceed 30-40 g total daily dose, and in severe renal insufficiency, maximum is 20 g/48 hours with frequent serum magnesium monitoring. 2
• Continuous maternal administration beyond 5-7 days can cause fetal abnormalities. 2

Laboratory Evaluation

• Obtain comprehensive labs to assess for end-organ damage: complete blood count (platelets), liver enzymes (AST/ALT), serum creatinine, and uric acid. 3, 1
• Evaluate specifically for HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which can occur even with normal blood pressure in 10-15% of cases. 4
• Thrombocytopenia <100,000/μL, liver transaminases >2× normal, renal failure, or persistent epigastric/right upper quadrant pain are all severity criteria requiring urgent action. 5

Fetal Assessment

• Perform ultrasound for fetal growth assessment, as massive proteinuria (>5 g/24h) is associated with placental insufficiency and more severe neonatal outcomes. 6, 7
• Assess fetal well-being with non-stress testing, as fetal compromise can be the first clinical indication of preeclampsia severity. 6

Delivery Decision Algorithm

Gestational Age ≥37 Weeks

• Proceed with delivery immediately after maternal stabilization. 1
• Do not delay delivery based on proteinuria quantification alone—massive proteinuria itself indicates high-risk disease. 1

Gestational Age 34-37 Weeks

• Deliver within 24-48 hours after maternal stabilization given the severe features (massive proteinuria + hypertension). 1
• The degree of proteinuria provides little additional risk stratification beyond identifying high-risk disease. 6

Gestational Age <34 Weeks

• Administer antenatal corticosteroids to promote fetal lung maturity. 5
• Delivery within 24-48 hours is still recommended given severe features, though cautious conservative management may be considered in highly selected cases with close monitoring. 7, 5
• Historical data shows that 88% of cases with proteinuria ≥5 g/24h required delivery within 2 weeks of onset, though occasional very preterm pregnancies could be prolonged 3+ weeks. 7
• Any maternal end-organ dysfunction or non-reassuring fetal testing mandates delivery at any gestational age. 5

Mode of Delivery

• Expect high likelihood of cesarean section (83% in severe proteinuria cases), with 91% requiring urgent operative delivery before labor onset. 7
• Neuraxial analgesia/anesthesia is strongly preferred over general anesthesia (absent thrombocytopenia), avoiding airway edema risks and intubation-induced blood pressure spikes. 5

Critical Clinical Pitfalls

Proteinuria Monitoring

• Do not repeat proteinuria measurements to guide delivery timing. The amount of proteinuria does not correlate with maternal/neonatal outcomes, and monitoring may lead to unindicated preterm deliveries. 8
• Proteinuria fluctuates widely hour-to-hour due to the vasospastic nature of preeclampsia. 4
• Delivery decisions should prioritize maternal organ dysfunction, fetal status, and gestational age—not proteinuria degree. 6, 1

Symptoms Requiring Immediate Action

• Headache is an independent risk factor for eclampsia. 6
• Epigastric pain and vomiting are independent risk factors for serious morbidity in severe preeclampsia. 6
• Visual disturbances suggest cerebral edema and impending eclampsia. 6
• Any of these symptoms require immediate assessment and likely expedited delivery. 6

Renal Function Monitoring

• In severe renal insufficiency, adjust magnesium dosing and monitor levels frequently. 2
• Massive proteinuria (>5 g/24h) confirms nephrotic syndrome, which has implications for thromboprophylaxis. 6

Postpartum Management

• Close monitoring for 48-72 hours postpartum is essential, as 20% of HELLP cases occur within 48 hours of delivery. 1
• Continue antihypertensive therapy and magnesium sulfate as clinically indicated. 1
• Reassess proteinuria at 3 months postpartum—if persistent, this indicates underlying primary renal disease requiring nephrology referral. 1
• Postpartum recovery from massive proteinuria is typically good, with resolution of proteinuria and no residual renal dysfunction in most cases. 7