Management of Severe Preeclampsia

 The definitive treatment of preeclampsia is the delivery of the placenta. The timing of delivery depends on gestational age, the severity of preeclampsia, and maternal and fetal conditions.

Another important aspect in the management of severe preeclampsia is the control of hypertension.

A. BP control

1.       Arterial pressure greater than 160/110 mmHg in preeclampsia can increase the risk of complications, and it should be controlled.

2.       BP control should only be done in the ICU, preferably with arterial line monitoring.

3.       BP control should also be done along with fetal monitoring. Avoid sudden falls in BP as it can result in fetal distress.

4.       The goal of BP control is a 15–25% reduction in the mean arterial pressure, and a reduction of pressure to baseline BP levels (<140/90 mmHg) rather than normal BP, should be avoided as it may compromise placental perfusion.

5.       Drugs

a)       Labetalol (IV 20 mg) can be given initially, followed by doubling the dose every 10 min to a cumulative dose of 300 mg. This drug can result in severe bradycardia. A continuous infusion of labetalol at a rate of 0.5–2 mg/min can also be used.

b)      Hydralazine (5–10 mg) can be given every 20 min (maximum of 40 mg) until BP is controlled.

c)       Nifedipine or nicardipine can be given (sudden precipitous decrease in BP or tachycardia can occur).

d)      Intravenous nitroglycerin (10–100 mg/min) or sodium nitroprusside (2–8 mg/min) can be given. Prolonged use of nitroglycerin may lead to methemoglobinemia. Cyanide toxicity in the mother and fetus may occur with sodium nitroprusside, limiting its use to less than 4 h and only as a last resort.

B. Seizure control

1.       The initial management of eclampsia includes airway, breathing, and circulation.

2.       Seizure prophylaxis is given intrapartum or postpartum with magnesium sulfate in cases of severe preeclampsia.

3.       The initial bolus of magnesium (4 g over 5–15 min) is followed by an infusion of 1–2 g/h maintained for 24 hrs.

4.       The mechanism of action of magnesium is unknown, but magnesium suppresses excitatory neurotransmitter release by replacing calcium at nerve endings.

a)       Monitor toxicity—loss of deep tendon reflexes; loss of patellar reflex occurs when the plasma magnesium level is more than 10 mg%. Look for respiratory muscle weakness.

b)      Magnesium has a relatively narrow therapeutic range, and target magnesium serum concentrations are 5–8 mg/dL.

c)       Infusion dose should be reduced in cases of renal dysfunction. Serum magnesium levels should be monitored every 4–6 hours and whenever a seizure occurs, or signs of toxicity are present, as per Table

Clinical manifestations related to the serum concentration of magnesium
Serum magnesium levels (mg/dL)	Effects
5–8	Therapeutic
8–12	Loss of deep tendon reflexes
12–16	Muscular paralysis and respiratory difficulties
>17	Conduction disturbances
>25	Cardiac arrest

 

d)       In recurrent seizures, an additional 2–4 g of magnesium sulfate can be given over 5 mins concurrently with the magnesium sulfate infusion.

e)      Calcium gluconate 15–30 mL of a 10% solution, administered intravenously over 2–5 minutes, is given to women with cardiac arrest or severe cardiac toxicity related to magnesium toxicity.

f)        If seizures are not controlled by a repeat magnesium bolus, then diazepam or lorazepam can be administered.

g)       Discontinue magnesium sulfate 24 h after delivery.

 

 

C. Fluid management

1.       Despite peripheral edema, patients with preeclampsia are volume-depleted with high peripheral vascular resistance. Diuretics should be avoided.

2.       Aggressive volume resuscitation, on the other hand, may lead to pulmonary edema, which is a common cause of maternal morbidity and mortality. Because volume expansion has no demonstrated benefit, patients should be fluid-restricted, when possible, at least until the period of postpartum diuresis.

3.       Central venous or pulmonary artery pressure monitoring or other hemodynamic monitoring modalities may be indicated in critical cases.

4.       Careful measurement of fluid input and output is advisable, particularly in the immediate postpartum period.

5.       D. Decide the timing and type of delivery

6.       As maternal morbidity is very high with severe preeclampsia, prompt delivery is indicated regardless of gestational age.

7.       Women with severe preeclampsia who are managed expectantly (non-severe disease) must be delivered under the following circumstances:

a.       Severe hypertension develops refractoriness to treatment

b.       Non-reassuring fetal heart status

c.       Uncontrollable BP

d.       Oligohydramnios, with amniotic fluid index of less than 5 cm.

e.       Severe intrauterine growth restriction.

f.        Oliguria (<500 mL/24 h)

g.       Serum creatinine level of at least 1.5 mg/dL

h.       Pulmonary edema

i.         Shortness of breath or chest pain with pulse oximetry of <94% on room air

j.         Headache that is persistent and severe Right upper quadrant tenderness with deteriorating liver function test

k.       Development of HELLP syndrome

l.         Severe hypertension after 34 weeks when their blood pressure has been controlled and a course of corticosteroids has been completed (if appropriate).

m.     Offer birth to women with pre-eclampsia before 34 weeks only after discussion with neonatal and anesthetic teams and a course of corticosteroids has been given.

n.       Preeclampsia is not an indication for caesarian delivery and many patients can have a normal vaginal delivery.

Watch for complications

1.       Abruptio placentae

2.       Disseminated intravascular coagulopathy (DIC)

3.       Renal insufficiency and acute renal failure

4.       HELLP syndrome

5.       Eclampsia

6.       Cerebral hemorrhage

7.       Fetal changes—intrauterine growth restriction, abruptio placentae, oligohydramnios

8.        Intrauterine fetal death

Managing Complications

HELLP syndrome

1.       HELLP syndrome can complicate 4–12% of patients with severe preeclampsia.

2.       Signs and symptoms are right upper quadrant or epigastric pain, nausea and vomiting, malaise, and nonspecific viral-like symptoms. Physical examination findings include right upper quadrant or epigastrium tenderness and generalized edema.

Tennessee classification:

1.       Hemolysis: established by the presence of at least two of the following:

2.       Peripheral smear showing schistocytes and burr cells

3.       Serum bilirubin ≥1.2 mg/dL

4.       Low serum haptoglobin (≤25 mg/dL) or LDH ≥2 times the upper level of normal

5.       Severe anemia unrelated to blood loss, Elevated liver enzymes Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≥2 times the upper level of normal, Low platelets: <100,000 cells/microL

 

Delivery is the definitive treatment for HELLP syndrome.

a.       Delivery is indicated for women with HELLP syndrome at greater than 34 weeks of gestation.

b.       During labor and for 24-h postpartum, patients should receive intravenous magnesium sulfate for seizure prophylaxis.

c.       If gestation is less than 34 weeks, delivery may be delayed for 48 hours to administer a steroid course of either betamethasone (12 mg intramuscular every 24 hours for two doses, with delivery 24 hours after the last dose) or dexamethasone (6 mg intramuscular every 12 hours for 2 days).

d.       Platelets are generally transfused when the platelet count is less than 20,000/mm. For cesarean delivery or with any significant bleeding, platelets should be transfused if the platelet count is less than 50,000/mm3.

Acute Pulmonary Edema

1.       Management is similar to non-pregnant patients.

2.       Intravenous furosemide (bolus 20–40 mg over 2 min) is used to promote diuresis. Repeated doses of 40–60 mg is given after 30 min or infusion if there is an inadequate diuretic response (maximum dose 120 mg/h).

3.       Careful fetal monitoring, fluid restriction, and strict fluid balance and positioning

Do you need Low Dose Aspirin Prophylaxis,

  

SMFM recommendation regarding low-dose aspirin prophylaxis for the prevention of preeclampsia. Low-dose aspirin (81 mg/d) prophylaxis is recommended for:

• Pregnant individuals at high risk of preeclampsia with one or more of the following risk factors:
  • History of preeclampsia, especially when accompanied by an adverse outcome
  • Multifetal gestation
  • Chronic hypertension
  • Pregestational type 1 or 2 diabetes
  • Kidney disease
  • Autoimmune disease (ie, systemic lupus erythematous, antiphospholipid syndrome)
  • Combinations of multiple moderate-risk factors

These risk factors are consistently associated with the greatest risk for preeclampsia. Preeclampsia incidence would likely be at least 8% in a population of pregnant individuals having one of these risk factors.

• Pregnant individuals with more than one of several moderate risk factors:
  • Nulliparity
  • Obesity (ie, body mass index > 30)
  • Family history of preeclampsia (ie, mother or sister)
  • Black race (as a proxy for underlying racism)
  • Lower income
  • Age 35 years or older
  • Personal history factors (eg, low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval)
  • In vitro fertilization

These factors are independently associated with moderate risk for preeclampsia, some more consistently than others. A combination of multiple moderate-risk factors may place a pregnant person at higher risk for preeclampsia.

Additionally, low-dose aspirin can be considered if the patient has one or more of the following moderate-risk factors: Black race (as a proxy for underlying racism), or lower income. The underlying risk to health is racism and not race. However, there are not yet adequate tools for measuring the known impact of racism on health. Therefore, in this document, Black race serves as a proxy for underlying racism. These factors are associated with increased risk due to environmental, social, structural, and historical inequities shaping health exposures, access to health care, and the unequal distribution of resources, not biological propensities.

When recommended, low-dose aspirin should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery

PREECLAMPSIA- ECLAMPSIA (/pregnancy-induced hypertension (PIH))

Terminology and Classification:

The current classification system by ACOG includes four distinct disorders:

        I. Gestational Hypertension: New-onset hypertension after 20 weeks without proteinuria or other signs of end-organ damage. It typically resolves by 12 weeks postpartum.

      II. Preeclampsia/Superimposed Preeclampsia: The new onset of hypertension after 20 weeks of gestation, accompanied by one or more of the following:

a.       Proteinuria

b.      Thrombocytopenia (platelet count < 100,000/μL)

c.       Impaired liver function (elevated transaminases to twice the normal concentration)

d.      Renal insufficiency (serum creatinine > 1.1 mg/dL or a doubling of baseline)

e.       Pulmonary edema

f.        New onset cerebral or visual disturbances.

    III.            Eclampsia: The onset of grand mal seizures in a patient with preeclampsia that cannot be attributed to other causes.

    IV.            Chronic Hypertension: Hypertension present before pregnancy or diagnosed before 20 weeks' gestation.

Pathogenesis:

        I. Pathophysiology: The primary pathophysiologic basis is now understood to be placental and endothelial dysfunction, leading to:

a.       Generalized Vasospasm (causing hypertension and reduced organ perfusion).

b.      Increased Capillary Permeability (causing edema, including pulmonary edema).

c.       Activation of the Coagulation System (causing thrombocytopenia).

      II. Diagnosis: RollOver Test: This test is obsolete and no longer used in clinical practice. It has been replaced by more reliable clinical monitoring and biomarker research.

Assessment and Diagnostic Criteria

The "mild" vs. "severe" classification of preeclampsia is outdated. The current standard is Preeclampsia vs. Preeclampsia with Severe Features.

Preeclampsia with Severe Features is diagnosed by the presence of any of the following: 

                 i.      Systolic BP ≥ 160 mm Hg or Diastolic BP ≥ 110 mm Hg on two occasions at least 4 hours apart (antihypertensive therapy is often initiated sooner).

                ii.      Thrombocytopenia (Platelets < 100,000/μL).

              iii.      Impaired Liver Function (Elevated AST/ALT to twice the normal concentration).  

              iv.      Severe Persistent Right Upper Quadrant or Epigastric Pain (This indicates liver involvement, not merely an "aura").

                v.      Renal Insufficiency (Serum Creatinine > 1.1 mg/dL or a doubling from baseline).

              vi.      Pulmonary Edema.

            vii.      New Onset Cerebral or Visual Disturbances (e.g., severe headache, scotomata, blurred vision).

Signs/Symptoms:

        I. Proteinuria: Diagnostic threshold is ≥ 0.3 grams in a 24hour urine collection (gold standard),

      II. Oliguria: Defined as < 30 mL/hour over 24 hours,

    III.  Weight Gain/Edema: These are not reliable diagnostic criteria as they are common in normal pregnancy.

    IV.   Diagnosis is based on BP and evidence of organ dysfunction.

      V.  HELLP Syndrome: A severe variant of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets.

Management

A. General and Supportive Care:

        I.  Bed Rest: Strict bed rest is no longer recommended due to the increased risk of thromboembolism and lack of proven benefit. Activity may be modified, but mobility is encouraged.

      II.  Diet: Salt restriction and specific high-protein diets are not recommended. A balanced, nutritious diet is advised. Salt restriction can be detrimental.

    III.   Environment: A calm environment is supportive, but the primary seizure prophylaxis is pharmacological, not environmental.

 

B. Medication Management (Magnesium Sulfate): Indication: First-line for seizure prophylaxis in preeclampsia with severe features and for treatment of eclampsia.

        I.            Dosing (Updated):

a.       Loading Dose: 4-6 grams IV over 15-20 minutes.

b.      Maintenance Dose: 1-2 grams/hour via continuous IV infusion pump.

      II.            Monitoring for Toxicity (Updated):

a.       Respiratory Rate: Must be > 16/minute.

b.      Urine Output: Must be > 30 mL/hour.

c.       Deep Tendon Reflexes: Must be present (absence is the first sign of toxicity).

d.      Serum Magnesium Levels: Therapeutic range is 48 mg/dL.

    III.            Antidote: Calcium Gluconate 1 gram (10% solution) IV over 10 minutes must be available at the bedside.

C. Blood Pressure Management:  Antihypertensive medications (e.g., Labetalol, Nifedipine) are used to manage severe hypertension (≥ 160/110 mm Hg) to prevent maternal stroke.

D. Delivery:

   Delivery is the only definitive cure for preeclampsia. The timing is based on gestational age and disease severity. Vaginal delivery is preferred, but cesarean section is performed for standard obstetric indications.

Nursing Problem Priorities:

        I. Seizure Prophylaxis & Neurologic Monitoring: Administer MgSO₄ and monitor for signs of toxicity and CNS irritability.

      II. Severe Hypertension Management: Administer antihypertensive medications as ordered to prevent cerebral vascular accident (stroke).

    III. Maternal-Fetal Surveillance: Continuous fetal monitoring; frequent maternal vital signs, strict I&O, and assessment for symptoms of severe features (headache, epigastric pain, visual changes).

    IV.  Fluid Balance Management: Monitor for pulmonary edema; avoid fluid overload.

      V.    Prevention of Complications: Monitor for progression to HELLP syndrome, eclampsia, placental abruption, and pulmonary edema.

    VI.    Patient & Family Education: Educate on signs/symptoms of worsening condition, emphasizing that the risk persists up to 46 weeks postpartum.

 Dosing Details: First-Line Antihypertensive Medications in Pregnancy:

The following table provides specific dosing for both acute/severe hypertension and ongoing maintenance therapy.

Medication	Route	Indication	Dosing Protocol	Key Monitoring & Nursing Considerations
Labetalol	IV	Acute Severe Hypertension	• Initial Dose: 20 mg IV push over 2 minutes. • Repeat Dosing: If target BP not reached in 10 minutes, give 40 mg IV. Then 80 mg IV every 10 minutes as needed. • Maximum Cumulative Dose: 300 mg per course. • Continuous Infusion (Alternative): 1-2 mg/min, titrate to effect (max 300 mg).	• Contraindicated in patients with asthma, heart failure, or bradycardia. • Monitor maternal heart rate (can cause bradycardia). • Monitor for neonatal hypoglycemia after birth.
Nifedipine	Oral (Capsule)	Acute Severe Hypertension	• Dose: 10 mg orally. • Repeat Dosing: May repeat in 20-30 minutes if needed. • Maximum Dose: 30 mg in 1 hour. • Formulation Note: Use immediate-release capsule. The capsule can be pierced and swallowed if the patient cannot swallow it whole.	• Avoid sublingual administration due to risk of precipitous BP drop. • Common side effects: headache, flushing, tachycardia. • Synergistic effect with magnesium sulfate; monitor for potential hypotension.
Hydralazine	IV	Acute Severe Hypertension	• Initial Dose: 5 mg IV push over 2 minutes. • Repeat Dosing: If no effect in 20 minutes, give 5-10 mg IV. • Subsequent doses of 10 mg can be given every 20-40 minutes as needed. • Maximum Dose: 20-30 mg total.	• Onset of action can be slower (10-20 minutes). • Can cause reflex tachycardia and headaches. • Associated with more fetal heart rate decelerations than other agents.
Labetalol	Oral	Maintenance Therapy	• Starting Dose: 100 mg twice daily. • Titration: Increase every 2-3 days as needed. • Usual Dosage Range: 200-800 mg twice daily (max 2400 mg/day).	• Monitor heart rate and BP. • Advise patient to avoid sudden position changes (orthostatic hypotension).
Nifedipine	Oral (ER)	Maintenance Therapy	• Starting Dose: 30 mg once daily (extended-release formulation). • Titration: Can increase to 60 mg or 90 mg once daily. • Maximum Dose: 120 mg daily.	• Use extended-release (ER/XL) for maintenance. • Monitor for peripheral edema and gingival hyperplasia with long-term use.
Methyldopa	Oral	Maintenance Therapy	• Starting Dose: 250 mg two or three times daily. • Titration: Increase every 2 days as needed. • Usual Dosage Range: 500 mg to 2000 mg daily in 2-4 divided doses (max 3000 mg/day).	• Safest for long-term use in pregnancy (extensive safety data). • Side effects: drowsiness, dry mouth, depression (monitor mood). • Can cause a positive Coombs' test, rarely hemolytic anemia.

 

Clinical Protocol for Acute Severe Hypertension (≥160/110 mm Hg)

This is often managed using a standardized algorithm or "severe hypertension pathway" to ensure timely treatment.

1. Confirm Reading: Re-check BP after 15 minutes with an appropriate-sized cuff.
2. Administer First-Line Agent: Choose one (e.g., Labetalol 20 mg IV).
3. Re-assess BP: Check BP every 10-20 minutes.
4. Escalate if Needed:
• If BP remains ≥160/110 mm Hg after 10-20 minutes, administer the next dose in the sequence (e.g., Labetalol 40 mg IV).
5. Switch Agents if Goal Not Met: If the maximum dose of the first agent is ineffective (e.g., BP still severe after Labetalol 80 mg), switch to a second-line agent (e.g., Nifedipine 10 mg orally).
6. Target: The goal is to achieve a BP below 160/110 mm Hg within 30-60 minutes and then maintain it in a safer range (e.g., 140-150/90-100 mm Hg).
7. Notify Physician: If the BP does not respond to two first-line agents, this is considered refractory hypertension and requires immediate physician consultation, as it may signal impending crisis.

Important Note: These protocols are for educational purposes. All medication administration must follow specific, written physician orders and the official protocols of the treating institution.