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Regardless of gestational age, emergent delivery is recommended if there are signs of maternal hypertensive crisis, abruptio placentae, uterine rupture, or fetal distress.
Seizures: control of convulsions, correction of hypoxia and acidosis, lowering of BP, steps to effect delivery as soon as convulsions are controlled
Administer betamethasone 12 mg IM daily ƒ — 2 doses or dexamethasone 6 mg every 12 hours ƒ — 4 doses if delivery <34 weeks possible.
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MEDICATION
First Line
- For seizure prophylaxis for women with severe preeclampsia: magnesium sulfate (MgSO4): loading dose 4 g IV in 200 mL normal saline over 20 to 30 minutes; maintenance dose 1 to 2 g/hr IV continuous infusion (although recent guidelines suggest it not be universally administered for seizure prophylaxis to prevent eclampsia, the quality of the evidence is low, and the strength of the recommendation is qualified) (1)[C]
- For BP control
- Antihypertensives are inadvisable for mildly elevated BP (without severe features).
- Labetalol (IV): 20 mg over 2 minutes followed at 20 to 30 minutes intervals with doses of 20 to 80 mg titrated to keep BP <160/110 mm Hg; max of 300 mg/24 hr. (Contraindicated in asthma, heart disease, congestive heart failure.)
- Hydralazine (IV): 5 to 10 mg over 2 minutes, followed at 20 minutes intervals with 5 to 10 mg IV boluses; titrated to keep BP<160/110 mm Hg; max of 25 mg/24 hr.
- Nifedipine sustained-release (PO) (used in the postpartum): 30 to 120 mg/day (caution with combination of nifedipine and magnesium sulfate resulting in hypotension and neuromuscular blockade)
- For eclampsia/seizures
- In recent randomized trials, magnesium sulfate was found to be superior to phenytoin in the treatment and prevention of eclampsia and probably more effective and safer than diazepam.
- Magnesium sulfate for seizures
- 4 to 6 g IV over 15 to 20 minutes followed by 1 to 2 g/hr infusion
- Further boluses of magnesium may be given for recurrent convulsions with the amount given based on the neurologic examination and patellar reflexes.
- Contraindications: myasthenia gravis, renal failure, pulmonary edema
- Levels of 6 to 8 mEq/mL are considered therapeutic, but clinical status is most important and must ensure that
- Patellar reflexes are present.
- Respirations are not depressed.
- Urine output is ≥25 mL/hr.
- May be given safely, even in the presence of renal insufficiency
- Fluid therapy
- Ringer lactated solution with 5% dextrose at 60 to 120 mL/hr, with careful attention to fluid " “volume status
- Precautions: Do not use diuretics. Carefully monitor neurologic status, urine output, respirations, and fetal status.
- Calcium carbonate (1 g, administered slowly IV) may reverse magnesium-induced respiratory depression.
Second Line
- Diazepam 2 mg/min until resolution or 20 mg given or
- Lorazepam 1 to 2 mg/min up to total of 10 mg or
- Phenytoin 15 to 20 mg/kg at a maximum rate of 50 mg/min or
- Levetiracetam 500 mg IV or oral, may be repeated in 12 hours (dose needs to be adjusted in renal impairment) or
- Phenobarbital 20 mg/kg infused at 50 mg/min; may repeat with additional 5 to 10 mg/kg after 15 minutes
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Without severe features: restricted activity; with severe features: restricted activity, in hospital
- Women with a history of preeclampsia should report this to physicians caring for them in later life. It is a potent cardiovascular disease risk factor.
DIET
- Salt restriction is inadvisable because the patient often is experiencing intravascular hypovolemia (1)[C].
- Calcium supplementation may be recommended for women who have low calcium intake (<600 mg/day) (1,6)[A].
PATIENT EDUCATION
American College of Obstetricians and Gynecologists, 409 12th St. SW, Washington, DC 20024-2188; (800) 762-ACOG; http://www.acog.org/ ‚
PROGNOSIS
- For nulliparous women with preeclampsia before 30 weeks of gestation, the recurrence rate for the disorder may be as high as 40% in future pregnancies.
- 25% of eclamptic women will have HTN during subsequent pregnancies, but only 5% of these will be severe and only 2% will be eclamptic again.
- Preeclamptic, multiparous women may be at higher risk for subsequent essential HTN; they also have higher mortality during subsequent pregnancies than do primiparous women.
COMPLICATIONS
- Most women do not have long-term sequelae from eclampsia, although many may have transient neurologic deficits.
- A history of preeclampsia is equivalent to traditional risk factors for cardiovascular disease. Women with a history of preeclampsia should be strongly advised to avoid obesity and smoking. Other signs of metabolic syndrome should be closely monitored as well.
- Maternal and/or fetal death
REFERENCES
11 American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists ' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122 " “1131.22 Gauer ‚ R, Atlas ‚ M, Hill ‚ J. Clinical inquiries. Does low-dose aspirin reduce preeclampsia and other maternal-fetal complications? J Fam Pract. 2008;57(1):54 " “56.33 Villa ‚ PM, Kajantie ‚ E, R ƒ ¤ikk ƒ ¶nen ‚ K, et al. Aspirin in the prevention of pre-eclampsia in high-risk women: a randomised placebo-controlled PREDO Trial and a meta-analysis of randomised trials. BJOG. 2013;120(1);64 " “74.44 Duley ‚ L, Henderson-Smart ‚ DJ, Meher ‚ S, et al. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database of Syst Rev. 2007;(2):CD004659. doi:10.1002/14651858.CD004659.pub2.55 Hofmeyr ‚ GJ, Beliz ƒ ¡n ‚ JM, von Dadelszen ‚ P. Low-dose calcium supplementation for preventing pre-eclampsia: a systematic review and commentary. BJOG. 2014;121(8):951 " “957.66 Magee ‚ LA, Helewa ‚ M, Moutquin ‚ JM, et al. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. J Obstet Gynaecol Can. 2008;30(3 Suppl):S1 " “S48.
CODES
ICD10
- O14.90 Unspecified pre-eclampsia, unspecified trimester
- O15.00 Eclampsia in pregnancy, unspecified trimester
- O14.00 Mild to moderate pre-eclampsia, unspecified trimester
- O14.10 Severe pre-eclampsia, unspecified trimester
- O14.03 Mild to moderate pre-eclampsia, third trimester
- O15.02 Eclampsia in pregnancy, second trimester
- O15.03 Eclampsia in pregnancy, third trimester
- O14.93 Unspecified pre-eclampsia, third trimester
- O14.13 Severe pre-eclampsia, third trimester
- O14.02 Mild to moderate pre-eclampsia, second trimester
- O14.22 HELLP syndrome (HELLP), second trimester
- O14.12 Severe pre-eclampsia, second trimester
- O15.2 Eclampsia in the puerperium
- O14.92 Unspecified pre-eclampsia, second trimester
- O14.20 HELLP syndrome (HELLP), unspecified trimester
- O14.23 HELLP syndrome (HELLP), third trimester
- O15.9 Eclampsia, unspecified as to time period
ICD9
- 642.40 Mild or unspecified pre-eclampsia, unspecified as to episode of care or not applicable
- 642.60 Eclampsia, unspecified as to episode of care or not applicable
- 642.70 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, unspecified as to episode of care or not applicable
- 642.50 Severe pre-eclampsia, unspecified as to episode of care or not applicable
- 642.43 Mild or unspecified pre-eclampsia, antepartum condition or complication
- 642.71 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with or without mention of antepartum condition
- 642.41 Mild or unspecified pre-eclampsia, delivered, with or without mention of antepartum condition
- 642.53 Severe pre-eclampsia, antepartum condition or complication
- 642.61 Eclampsia, delivered, with or without mention of antepartum condition
- 642.73 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, antepartum condition or complication
- 642.52 Severe pre-eclampsia, delivered, with mention of postpartum complication
- 642.63 Eclampsia, antepartum condition or complication
- 642.44 Mild or unspecified pre-eclampsia, postpartum condition or complication
- 642.72 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, delivered, with mention of postpartum complication
- 642.74 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, postpartum condition or complication
- 642.54 Severe pre-eclampsia, postpartum condition or complication
- 642.51 Severe pre-eclampsia, delivered, with or without mention of antepartum condition
- 642.62 Eclampsia, delivered, with mention of postpartum complication
- 642.64 Eclampsia, postpartum condition or complication
- 642.42 Mild or unspecified pre-eclampsia, delivered, with mention of postpartum complication
SNOMED
- 398254007 Pre-eclampsia (disorder)
- 198992004 Eclampsia in pregnancy
- 41114007 Mild pre-eclampsia (disorder)
- 46764007 Severe pre-eclampsia (disorder)
- 303063000 Eclampsia in puerperium
- 67359005 Pre-eclampsia added to pre-existing hypertension (disorder)
- 199002002 Pre-eclampsia or eclampsia with pre-existing hypertension - not delivered (disorder)
- 198997005 pre-eclampsia or eclampsia with pre-existing hypertension (disorder)
- 198999008 Pre-eclampsia or eclampsia with pre-existing hypertension - delivered (disorder)
- 199000005 Pre-eclampsia or eclampsia with pre-existing hypertension - delivered with postnatal complication (disorder)
- 198991006 Eclampsia - delivered with postnatal complication
- 198993009 Eclampsia with postnatal complication (disorder)
- 199003007 Pre-eclampsia or eclampsia with pre-existing hypertension with postnatal complication (disorder)
- 69909000 Eclampsia added to pre-existing hypertension
- 198990007 Eclampsia - delivered
CLINICAL PEARLS
- Management of preeclampsia depends on both the severity of the condition and the gestational age of the fetus.
- Diagnosis no longer requires presence of proteinuria.