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9/1/2018

Management of Preeclampsia at Term

Management of preeclampsia at term (≥ 37 0/7 weeks) involves assessing the maternal-fetal status, preparing for delivery, and monitoring for disease severity and progression. 

Delivery is indicated when preeclampsia is diagnosed at term regardless of the presence/absence of severe features.  Approach to delivery depends on usual obstetric considerations: cervical status, fetal presentation, and maternal-fetal well-being.  Vaginal delivery is preferred, provided usual contraindications are absent.  Cesarean delivery is reserved for usual obstetric indications or if preeclampsia worsens resulting in maternal or fetal instability remote from delivery.

Critical to intrapartum and postpartum care is blood pressure monitoring which should occur minimally every hour, unless measurements of ≥ 160 or 110 mmHg systolic or diastolic respectively are encountered.  Severe hypertension require increased frequency of evaluation and if persistent over 15 minutes, they require treatment with either IV labetalol or hydralazine, or oral short-acting nifedipine.  Sample order sets exist which provide guidance on increasing dosages, timing between medication administration and blood pressure evaluations, plus additional supports (See Committee Opinion reference). In general, after administration of 3 doses of the initially selected agent, transition to a different agent, and emergency consultation with relevant specialists/subspecialists is recommended. If hypertension management requires acute IV treatment, it is often prudent to initiate oral labetalol or extended-release nifedipine to maintain blood pressures below the severe range. Intrapartum blood pressure management and consultation should not delay progress towards delivery.  Fetal monitoring should be continuous.

In addition to evaluating and treating for severe-range blood pressures, monitoring for other severe features including signs/symptoms of organ dysfunction (thrombocytopenia, impaired liver function, renal insufficiency, new onset headache unresponsive to treatment, visual disturbances), is vital throughout the intra- and postpartum periods. Laboratory values and symptom assessment should be obtained at regular intervals with severe features; discontinuation can be considered after two normal sets with low threshold to obtain if clinical condition changes.  Care should be made to assess for HELLP syndrome, and pulmonary edema. It is important to note that there may be variable presentations of the severe disease (which may or may not include proteinuria for instance).  

Patients with preeclampsia with severe features should be administered magnesium sulfate for seizure prevention. An initial IV loading dose is administered (4-6 grams bolus) followed by maintenance dosing (1-2 grams/hour); dose adjustments may be required with evidence of renal

dysfunction.  While the patient is receiving magnesium sulfate, it is important to monitor for magnesium toxicity (e.g.; absent deep tendon reflexes, respiratory depression).  As magnesium sulfate is cleared renally, it is important to monitor urine output.  Calcium gluconate (1 g IV) is the antidote for magnesium toxicity.  Consider obtaining serum magnesium levels in patients with a BMI ≥ 30 kg/m2 to confirm levels are in the therapeutic range (4.8–8.4 mg/dL).  Magnesium sulfate should continue until 24 hours after delivery or from the time of the last seizure, if eclampsia ensues.  There are a few contraindications to magnesium (myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, heart block, or myocarditis); phenytoin or benzodiazepines can be considered for seizure prophylaxis in these instances. 

Postpartum management includes:

1. Monitoring for and treating severely elevated blood pressures;
2. Continuing/initiating magnesium sulfate in the context of preeclampsia with severe features for 24 hours post-delivery; and
3. After discharge, assessing blood pressures and symptoms soon after discharge.

Close follow-up and medication management is imperative until the patient’s blood pressures normalize, or if a diagnosis of chronic hypertension is suspected, appropriate referral is made, maintaining a high suspicion for postpartum preeclampsia.

 

Further Reading:

Roberts JM, August PA, Bakris G, et al; 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 Nov;122(5):1122-31. doi: 10.1097/01.AOG.0000437382.03963.88.

Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260. doi: 10.1097/AOG.0000000000003891. PMID: 32443079.

Initial Approval May 2018; Reaffirmed January 2020; Revised September 2021. Minor Revision September 2023.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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