gynecology and obstetrics
Preeclampsia and Eclampsia
Treatment of Preeclampsia and Eclampsia
Usually hospitalization and sometimes antihypertensive treatment Delivery, depending on factors such as gestational age, fetal status, and severity of preeclampsia Sometimes magnesium sulfate to prevent or treat new seizures or to prevent seizures from recurring Definitive treatment for preeclampsia is delivery. However, risk of preterm delivery is balanced against gestational age, fetal growth restriction, fetal distress, severity of preeclampsia, and response to other treatments. Usually, immediate delivery after maternal stabilization (eg, controlling seizures, beginning to control blood pressure [BP]) is indicated for the following: Pregnancy of≥37 weeks Preeclampsia with severe features if pregnancy is ≥ 34 weeks Deteriorating renal, pulmonary, cardiac, or hepatic function (eg, HELLP syndrome) Nonreassuring results of fetal monitoring or testing Eclampsia Other treatments aim to optimize maternal health, which usually optimizes fetal health. If delivery can be safely delayed in pregnancies of < 34 weeks, corticosteroids are given for 48 hours to accelerate fetal lung maturity. Some stable patients can be given corticosteroids after 34 weeks and before 36 weeks (late preterm period) if they have not been given corticosteroids earlier in the pregnancy. Most patients are hospitalized. Patients with eclampsia or preeclampsia with severe features are often admitted to a maternal special care unit or an intensive care unit (ICU). Most patients who have preeclampsia without severe features before 37 weeks gestation are hospitalized for evaluation, at least initially. If maternal and fetal status are reassuring, outpatient treatment is possible; it includes modified activity (modified rest), BP measurements, laboratory monitoring, fetal nonstress testing, and physician visits at least once a week. As long as no criteria for preeclampsia with severe features develop, delivery can occur (eg, by induction) at 37 weeks. Allhospitalized patientswith preeclampsia are evaluated frequently for evidence of seizures, preeclampsia with severe features, and vaginal bleeding; BP, reflexes, and fetal heart status (with nonstress testing or a biophysical profile) are also checked. Platelet count, serum creatinine, and serum liver enzymes are measured frequently until stable, then at least once a week. Outpatientsare usually followed by an obstetrician or a maternal-fetal medicine specialist and evaluated at least once a week with the same testing as inpatients. Evaluation is more frequent if preeclampsia with severe features is diagnosed or if gestational age is < 34 weeks. As soon as eclampsia is diagnosed, magnesium sulfate must be given to prevent seizures from recurring. If patients have preeclampsia with severe features, magnesium sulfate may be given to prevent seizures. Magnesium sulfate is given for 12 to 24 hours postpartum. Whether patients who have preeclampsia without severe features always require magnesium sulfate before delivery is controversial. Magnesium sulfate 4 g IV over 20 minutes is given, followed by a constant IV infusion of 2 g/hour. Dose is adjusted based on the patient’s symptoms or on whether renal insufficiency is present. Patients with abnormally high magnesium levels (eg, with magnesium levels>10 mEq/L or a sudden decrease in reflex reactivity), cardiac dysfunction (eg, with dyspnea or chest pain), or hypoventilation after treatment with magnesium sulfate can be treated withcalcium gluconate1 g IV. IV magnesium sulfate may cause lethargy, hypotonia, and transient respiratory depression in neonates. However, serious neonatal complications are uncommon. If oral intake is prohibited, hospitalized patients are given IV Ringer lactate or 0.9% normal saline solution, beginning at about 125 mL/hour (to maintain hemodynamic status). Persistent oliguria is treated with a carefully monitored fluid challenge. Diuretics are usually not used. Monitoring with a pulmonary artery catheter is rarely necessary and, if needed, is done in consultation with a critical care specialist and in an intensive care unit (ICU). Anuric patients with normovolemia may require renal vasodilators or dialysis. If seizures occur despite magnesium therapy,diazepamorlorazepamcan be given IV to stop seizures, and IVhydralazineorlabetalolis given in a dose titrated to lower systolic BP to 140 to 155 mm Hg and diastolic BP to 90 to 105 mm Hg. The most efficient method of delivery should be used. If the cervix is favorable and rapid vaginal delivery seems feasible, a dilute IV infusion ofoxytocinis given to accelerate labor; if labor is active, the membranes are ruptured. If the cervix is unfavorable and prompt vaginal delivery is unlikely, cesarean delivery can be considered. Preeclampsia and eclampsia, if not resolved before delivery, usually resolve rapidly afterward, within 6 to 12 hours. Patients should be evaluated at least every 1 to 2 weeks postpartum with periodic BP measurement. If BP remains high after 6 weeks postpartum, patients may have chronic hypertension and should be referred to their primary care physician for management. 1.American College of Obstetricians and Gynecologists (ACOG): Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222.Obstet Gynecol135 (6):e237–e260, 2020. 