Evidence-based management for preeclampsia

This review reflects both the variable presentation and the systemic nature of preeclampsia. Recommendations for the comprehensive evaluation and management of organ dysfunction associated with preeclampsia are included. The main points in the review are that: ( 1) Preeclampsia is a systemic disorder that may affect many organ systems. ( 2) For preeclampsia remote from term (<34 weeks), expectant management improves perinatal outcomes, but requires obsessive surveillance to mitigate maternal risks and is a "package." ( 3) Initial assessment and ongoing surveillance of women with preeclampsia should include assessment of all vulnerable maternal organs as well as of the fetus. ( 4) Initiate antihypertensive drug treatment immediately if sBP >= 160mmHg or dBP >= 110mmHg, or if sBP 140-159mmHg and/or dBP 85-109mmHg (prepregnancy renal disease or diabetes). ( 5) The treatment of nonsevere pregnancy hypertension should include a treatment goal of dBP 80105 mmHg ( depending on practitioner preference), with one of the following agents, Methyldopa, Labetalol, Nifedipine, or, with special indications ( renal or cardiac diseases), diuretics. ( 6) Drugs to avoid: angiotensin-converting enzyme inhibitors; angiotensin II receptor antagonists; and atenolol. ( 7) For the acute management of severe hypertension, initially reduce dBP by 10mmHg and maintain the blood pressure at or below that level with either Nifedipine or Labetalol. ( 8) For both prophylaxis against and treatment of eclampsia, MgSO4 (4g IV stat, then 1g/hr). ( 9) For recurrent seizures, MgSO4 (2g IV stat, then increase to 1.5g/hr). ( 10) Total fluid intake should not exceed 80ml/hr; tolerate urine outputs as low as 10ml/hr. (11) Early-onset and/or severe preeclampsia predict later cardiovascular morbidity and mortality; it would seem prudent to offer such women screening and lipid lowering inteventions.