Management of Preeclampsia at 22 Weeks Gestation

Initial Assessment and Severity Classification

The American College of Cardiology recommends confirming the diagnosis of preeclampsia by documenting blood pressure ≥140/90 mmHg on repeat measurements and assessing for proteinuria using urine protein/creatinine ratio (≥30 mg/mmol is abnormal) 1
The American Heart Association suggests immediately evaluating for severe features, including severe hypertension (≥160/110 mmHg), pulmonary edema, and severe persistent headache, visual disturbances, or epigastric/right upper quadrant pain 1
Obtain baseline laboratory tests at least twice weekly, including complete blood count with hemoglobin and platelets, liver enzymes, creatinine, and uric acid, as recommended by the American College of Obstetricians and Gynecologists 1

The European Society of Cardiology recommends initiating urgent antihypertensive therapy within 15 minutes to prevent maternal stroke, targeting systolic BP 110-140 mmHg and diastolic BP 85 mmHg, in cases of severe hypertension (≥160/110 mmHg) 1, 2
First-line medications include oral nifedipine, as suggested by the European Society of Cardiology 2
The American Heart Association recommends avoiding ACE inhibitors, ARBs, and direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis 3, 2
The European Society of Cardiology suggests avoiding diuretics as they further reduce plasma volume, which is already compromised in preeclampsia and can worsen uteroplacental perfusion 3

The American College of Obstetricians and Gynecologists recommends administering magnesium sulfate if severe features are present to prevent eclamptic seizures 2

The American Heart Association suggests monitoring blood pressure continuously or every 4 hours while awake 1
Perform clinical assessments, including deep tendon reflexes and clonus evaluation, as recommended by the American College of Cardiology 1
Repeat laboratory tests at least twice weekly or more frequently if clinical deterioration occurs, as suggested by the American College of Obstetricians and Gynecologists 1

The American Institute of Ultrasound in Medicine recommends initiating serial ultrasound assessments for fetal biometry, amniotic fluid volume, and umbilical artery Doppler to monitor for intrauterine growth restriction 1
Perform electronic fetal heart rate monitoring to assess fetal well-being, as suggested by the American College of Obstetricians and Gynecologists 1

The American College of Obstetricians and Gynecologists recommends delivering immediately if any of the following develop: repeated episodes of severe hypertension despite treatment, progressive thrombocytopenia, progressively abnormal liver or renal function tests, pulmonary edema, severe intractable headache, repeated visual scotomata, or eclamptic seizures 1
Deliver immediately if non-reassuring fetal status is present, as recommended by the American College of Obstetricians and Gynecologists 1

The American Heart Association recommends not using blood pressure level alone to determine disease severity, as serious organ dysfunction can develop at relatively mild blood pressure elevations 4
Do not use serum uric acid level or degree of proteinuria as indications for delivery, as suggested by the American College of Obstetricians and Gynecologists 4
The American College of Cardiology recommends not administering NSAIDs for analgesia if delivery occurs, as they can worsen renal function in preeclampsia 1
Do not use low molecular weight heparin for prevention, as it is not indicated even with prior early-onset preeclampsia, as recommended by the American College of Chest Physicians 1

The American College of Obstetricians and Gynecologists recommends that management must occur in a hospital with appropriate obstetrical care facilities, maternal intensive care capabilities, and neonatal intensive care unit for extremely premature infants, with coordination of care with maternal-fetal medicine specialists, neonatology, and anesthesiology teams 2

The European Heart Journal recommends first-line medication as oral nifedipine for severe hypertension, with alternative options including intravenous labetalol or methyldopa, and critical contraindications include ACE inhibitors, ARBs, or direct renin inhibitors due to severe fetotoxicity, and intravenous hydralazine due to more perinatal adverse effects 5

The European Heart Journal notes that preeclampsia rarely occurs before 20 weeks except in the presence of trophoblast diseases such as hydatidiform mole, so alternative diagnoses must be considered 6