Management of Preeclampsia with Severe Hypertension and Fetal Growth Restriction

Clinical Presentation and Diagnosis

The American College of Cardiology recommends that patients with severe hypertension (160/100 mmHg) at 37 weeks gestation should be assessed for preeclampsia with fetal growth restriction 1
The International Society for the Study of Hypertension in Pregnancy (ISSHP) guidelines state that absent end-diastolic flow on umbilical artery Doppler is an absolute indication for delivery regardless of other factors 1, 2, 3
Severe hypertension and absent end-diastolic flow on umbilical artery Doppler mandates inpatient management 2, 3
Fundal height discrepancy (35 weeks at 37 weeks GA) indicates fetal growth restriction 3

The ISSHP guidelines recommend that women with preeclampsia should be delivered at 37 weeks gestation 1
Target blood pressure: diastolic 85 mmHg and systolic <160 mmHg 1
First-line agents for antihypertensive therapy include oral labetalol (100 mg twice daily, up to 2400 mg/day) 4, 5, oral nifedipine 1, 3, and oral methyldopa 1, 5
For hypertensive crisis (≥160/110 mmHg), use IV labetalol 6, 5
Magnesium sulfate should be administered for seizure prophylaxis in patients with severe hypertension and neurological signs (irritability) 1

Blood pressure monitoring every 15-30 minutes until controlled 1
Laboratory tests immediately: complete blood count (platelets), liver transaminases, creatinine, uric acid 1
Clinical assessment for clonus, visual symptoms, severe headache 1
Urine protein quantification if not already done 1
Continuous cardiotocography given absent end-diastolic flow on umbilical artery Doppler 2, 3
Ultrasound assessment of amniotic fluid volume 2, 3

Cesarean section is likely indicated given absent end-diastolic flow on Doppler, unfavorable cervix, primigravida status with severe preeclampsia, and fetal growth restriction 1, 2, 3
However, induction of labor could be considered if fetal monitoring is reassuring and the maternal condition is stable 1, 2, 3

ACE inhibitors, ARBs, or direct renin inhibitors are strictly contraindicated in pregnancy due to severe fetotoxicity 4, 5