Management of Preeclampsia with Severe Features

Clinical Presentation and Diagnosis

The American College of Cardiology recommends that women with preeclampsia who have hypertension with neurological signs or symptoms should receive magnesium sulfate for convulsion prophylaxis, as these are warning signs of impending eclampsia 1, 2
The presence of headache and visual disturbances in a pregnant woman with hypertension requires immediate treatment, with a target blood pressure of diastolic 85 mmHg, systolic <160 mmHg 1, 2
The European Society of Cardiology states that ACE inhibitors, such as lisinopril, are absolutely contraindicated in pregnancy due to fetal renal toxicity, oligohydramnios, and fetal death 6
The American Heart Association recommends that angiotensin receptor blockers, such as losartan, are also contraindicated in pregnancy due to similar fetal complications 6

The American College of Obstetricians and Gynecologists recommends that magnesium sulfate should be administered with a loading dose of 4 g IV over 10-15 minutes, followed by maintenance doses of 5 g IM every 4 hours or 1 g/hour IV infusion 2
Labetalol is the first-line antihypertensive for blood pressure control in pregnant women with preeclampsia, with an initial oral dose of 200 mg three times daily, up to 2400 mg per day 6, 3
The European Society of Cardiology recommends that the target blood pressure for pregnant women with preeclampsia should be diastolic 85 mmHg, systolic <160 mmHg 1, 2

The American College of Obstetricians and Gynecologists recommends that women with preeclampsia at ≥37 weeks' gestation should be delivered, and that abnormal neurological features such as severe intractable headache or repeated visual scotomata are indications for delivery 1, 4, 5
The American College of Cardiology states that delivery should be expedited in pregnant women with preeclampsia and severe features, regardless of prior cesarean sections 1

The American College of Obstetricians and Gynecologists recommends that clinical monitoring, including respiratory rate, deep tendon reflexes, and urine output, should be performed during magnesium sulfate administration 3
The European Society of Cardiology states that blood pressure monitoring should be performed every 4-6 hours, continuously during magnesium infusion, and that neurological assessment should be performed for worsening headache, visual changes, or altered mental status 3
The American Heart Association recommends that laboratory monitoring, including hemoglobin, platelets, liver transaminases, creatinine, and uric acid, should be performed twice weekly, or daily if unstable 4, 2, 3