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  • Multisystem disease attributable to endothelial dysfunction.

  • Preeclampsia is clinically defined by new onset (after 20 weeks of gestation) of hypertension (systolic blood pressure [SBP] ≥140 mm Hg or diastolic blood pressure [DBP] ≥90 mm Hg) and proteinuria. Preeclampsia can also be diagnosed in the absence of proteinuria, if one or more systemic manifestations are present (see Table 14-1).1

  • Preeclampsia is said to have severe features if blood pressure is high, i.e., SBP ≥160 mm Hg or DBP ≥110 mm Hg, or with the presence of one or more systemic manifestations (see below).1

  • Early onset (<34 weeks gestational age) preeclampsia typically carries greater risk of maternal/fetal complications (see Table 14-2).

  • Occurrence of seizures not attributable to any other cause = eclampsia (seizure may be a presenting sign).

TABLE 14-1Systemic Manifestations of Preeclampsia
TABLE 14-2Additional Potential Complications


Obstetric Decision-Making Examples1

Preeclampsia without severe features: continued monitoring and expectant management until 37 weeks of gestational age, then induction of labor (or cesarean delivery if obstetric indication is present).

Preeclampsia with severe features:

  • ≥34 weeks of gestational age, delivery is recommended after maternal stabilization.

  • <34 weeks of gestational age with stable maternal and fetal condition, expectant management may be considered.

  • <34 weeks of gestational age with any clinical instability, delivery soon after maternal stabilization.

Intrapartum Management Cornerstones

  1. Blood pressure (BP) monitoring and treatment:

    • At least once per hour predelivery

    • Automated BP cuff may underestimate actual BP. Check with manual cuff. Place arterial line for monitoring if divergent.

    • Target SBP <160 mm Hg, DBP <110 mm Hg. Be aware that excessive lowering BP can cause a rapid decrease in uteroplacental perfusion.

    • First-line therapy: labetalol; second-line: hydralazine, nifedipine.

  2. Seizure prophylaxis2:

    • Magnesium sulfate 4 to 6 g intravenous bolus followed by 1 to 2 g/h infusion (renally cleared; reduce dose if renal insufficiency).

    • Target range: 5 to 9 mg/dL.

    • Signs of toxicity: loss of deep tendon reflexes (9.6-12 mg/dL), hypotension, respiratory depression (12-18 mg/dL), hypoxia, EKG changes, and cardiac arrest (24-30 mg/dL).

    • Treatment of magnesium toxicity: CaCl2 intravenously.

  3. Mild fluid restriction (<1 mL/kg/h maintenance during induction of labor and ...

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