Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

before delivery

1st line – hospital admission and monitoring

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ACUTE
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before delivery
1st line – 

hospital admission and monitoring

Women with clinical findings that warrant close attention should be managed in an inpatient care facility.[1][2][16] On admission, further assessment is required. BP should be monitored regularly for rising levels, need for intervention, and response to therapy; however, there is little guidance on how often this should be performed. A good guide is at least 4 times per day on a floor, or continuously in an intensive care unit.[16]

In cases of well-controlled mild to moderate disease, outpatient management can be considered, although close outpatient monitoring in a day unit or equivalent is required.[1][16][54][Evidence C]

Validated risk prediction models such as fullPIERS or PREP-S may be helpful to guide decisions about admission and thresholds for intervention, alongside full clinical assessment.[16]

Plus – decision regarding delivery

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ACUTE
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before delivery
Plus – 

decision regarding delivery

Treatment recommended for ALL patients in selected patient group

Early delivery may be indicated if there are concerns regarding maternal condition, such as uncontrolled hypertension, deteriorating blood test results, reduced oxygen saturation, or signs of placental abruption. Delivery may also be warranted for fetal indications, such as abnormal umbilical artery Doppler, or cardiotocography concerns.

A rushed delivery for a woman in an unstable condition can be dangerous. Treatment with magnesium sulfate and antihypertensive therapy is necessary before delivery is considered in these women (i.e., presence of seizures, uncontrolled hypertension).[1] Delivery should be considered after the woman’s condition has been stabilized.

At <34 weeks' gestation, prolonging the pregnancy is beneficial for the fetus, as long as maternal and fetal assessments are satisfactory. At 34 to 36 weeks' plus 6 days gestation, there is limited evidence to guide management, and decisions should be made on a case-by-case basis. At 37 weeks' gestation or greater, delivery is the most sensible approach.

Mode of delivery depends on the gestational age, and is determined by individual maternal and fetal factors.[1][16][54]​​ At <32 weeks' gestation, cesarean section is most likely. At >32 weeks' gestation, the decision should be made on a case-by-case basis considering maternal and fetal condition, and the mother's preferences.[16]

If a cesarean is performed, regional anesthesia is preferred if tolerated and there is no coagulopathy. If a general anesthetic is used, care should be taken to prevent the hypertensive response to intubation and extubation, and the problems of laryngeal edema.[81]

Consider – corticosteroid

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ACUTE
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before delivery
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

Prenatal corticosteroids are recommended before 34 weeks' gestation to mature fetal lungs.[16]

There is likely to be a benefit from the administration of corticosteroids at 34 to 36 weeks' gestation, and they should be considered for women who are in suspected, diagnosed, or established preterm labor; are having a planned preterm birth; or have preterm prelabor rupture of membranes.[16]

Primary options

betamethasone sodium phosphate/betamethasone acetate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – magnesium sulfate

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ACUTE
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before delivery
Consider – 

magnesium sulfate

Treatment recommended for SOME patients in selected patient group

Magnesium sulfate is recommended before 34 weeks' gestation for neuroprotection of the baby if women are in established preterm labor or having a planned preterm birth within 24 hours.[16][76] Monitor for clinical signs of magnesium toxicity at least every 4 hours. If there are signs of renal failure (e.g., oliguria), monitor more frequently for magnesium toxicity or reduce the dose of magnesium sulfate. 

Despite initial prophylactic treatment with magnesium sulfate in women before 34 weeks’ gestation if they are in established preterm labor or having a planned preterm birth within 24 hours, some women may still develop eclampsia, albeit rarely. If the mother starts to have seizures, that becomes the main target for management, but the baby still gets the benefit.

Magnesium sulfate is the treatment of choice for women with eclampsia.[1][2]​​[16] Intramuscular or intravenous administration are equally efficacious.[85] The ideal dosage of magnesium sulfate remains uncertain, with higher doses recommended in the US.[1][16] If a high-dose regimen is used, serum magnesium levels should be checked 6 hours after administration, and then as needed. Therapeutic levels are 4.8 to 9.6 mg/dL (4-8 mEq/L).[1] Respiratory depression may occur and patellar reflexes may disappear once the level reaches 10 mEq/L; calcium gluconate may be used to reverse these effects. A dose reduction may be required in women with renal impairment, as well as more frequent monitoring of serum magnesium levels and urine output.[1] 

The role of magnesium sulfate in prevention of seizures is uncertain.[85] In the US, magnesium sulfate is recommended for all women with severe preeclampsia.[1] In other countries, including the UK, a more targeted approach is recommended, allowing the physician to exercise individual judgment based on the woman's specific risk factors (e.g., presence of uncontrolled hypertension or deteriorating maternal condition).[16] 

The UK-based Medicines and Healthcare products Regulatory Agency recommends against any use of magnesium sulfate in pregnancy for longer than 5 to 7 days. If prolonged or repeated use occurs during pregnancy (e.g., multiple courses or use for more than 24 hours) consider monitoring of neonates for abnormal calcium and magnesium levels and skeletal adverse effects. The Food and Drug Administration issued a similar recommendation in 2013.[86][87]

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – antihypertensive therapy

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ACUTE
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before delivery
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with hypertension (BP 140/90 mmHg to 159/109 mmHg)
Plus – 

antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

The American College of Obstetricians and Gynecologists and the UK National Institute for Health and Care Excellence recommend oral labetalol, nifedipine, and methyldopa for these individuals.[1][16] Oral monotherapy with one of these three agents is effective in most cases, but some women might require combination therapy. The choice should be based on any preexisting treatment, side-effect profiles, risks (including fetal effects), and the woman's preference.[16] 

Labetalol is usually considered the antihypertensive of choice, and is effective as monotherapy in 80% of women.[1][4][16]​​ It seems to be safe and effective in pregnant women for the management of preeclampsia; however, it should be avoided in women with asthma or any other contraindication to its use.[1] 

Oral nifedipine can be used if labetalol is not suitable.

Methyldopa is widely used in lower- and middle-income countries and remains an acceptable alternative if labetalol and nifedipine are not suitable.[2]​​[16] Methyldopa should be avoided in the postpartum period because of its association with depression; women already taking methyldopa should change to an alternative antihypertensive treatment within 2 days of delivery.[16][84]

Primary options

labetalol: 100 mg orally twice daily initially, increase gradually according to response, usual dose 100-400 mg twice daily, maximum 2400 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90-120 mg/day (depending on brand)

OR

methyldopa: 250 mg orally two to three times daily initially, increase gradually according to response, usual dose 250-1000 mg/day given in 2-4 divided doses, maximum 3000 mg/day

Plus – antihypertensive therapy

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ACUTE
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before delivery
|
with severe hypertension (BP ≥160/110 mmHg)
Plus – 

antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

Antihypertensive therapy should be started if systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg.[1]

For acute-onset, severe hypertension managed in a critical care setting, intravenous labetalol, intravenous hydralazine, or oral nifedipine can be used first line. Discuss second-line options (e.g., combination therapy, alternative drugs) with a specialist if the woman does not respond to first-line therapies.[1][16]​​[Evidence C]

Labetalol is usually considered the antihypertensive of choice, and is effective as monotherapy in 80% of pregnant women.[1][4][16]​​[Evidence C] It seems to be safe and effective in pregnant women for the management of preeclampsia; however, it should be avoided in women with asthma or any other contraindication to its use.[1]

Oral nifedipine may be as effective as intravenous labetalol.[82]

Hydralazine is widely used to manage severe hypertension in pregnancy; however, it can produce an acute fall in BP and should be used along with plasma expansion.[16] Smaller, more frequent doses of hydralazine may be used.

Primary options

labetalol: 10-20 mg intravenously initially, followed by 20-80 mg every 10-30 minutes according to response, maximum 300 mg/total dose; or 1-2 mg/minute intravenous infusion

OR

nifedipine: 10-20 mg orally (immediate-release) initially, repeat in 20 minutes if needed, followed by 10-20 mg every 2-6 hours according to response, maximum 180 mg/day

OR

hydralazine: 5 mg intravenously initially, followed by 5-10 mg every 20-40 minutes according to response, maximum 20 mg/total dose; or 0.5 to 10 mg/hour intravenous infusion

ONGOING

after delivery

1st line – close monitoring of fluid balance

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ONGOING
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after delivery
1st line – 

close monitoring of fluid balance

During the postpartum period, the main risk to the mother is fluid overload. Although invasive hemodynamic monitoring is recommended in the US, UK guidelines recommend a fluid-restriction regimen of 80 mL/hour.[1][16]

Women should be on a fluid input/output chart. Intravenous fluids should be restricted to 80 mL/hour until the woman is drinking freely, as long as urine output is normal. There is no need to treat low urine output, and fluid challenges should not be given except after careful consideration and under strict surveillance. As long as there is cardiovascular stability, adequate urine output, and maintenance of oxygen saturation, there is no need for invasive monitoring.[16]

Consider – continue antihypertensives and magnesium sulfate

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ONGOING
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after delivery
Consider – 

continue antihypertensives and magnesium sulfate

Treatment recommended for SOME patients in selected patient group

Control of hypertension and seizures needs to be continued after delivery until recovery is apparent.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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