Preeclampsia Without Severe Features

Preeclampsia without severe features is new hypertension (140/90 mmHg or more but below 160/110 mmHg) after 20 weeks with proteinuria or mild organ involvement, and none of the severe criteria. It is caused by placental dysfunction. It matters because it can progress to severe disease within days, so careful surveillance and timed delivery are needed.

• Some women progress to severe features.
• Risk factors: first pregnancy, previous preeclampsia, chronic hypertension, diabetes, obesity, multiple pregnancy.
• Outpatient care is possible only for reliable women near a facility.

Women are usually well, with mild hypertension and proteinuria found on routine visits. Some have mild swelling or mild headache.

• Blood pressure 140/90 to 159/109 mmHg.
• No visual disturbance, epigastric pain, clonus or oliguria.
• Differential diagnosis: gestational hypertension, chronic hypertension, kidney disease, urinary tract infection with proteinuria, normal pregnancy oedema.
• Complications: progression to severe preeclampsia, eclampsia, HELLP syndrome, placental abruption, fetal growth restriction, preterm birth.

The diagnosis needs two readings 4 hours apart and proteinuria or organ dysfunction.

• Blood pressure 140/90 to 159/109 mmHg on two occasions; urine protein to creatinine ratio 30 mg/mmol or more or dipstick 1 plus or more.
• Full blood count, creatinine (below 90 micromol/L), alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, uric acid, urine protein to creatinine ratio.
• Ultrasound for growth and liquor volume, umbilical artery Doppler, cardiotocography.
• Repeat blood tests twice weekly; absence of any severe feature confirms the category.

The principle is blood pressure control, surveillance for progression and delivery at 37 weeks.

• Supportive: day care or admission at diagnosis; rest; normal salt diet; daily fetal movement counts; blood pressure measured 4-hourly in hospital or twice daily at home.
• Pharmacological: labetalol 200 mg oral every 8 to 12 hours (maximum 2.4 g daily) or nifedipine modified release 30 to 60 mg oral once daily (maximum 120 mg) or methyldopa 250 to 500 mg oral 8-hourly (maximum 3 g daily), aiming for 110 to 135/85 mmHg; aspirin 150 mg oral at night until 36 weeks; betamethasone 12 mg IM twice, 24 hours apart, if delivery before 34 weeks is expected; magnesium sulphate 4 g IV over 20 minutes then 1 g per hour for 24 hours if severe features appear; oxytocin 10 IU IM after birth, avoiding ergometrine.
• Procedures: induction of labour at 37 weeks using misoprostol 25 micrograms vaginal 6-hourly (maximum 4 doses) or a Foley catheter with a 30 mL balloon, then oxytocin 2 mU/minute doubling every 30 minutes to 32 mU/minute; earlier delivery if severe features develop.
• Special groups: asthma uses nifedipine instead of labetalol; diabetes needs insulin adjustment with steroid use.
• Red flags: blood pressure 160/110 mmHg or more, headache, visual change, epigastric pain, vomiting, reduced fetal movements, platelets below 100 x 10^9/L, creatinine above 90 micromol/L.
• Follow-up: review twice weekly with blood tests; growth scan every 2 weeks; blood pressure checks postpartum at 6 hours, daily for 5 days, then at 2 and 6 weeks.