Uzan et al more of the following signs indicates the need for imme- diate delivery: uncontrolled severe hypertension (not responsive to dual therapy), eclampsia, acute pulmonary edema, abruptio placentae, subcapsular hepatic hematoma, or thrombocytopenia ,50,000/mm3. Delivery after corticosteroid therapy for pulmonary maturation is necessary if any of the following criteria is present: persistent epigastric pain, signs of imminent eclampsia (headaches or persistent visual disorders), de novo creatinine .120 µmol/L, oliguria below 20 mL/hour, progressive HELLP syndrome, prolonged or severe variable decelerations with short-term variability less than 3 milliseconds. When emergency delivery is not required, labor can be induced by cervical ripening.22 Antihypertensive treatment is useful only in severe pre- eclampsia because the sole proven benefit of such management is to diminish the risk of maternal complications (cerebral hemorrhage, eclampsia, or acute pulmonary edema).29 There is no international consensus concerning antihypertensive treat- ment in pre-eclampsia. The four drugs authorized for the treat- ment of hypertension in severe pre-eclampsia in France are nicardipine, labetalol, clonidine, and dihydralazine.29 There is no ideal target blood pressure value, and too aggressive a reduction in blood pressure is harmful to the fetus.30 Therapy with a single agent is advised as first-line treatment, followed by combination treatment when appropriate. The algorithm for antihypertensive treatment proposed by French experts22 is shown in Figure 1. Pulmonary maturation using corticosteroids must be con- sidered, taking gestational age into account. Betamethasone remains the gold standard at a dosage of two injections of 12 mg 24 hours apart; this treatment reduces the risk of hyaline membrane disease, intraventricular hemorrhage, and neonatal mortality.31 Magnesium sulfate (MgSO4) may be part of the therapeutic armamentarium for severe pre-eclampsia. It is indicated in the treatment of eclamptic convulsions as well as for secondary prevention of eclampsia, thus replac- ing treatment by diazepam, phenytoin, or the combination of chlorpromazine, promethazine, and pethidine.32 The efficacy of MgSO4 in the reduction of maternal and neo- natal complications of eclampsia is well established. It is administered intravenously, first at a loading dose of 4 g over 15–20 minutes, which can be repeated at a half dose (2 g) if convulsion recurs, and then at a maintenance dose of 1 g/hour for 24 hours.22,32 MgSO4 treatment must be monitored in the intensive care unit because organ failure may occur. This monitoring is based on repeated check- ing for a Glasgow score of 15, tendon reflexes, respiratory 470 submit your manuscript | www.dovepress.com Dovepress Dovepress frequency .12 per minute, and diuresis .30 mL/hour. Any manifestation of overdose requires stopping the infusion, considering injection of calcium gluconate, and measuring blood magnesium levels.22 Eclampsia is generally considered an indication for emergency cesarean section. Nonetheless, a decision to delay a cesarean, albeit rare, may be based on fetal status and justified if the mother’s condition is stable and reassuring after treatment.33 Management following delivery Although delivery is the only effective treatment for pre-eclampsia, and despite the fact that clinical symptoms and laboratory abnormalities usually regress in the hours afterwards, the risk of complications persists for some time following delivery.6 Pre-eclampsia is associated with long- term morbidity and mortality. Approximately 20% of women with pre-eclampsia develop hypertension or microalbuminu- ria during long-term follow-up, and the risk of subsequent cardiovascular and cerebrovascular disease is doubled in women with pre-eclampsia and gestational hypertension compared with age-matched controls.34 A recent prospective epidemiological study with a median follow-up duration of 30 years provides evidence that pre-eclampsia is a marker of increased mortality from cardiovascular disease.35 Hemodynamic, neurological, and laboratory monitoring is necessary following delivery for patients with severe pre- eclampsia.36 Hemodynamic monitoring includes frequent blood pressure measurements to enable adjustment of anti- hypertensive treatment and frequent monitoring of diuresis and weight according to intake (oliguria should prompt progressive fluid resuscitation and sometimes diuretic use). Neurological monitoring consists of checking for signs of imminent eclampsia, including headaches, phosphene sig- nals, tinnitus, and brisk tendon reflexes. Clinical monitor- ing must be done several times daily during the week after delivery, a period considered at high risk for complications. If necessary, monitoring can be performed in an intensive care unit. Laboratory monitoring should be done several times daily in the first 72 hours after delivery and thereafter adapted according to progress of the indices. It must include a complete blood count, liver function tests, and measurement of lactate dehydrogenase. Discharge from hospital cannot be considered until all clinical and laboratory indices have returned to normal, and regular monitoring by the patient’s general practitioner as necessary if treatment for hypertension is to be continued after discharge. Vascular Health and Risk Management 2011:7