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Preeclampsia with severe features: Delaying delivery in pregnancies remote from term

Preeclampsia with severe features: Delaying delivery in pregnancies remote from term
Literature review current through: Jan 2024.
This topic last updated: Jan 30, 2023.

INTRODUCTION — In a patient with preeclampsia (table 1), the phrase "with severe features" is added when any of the features listed in the following table are present (table 2) [1]. These criteria for the severe spectrum of disease are widely used and based on consensus expert opinion and clinical experience.

Most patients who have preeclampsia with severe features are delivered promptly to prevent maternal and fetal complications. Since the disease is progressive and no medical treatment to prevent progression exists (other than magnesium sulfate to prevent eclampsia), delivery is always in the mother's best interest. However, because preterm birth may not be in the newborn's best interest, delaying delivery to increase fetal maturity and thereby reduce neonatal morbidity and mortality can be considered under certain circumstances.

The risk of delaying delivery is that worsening maternal endothelial dysfunction and continued poor perfusion of major maternal organs may lead to severe injury to these end-organs, including the brain, liver, kidneys, hematologic and vascular systems, and placenta. Fetal risks include progressive growth restriction and demise from placental abruption or uteroplacental insufficiency. Therefore, when the clinician and patient choose to delay delivery, the specific circumstances prompting this approach rather than prompt delivery should be clearly documented and the decision revisited at regular intervals.

This topic will discuss issues that should be considered in selecting patients with preeclampsia with severe features for delayed versus prompt delivery. The overall management of pregnancies complicated by preeclampsia is reviewed separately. (See "Preeclampsia: Antepartum management and timing of delivery".)

Other related topics include:

(See "Preeclampsia: Clinical features and diagnosis".)

(See "Hypertensive disorders in pregnancy: Approach to differential diagnosis".)

(See "Anesthesia for the patient with preeclampsia".)

(See "Preeclampsia: Pathogenesis".)

(See "Preeclampsia: Prevention".)

CHANGES IN TERMINOLOGY AND VARIATIONS IN CRITERIA — In 2013, the American College of Obstetricians and Gynecologists (ACOG) replaced the term "severe preeclampsia" with the term "preeclampsia with severe features." This topic will use the term preeclampsia with severe features as defined by ACOG, but it should be noted that studies published before the change in terminology used different features to characterize the severe end of the preeclampsia spectrum. The diagnosis of severe preeclampsia in these studies was sometimes based on hypertension with fetal growth restriction or proteinuria >5 grams/day, which ACOG no longer considers features of severe disease. There is minor variation in terminology worldwide; for example, some guidelines consider uteroplacental dysfunction (including fetal growth restriction) a defining characteristic of preeclampsia since preeclampsia is a primary placental disorder [2]. (See "Preeclampsia: Clinical features and diagnosis", section on 'Definitions/diagnostic criteria' and "Preeclampsia: Clinical features and diagnosis", section on 'Typical presentation' and "Preeclampsia: Clinical features and diagnosis", section on 'Rare and atypical presentations'.)

INCIDENCE — In a database of hospital discharge data for approximately 300,000 births in the United States from 1988 to 1997, the overall incidence of preeclampsia with severe features was approximately 1 percent [3]. Studies limited to nulliparous patients report a 2 to 2.5 percent incidence of preeclampsia with severe features [4,5].

Approximately 30 percent of cases occur before 34 weeks of gestation [6].

MORBIDITY AND MORTALITY

Maternal – Serious maternal complications of preeclampsia with severe features include pulmonary edema, hypertensive encephalopathy, stroke, kidney failure, liver failure or rupture, retinal detachment or cortical blindness, disseminated intravascular coagulation, placental abruption, seizures (eclampsia), myocardial infarction, cardiomyopathy, and death [7].

In studies of delaying delivery of preeclampsia with severe features with onset in the second trimester, 25 to 63 percent of patients developed serious complications, including HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), renal insufficiency, placental abruption, pulmonary edema, and eclampsia [8-11].

Fetal – Serious fetal complications of preeclampsia with severe features include growth restriction and death. The frequency of these complications depends, in part, on the gestational age at onset: Early onset (variably defined as either second trimester or <34 weeks of gestation) has a poorer prognosis than late onset (variably defined as either third trimester or ≥34 weeks of gestation). In one series, three neonatal deaths occurred among the 81 patients with early onset preeclampsia and none among the 511 patients with late-onset preeclampsia [12]. The frequency of a small for gestational age birth in patients with preeclampsia with severe features giving birth before versus after 34 weeks was 55 and 33 percent, respectively.

Perinatal mortality – Studies of delaying delivery of preeclampsia with severe features with onset in the second trimester describe high perinatal mortality (PNM) [8,11]:

Onset <22+6 weeks – PNM 98 percent

Onset 23+0 to 23+6 weeks – PNM 87 percent

Onset 24+0 to 24+6 weeks – PNM 67 percent

Onset 25+0 to 26+0 weeks – PNM 40 percent

A limitation of these data is that fewer than 100 cases were available at each gestational age range. PNM varies among hospitals and is impacted by factors other than gestational age, such as sex, birth weight, and receipt of antenatal corticosteroids, and these factors should be considered when counseling individual patients. (See "Periviable birth (limit of viability)".)

Neurodevelopment – Surviving infants are at high risk of short- and long-term morbidity, largely related to gestational age and weight at birth. For example, in a Dutch study that assessed neurodevelopmental outcome at age 4.5 years among 216 children of mothers with severe hypertensive complications of pregnancy, mean gestational age at delivery 31.4 weeks, and 91 percent incidence of growth restriction, only 54 percent had normal results on all tests of developmental outcome and 7 percent were attending special education classes, which is approximately sevenfold higher than the nationwide rate of 1 percent in the Netherlands [13]. (See "Overview of short-term complications in preterm infants" and "Infants with fetal (intrauterine) growth restriction".)

INITIAL PATIENT EVALUATION AND CARE — Patients with suspected preeclampsia should be admitted to the hospital to confirm the diagnosis, assess severity, monitor maternal and fetal status, and initiate supportive therapy or begin the process for delivery. Transfer to a tertiary care center should be considered, if necessary, to optimize care of the mother and the newborn in an intensive care setting and to access adequate ancillary support services (anesthesiology, blood bank, laboratory services) in the event of severe complications. (See "Preeclampsia: Clinical features and diagnosis" and "Preeclampsia: Antepartum management and timing of delivery".)

The following synopsis describes our initial assessment and management of pregnancies with preeclampsia with severe features:

Admission to the labor and delivery unit (or similar unit with equivalent monitoring and resources) – The patient may need to be monitored in an intensive care type setting for 48 hours or more.

Administration of antenatal corticosteroids to preterm pregnancies of appropriate gestational age if delivery is not imminent. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery".)

In pregnancies <34+0 weeks of gestation, reasonable efforts should be made to delay delivery for 48 hours to complete a full course of steroids. However, intervention will be necessary if maternal or fetal status deteriorates. Betamethasone and dexamethasone have low mineralocorticoid activity compared with other corticosteroids, do not aggravate hypertension, do not affect the severity or duration of severe preeclampsia, and have well-established favorable effects on newborn outcome, including in pregnancies complicated by hypertension [14-16].

Administration of magnesium sulfate for seizure prophylaxis. (See "Preeclampsia: Intrapartum and postpartum management and long-term prognosis", section on 'Seizure prophylaxis'.)

In pregnancies <32 weeks of gestation, magnesium sulfate also provides newborn neuroprotection in the event of preterm birth. (See "Neuroprotective effects of in utero exposure to magnesium sulfate".)

Frequent blood pressure monitoring, given the risk for severe hypertension.

Careful recording of fluid intake and urine output, given the risk for pulmonary edema.

Laboratory studies, including a complete blood count (including platelet count and smear), electrolytes, creatinine, alanine and aspartate aminotransferase (ALT, AST), and lactic acid dehydrogenase (LDH) [17].

We obtain a coagulopathy profile (prothrombin time [PT], partial thromboplastin time [PTT], fibrinogen) if the ALT and AST are more than twice the upper limit of normal, if the platelet count is less than 100,000 cells/microL, or if placental abruption is suspected.

Laboratory studies are repeated every 6 to 12 hours while the patient is on the labor unit. (See "Preeclampsia: Clinical features and diagnosis".)

Assessment of fetal well-being, including a nonstress test and ultrasound examination for amniotic fluid volume determination and estimation of fetal weight. If the fetus is growth restricted, umbilical artery and ductus venosus Doppler velocimetry are performed. (See "Fetal growth restriction: Evaluation".)

PREGNANCY OUTCOME WITH DELAYED VERSUS PROMPT DELIVERY — The goal of delaying delivery is to provide more time for the fetus to mature and thereby reduce neonatal morbidity and mortality from preterm birth without incurring serious maternal or fetal complications from disease progression.

Limited data suggest that expectant management results in pregnancy prolongation of approximately two weeks, with more favorable newborn outcomes than prompt delivery and low maternal risks.

In two small randomized trials comparing delayed delivery with prompt delivery in pregnancies with preeclampsia with severe features (based on blood pressure criteria alone) at 28 to 32 [18] and 28 to 34 [19] weeks of gestation, both trials reported significant prolongation of pregnancy and improvement in neonatal outcome with expectant management, with no increase in the rate of maternal complications.

Prolongation of pregnancy averaged 15.4 days (range 4 to 36 days) in the larger of these trials (95 participants) [18] and 7.1 days in the smaller trial (38 participants) [19].

In the larger trial, there were no cases of eclampsia or perinatal death and no increase in the frequency of abruption with expectant management (incidence of abruption: 4 percent) [18].

Newborns in the expectantly managed group had a significantly more advanced gestational age at delivery (32.9 versus 30.8 weeks) and higher mean birth weight (1622 versus 1233 grams), lower rate of admission to the neonatal intensive care unit (76 versus 100 percent), and lower rate of neonatal complications (respiratory distress 22 versus 50 percent; necrotizing enterocolitis 0 versus 11 percent) [18].

By comparison, the benefit of delaying delivery was unclear in a larger randomized trial (MEXPRE Latin Study) including 267 patients at 28 to 33 weeks of gestation with severe preeclampsia (based on blood pressure criteria plus proteinuria >5 grams or end-organ symptoms [headache, visual disturbances, epigastric pain, tinnitus] but excluding those with HELLP [hemolysis, elevated liver enzymes, low platelets], renal failure, pulmonary edema, and other comorbidities) [20]. In this trial, which was conducted in countries with limited resources:

Expectant management resulted in an eight-day prolongation of pregnancy (10.3 versus 2.2 days for pregnancies delivered in 24 to 72 hours after a course of antenatal corticosteroids).

However, perinatal mortality was similar in both groups (9.4 versus 8.7 percent), as was composite neonatal morbidity (56.4 versus 55.6 percent).

Expectant management increased the risk of small for gestational age (21.7 versus 9.4 percent, relative risk [RR] 2.27, 95% CI 1.21-4.14) and abruption (7.6 versus 1.5 percent, RR 5.07, 95% CI 1.13-22.7).

The lack of newborn benefit from delaying delivery in this trial compared with the previous two trials may have been due to selection of patients at the most severe end of disease spectrum. Forty percent of patients in the expectant management group were delivered for uncontrollable hypertension (compared with 6 percent in an earlier trial [18]), which suggests that more aggressive attempts at blood pressure control might have resulted in greater prolongation of pregnancy and, in turn, less neonatal morbidity from preterm birth. In addition, the lack of reduction in perinatal mortality despite pregnancy prolongation may have been related to inadequate neonatal intensive care resources in some countries.

Data from observational studies – Although lower-quality data, observational data also support use of delaying delivery of appropriately selected patients with preeclampsia with severe features. In a systematic review of observational studies of expectant versus interventionist care of preeclampsia with severe features <34 weeks of gestation (39 studies, 4650 patients) [7]:

Expectant management was associated with pregnancy prolongation ranging from 7 to 14 days; only one-third of patients remained pregnant beyond seven days.

One-half of expectantly managed patients delivered for maternal indications, and the other half delivered for fetal indications.

The median rate of serious maternal complication was <5 percent, which was similar to that with prompt intervention (two studies, 42 patients).

TIMING OF DELIVERY — Our approach to delivery timing is described in the algorithm (algorithm 1) and in the following sections.

Shared decision-making — We employ shared decision-making to carefully weigh the risks and benefits of delaying delivery versus prompt delivery (or pregnancy termination), considering individual clinical factors, such as the gestational age, estimated fetal weight, presence/absence of growth restriction, results of fetal testing, presence/absence of oligohydramnios, whether a full course of corticosteroids can be/has been administered, the neonatologist's assessment of the neonatal prognosis, and the mother's values and preferences. Use of the NICHD birth outcome predictor tool can be helpful for counseling patients at 22 to 25 weeks of gestation.

We emphasize to patients that delaying delivery is not associated with any direct maternal benefits. The mother is taking on a small but serious risk to their own health to delay delivery until a more advanced gestational age is reached with a more favorable neonatal prognosis [21]. (See 'Pregnancy outcome with delayed versus prompt delivery' above and 'Morbidity and mortality' above.)

Contraindications to delaying delivery — In some clinical situations, we believe the risks associated with delaying delivery are greater than any potential benefits [1,6,22]. Under these circumstances, we advise patients to undergo delivery regardless of gestational age and even if the second corticosteroid dose has not been given or the maximum therapeutic effect of steroids has not been achieved.

Fetal conditions warranting delivery include:

Demise.

Abnormal fetal testing (eg, nonreactive nonstress test or low biophysical profile score, growth restriction with absent/reversed diastolic flow on umbilical artery Doppler or abnormal ductus venosus waveform).

Estimated fetal weight less than the fifth percentile for gestational age. Although ACOG considered fetal growth restriction defined as an estimated weight <10th percentile as an indication for delivery in the past, in the setting of normal fetal parameters (eg, amniotic fluid volume, Doppler findings, antenatal fetal testing), in 2019 they suggested that continuation of expectant management may be reasonable in the absence of other maternal and fetal criteria [1].

Oligohydramnios (amniotic fluid index <5 cm or single deepest vertical pocket <2 cm).

No expectation for survival at the time of maternal diagnosis (eg, lethal anomaly, extreme prematurity).

Maternal conditions warranting delivery include:

Hemodynamic instability (shock).

Persistent severe hypertension unresponsive to antihypertensive therapy. (See 'Patients with preeclampsia with severe features based on blood pressure criteria alone' below.)

Symptoms of severe disease: Severe persistent headache (ie, new-onset headache unresponsive to acetaminophen and not accounted for by alternative diagnoses or visual disturbances [1]) or epigastric/right upper quadrant pain unresponsive to analgesics.

Motor deficit or altered sensorium.

Pulmonary edema.

Kidney failure.

Stroke.

Myocardial infarction or cardiomyopathy.

Laboratory abnormalities, such as:

Aminotransferases increasing over 6 to 12 hours and reaching levels twice the upper limit of normal

Progressive decrease in platelet count to <100,000 cells/microL

Coagulopathy

New or worsening renal dysfunction (serum creatinine >1.1 mg/dL [97 micromol/L] or twice baseline)

Maternal request for immediate delivery.

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) – Although some studies have reported serious maternal complications in the setting of expectant management of HELLP syndrome, these are uncommon with careful maternal monitoring. Nonetheless, the benefit of expectant management in this setting has not been demonstrated [23,24]. The aim of expectant management is to improve neonatal morbidity and mortality; there is no evidence that overall perinatal outcome is improved with expectant management of HELLP compared with pregnancies delivered after a course of corticosteroids. We consider expectant management in this setting an investigational approach. (See "HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)".)

Eclampsia. (See "Eclampsia".)

Obstetric conditions warranting delivery include:

Placental abruption

Preterm labor

Preterm prelabor rupture of membranes

Our approach

Gestational age ≥34 weeks of gestation — We suggest prompt delivery for all patients with preeclampsia with severe features who have reached ≥34 weeks of gestation. Prolonging pregnancy subjects the mother and fetus to serious risks with relatively small potential newborn benefits at this gestational age [25]. Our approach is consistent with recommendations by expert groups, such as the American College of Obstetricians and Gynecologists (ACOG) [1]. The desire for prompt delivery does not necessarily preclude a trial of labor and vaginal birth. (See 'Delivery' below.)

Gestational age before or at the limit of viability — The limit of viability is the earliest stage of fetal maturity where there is a reasonable chance, although not a high likelihood, of extrauterine survival. In both of the following clinical scenarios, it is unlikely that pregnancy can be prolonged sufficiently to substantially benefit the newborn while placing the mother at substantial risk for serious complications, as described above (see 'Morbidity and mortality' above). Therefore:

For preeclampsia with severe features before the limit of viability, we suggest pregnancy termination to reduce the mother's risk of developing life-threatening morbidity or death when newborn survival is highly unlikely.

For preeclampsia with severe features at the limit of viability, we offer pregnancy termination to reduce the mother's risk of developing life-threatening morbidity or death and, depending upon the mother's wishes, to prevent the birth of a newborn at high risk of death or severe permanent disability. (See "Periviable birth (limit of viability)".)

Gestational age between the limit of viability and 34 weeks of gestation — We typically offer expectant management to patients with preeclampsia with severe features <34 weeks of gestation in whom the diagnosis is based on blood pressure criteria alone or laboratory criteria alone and who have no contraindications to continuing the pregnancy. (See 'Contraindications to delaying delivery' above.)

Approximately 40 percent of patients with preeclampsia with severe features meet these criteria for delaying delivery [7].

Patients with preeclampsia with severe features based on blood pressure criteria alone — Delaying delivery of asymptomatic patients with preeclampsia with severe features based on blood pressure criteria alone appears to be safe and beneficial to the neonate in pregnancies in which severe hypertension can be controlled with antihypertensive drugs and fetal testing is reassuring [18,19]. The use of antihypertensive drugs does not alter the course of preeclampsia or reduce perinatal morbidity or mortality, and their use may diminish uteroplacental perfusion or mask an increase in blood pressure, which can be a sensitive marker of worsening preeclampsia [26,27]. For these reasons, treatment of mild hypertension in patients with preeclampsia is generally not recommended; however, antihypertensive agents should be used promptly in patients with severe hypertension to prevent stroke in the mother and possibly prevent placental abruption. (See "Treatment of hypertension in pregnant and postpartum patients", section on 'Acute therapy of severe hypertension' and "Treatment of hypertension in pregnant and postpartum patients", section on 'Target blood pressure'.)

We begin antihypertensive therapy (algorithm 2) with the agents in the table (table 3).

If blood pressure cannot be reduced to a safe level for the mother (typically <160/110 mmHg) with labetalol, hydralazine, or nifedipine, then we would move towards delivery.

If blood pressure can be reduced to a safe level for the mother (typically <160/110 mmHg) and underlying chronic hypertension is suspected or previously documented, we begin oral antihypertensive drugs or increase the patient's existing medications to maintain blood pressure below severe levels (table 4). (See "Treatment of hypertension in pregnant and postpartum patients", section on 'Oral maintenance therapy'.)

If blood pressure was treated effectively and the patient will not be delivered, it is reasonable to begin oral antihypertensive therapy, especially in pregnancies <32 weeks, to attempt to delay delivery until 34 weeks [18,19]. This is a shared decision with the patient and it should be documented that there is no maternal benefit to continuing the pregnancy but the patient desires to delay delivery under closely monitored, controlled inpatient conditions for fetal benefit. (See 'Antepartum monitoring' below.)

If severe hypertension recurs, prompt retreatment (table 3) is required to reduce the risk of maternal cardiovascular complications and we would generally move toward delivery.

Patients with preeclampsia with severe features based on transient laboratory abnormalities alone — Delaying delivery of asymptomatic patients with preeclampsia with severe features by laboratory criteria alone (alanine and aspartate aminotransferase [ALT, AST] twice the upper limit of normal, platelet count less than 100,000 cells/microL) appears to be safe and beneficial for the neonate if the abnormalities resolve within 24 to 48 hours of hospitalization [18,19].

In otherwise asymptomatic or mildly hypertensive patients, it is reasonable to delay delivery, administer a course of antenatal corticosteroids, and repeat the laboratory tests (AST, ALT, platelet count) every 6 to 12 hours to see if they improve. (See 'Initial patient evaluation and care' above.)

We promptly deliver patients with initially abnormal laboratory results who have worsening liver chemistries or falling platelet counts over a period of 6 to 12 hours and those who develop other signs of preeclampsia with severe features.

If the initially abnormal laboratory results improve, we offer delayed delivery and closely monitor the mother and fetus. (See 'Antepartum monitoring' below.)

If the initially abnormal laboratory results remain stable, we often offer delayed delivery with close maternal-fetal monitoring, but this decision is made on a case-by-case basis. ALT, AST, and platelet counts are followed closely as initial improvements in these values may be a transient result of antenatal corticosteroid therapy. (See 'Antepartum monitoring' below.)

Antepartum monitoring — Close supervision of mother and fetus is crucial when delivery is delayed as it is impossible to predict the clinical course of the disease after admission and clinical deterioration can occur rapidly [28]. There are no data from randomized trials on which to base an evidence-based protocol for managing these pregnancies. Our general approach to surveillance is as follows.

Obtain high-level care – Patients are hospitalized and cared for by, or in consultation with, a maternal-fetal medicine specialist, at a facility with adequate maternal and neonatal intensive care resources.

Transfer the patient to an antepartum unit when stable – After initial assessment and stabilization on the labor and delivery unit for 12 to 24 hours (see 'Initial patient evaluation and care' above), patients can be monitored and medically managed on an antepartum unit if delivery is not anticipated and there are no contraindications to delaying delivery. All the following should be present before transfer to a less intensive level of care:

The patient should be asymptomatic.

Blood pressure should be stable at a safe level without labile elevations into the severe range.

Laboratory results should be in the normal range or improving.

Fetal testing should be reassuring.

Hospitalize until delivery – Findings from frequent maternal and fetal assessment are reviewed throughout the day, and the ongoing risks of expectant management versus the benefit of further fetal maturation are reevaluated frequently. Patients with preeclampsia with severe features are not candidates for outpatient management.

Monitor blood pressure every four hours. We do not awaken patients at night to check blood pressure if they are asymptomatic and blood pressure has been well-controlled during the day. Development of recurrent severe hypertension would warrant delivery. (See "Treatment of hypertension in pregnant and postpartum patients".)

Frequently assess maternal symptoms (eg, headache, vision changes, epigastric or abdominal pain, decreased fetal activity, vaginal bleeding). Symptoms of preeclampsia with severe features would warrant delivery.

Accurately record fluid intake and urine output to identify oliguria (defined as <500 mL over 24 hours). Although oliguria is no longer one of the criteria for preeclampsia with severe features, it is still a sign of severe disease if it is caused by intrinsic kidney disease. Deteriorating kidney function (rising creatinine to above 1.1 mg/dL [0.1 mmol/L]) and persistent oliguria over 24 to 48 hours would warrant delivery. Daily maternal weights can also be useful in monitoring fluid status.    

Repeat laboratory tests – Obtain a complete blood count, serum creatinine, and liver chemistries at least twice weekly. If laboratory abnormalities worsen after an initial improvement, we would repeat the tests in 12 to 24 hours and deliver if any of the following:

Elevated liver chemistries (twice the upper limit of normal)

Thrombocytopenia <100,000 platelets/microL

Rising creatinine level that is above 1.1 mg/dL (0.1 mmol/L) is confirmed

Finish the course of antenatal corticosteroids, if not already completed.

Regularly assess fetal well-being – There is no standardized protocol for fetal assessment in this setting. We obtain fetal kick counts and nonstress tests at least daily, ultrasound assessment of amniotic fluid volume once or twice per week, and ultrasound estimation of fetal growth no more than every two to three weeks; the potential 20 percent margin of error of a single examination limits the reliability of serial examinations at more frequent intervals. If the fetus is growth restricted, we obtain weekly Doppler velocimetry of the umbilical artery and ductus venosus. (See "Nonstress test and contraction stress test" and "Assessment of amniotic fluid volume" and "Fetal growth restriction: Pregnancy management and outcome", section on 'Prenatal care'.)

Continue magnesium sulfate seizure prophylaxis until completion of the course of antenatal corticosteroids. If the patient remains a candidate for expectant management at that time, the magnesium sulfate can be discontinued until her status changes and preterm delivery becomes indicated.

Consult with neonatology and anesthesiology services.

Several management strategies with no proven benefit in the setting of severe preeclampsia are commonly recommended but are best avoided because of potential morbidity, cost, and/or patient inconvenience. These include routine use of continuous fetal heart rate monitoring on antepartum patient units, routine initiation of antihypertensive therapy in women with nonsevere hypertension, antepartum administration of magnesium sulfate seizure prophylaxis for over 48 hours, strict bedrest, and serial 24-hour urine collections for protein quantitation.

DELIVERY

Route – Cesarean birth is reserved for standard obstetric indications. A decision to expedite delivery in the setting of preeclampsia with severe features does not mandate cesarean birth [29]. Cervical ripening agents may be used if the cervix is unfavorable prior to induction [30]; however, we believe a prolonged induction is best avoided. There is no consensus on what constitutes a prolonged induction, but if we fail to see significant cervical change in response to cervical ripening agents within 12 hours, then we consider moving on to cesarean. Obviously, we would move to cesarean sooner if the patient's condition worsens. (See "Induction of labor: Techniques for preinduction cervical ripening".)

The safety of induction for the neonate was illustrated by two retrospective series that compared neonatal outcome of over 700 singleton, liveborn, preterm infants of patients with preeclampsia with severe features who underwent induction or scheduled cesarean birth [31,32]. Induction was not associated with a significant increase in the rate of any major neonatal complications (respiratory distress syndrome, intraventricular hemorrhage, seizures, sepsis, death).

At ≥32 weeks of gestation, the rate of vaginal birth after labor induction exceeds 60 percent, but at ≤28 weeks, it falls to 0 to 32 percent in patients with preeclampsia with severe features/eclampsia because of the high frequency of abnormal fetal heart rate tracings and failure of the cervix to dilate (time frame for diagnosing failure was not defined in these studies) [30,32,33]. For this reason, some experts recommend scheduled cesarean for patients with preeclampsia with severe features who are less than 28 to 30 weeks of gestation, especially if they have an unfavorable cervix (low Bishop score) [32,34]. We generally agree but take parity and prior labor course into consideration, as well.

Anesthesia – Neuraxial anesthetic techniques are generally not contraindicated and are typically preferred. The anesthesiologist's choice of a particular neuraxial technique is based on many factors, including the patient's platelet count and the urgency and expected duration of labor and delivery. The obstetrician and anesthesiologist should discuss these factors prior to the administration of the anesthetic. (See "Anesthesia for the patient with preeclampsia".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertensive disorders of pregnancy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: Preeclampsia (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Diagnosis – In patients with preeclampsia (table 1), the phrase "with severe features" is added when any of the features listed in the following table is present (table 2). (See 'Introduction' above and 'Changes in terminology and variations in criteria' above.)

Morbidity and mortality – Preeclampsia is a progressive disease. Worsening maternal endothelial dysfunction and continued poor perfusion of major maternal organs have the potential for severe end-organ damage to the brain, liver, kidneys, hematologic and vascular systems, and placenta. Fetal risks include progressive growth restriction and demise from placental abruption or uteroplacental insufficiency.

The frequency of complications depends, in part, on the gestational age at onset: Early onset (defined as either second trimester or <34 weeks of gestation) has a poorer prognosis than late onset (defined as either third trimester or ≥34 weeks of gestation). (See 'Morbidity and mortality' above.)

Timing of delivery – Delaying delivery to allow fetal maturation can improve perinatal outcome in appropriately selected, closely monitored preterm pregnancies (algorithm 1) but has no maternal benefit. (See 'Pregnancy outcome with delayed versus prompt delivery' above.)

For pregnancies ≥34 weeks of gestation, we suggest prompt delivery (Grade 2C). At this gestational age, the maternal and fetal risks of prolonging the pregnancy generally outweigh the benefits of further fetal and cervical maturation. (See 'Gestational age ≥34 weeks of gestation' above and 'Pregnancy outcome with delayed versus prompt delivery' above.)

For pregnancies above the lower limit of viability and <34 weeks of gestation, we suggest expectant management in the following settings (see 'Gestational age between the limit of viability and 34 weeks of gestation' above and 'Pregnancy outcome with delayed versus prompt delivery' above):

-Severe hypertension as the only persistent criterion for severe disease (Grade 2C).

-Laboratory abnormalities that are transient (Grade 2C).

Prompt delivery is indicated if maternal or fetal status deteriorates during expectant management. (See 'Delivery' above and 'Contraindications to delaying delivery' above.)

For pregnancies at or below the lower limit of viability, we suggest prompt delivery (Grade 2C). Expectant management is associated with a high risk of severe maternal morbidity, perinatal mortality, and severe neonatal morbidity. (See 'Gestational age before or at the limit of viability' above and 'Pregnancy outcome with delayed versus prompt delivery' above.)

Antepartum surveillance Patients who are expectantly managed should be hospitalized in a facility with appropriate resources for managing critically ill pregnant patients and cared for by, or in consultation with, a maternal-fetal medicine specialist. (See 'Antepartum monitoring' above.)

Daily maternal and fetal assessment with ongoing review of the risks of continuing expectant management is essential.

Severe hypertension should be treated promptly with antihypertensive drugs to reduce the risk of stroke (algorithm 2 and table 3), with maintenance oral therapy (table 4) as needed. (See 'Patients with preeclampsia with severe features based on blood pressure criteria alone' above.)

Expectant management is terminated and delivery is initiated if there is maternal or fetal deterioration (see 'Contraindications to delaying delivery' above) or at 34+0 weeks of gestation. (See 'Gestational age ≥34 weeks of gestation' above.)

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Topic 6791 Version 39.0

References

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