Expectant management of preeclampsia with severe features
- Errol R Norwitz, MD, PhD, MBA
Errol R Norwitz, MD, PhD, MBA
- Professor and Chair
- Department of Obstetrics and Gynecology
- Tufts Medical Center and Tufts University School of Medicine
- Edmund F Funai, MD
Edmund F Funai, MD
- Professor and Chief Operating Officer
- USF Health
Preeclampsia refers to the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman (table 1). The term “preeclampsia with severe features” is used when any of the features listed in the following table are present (table 2) .
Women with preeclampsia with severe features are usually delivered promptly to prevent maternal and fetal complications. Since the disease is progressive and there is no medical treatment, delivery is always in the best interest of the mother. However, preterm delivery is not always in the best interest of the fetus; therefore, a decision to delay delivery can be considered under certain circumstances. The rationale for delaying delivery in these pregnancies is to reduce perinatal morbidity and mortality by delivery of a more mature fetus and, to a lesser degree, to achieve a more favorable cervix for vaginal birth. The risk of prolonging pregnancy is worsening maternal endothelial dysfunction and continued poor perfusion of major maternal organs with the potential for severe end organ damage to the brain, liver, kidneys, placenta/fetus, and hematologic and vascular systems.
This topic will discuss issues that should be considered in selecting women with preeclampsia with severe features for prompt delivery versus expectant management. The general management of pregnancies complicated by preeclampsia is reviewed separately. (See "Preeclampsia: Management and prognosis".)
In 2013, the American College of Obstetricians and Gynecologists replaced the term “severe preeclampsia” with the term “preeclampsia with severe features.” This topic will use the term “preeclampsia with severe features”, 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. For example, the diagnosis of “severe preeclampsia” in these studies may have been based on hypertension with fetal growth restriction or proteinuria >5 grams/day, which are no longer considered features of severe disease.
A database of hospital discharge data from approximately 300,000 deliveries in the United States found the overall incidence of preeclampsia with severe features was approximately 1 percent of all pregnancies . Studies limited to nulliparous women report that approximately 5 percent develop preeclampsia and 40 to 50 percent of these women develop features of severe disease [3,4]. The incidence of preeclampsia with severe features before 34 weeks is 0.3 percent . However, these figures were derived from studies using the pre-2013 definition of severe preeclampsia. (See 'Terminology' above.)
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- CONSEQUENCES OF PREECLAMPSIA WITH SEVERE FEATURES
- Consequences of expectant management by gestational age
- - Second trimester
- - Pregnancies ≥28 weeks
- - Pregnancies <34 weeks
- Long-term outcome
- - Offspring
- - Maternal
- OUR GESTATIONAL AGE BASED APPROACH TO PREECLAMPSIA WITH SEVERE FEATURES
- Selection of candidates for expectant management
- Contraindications to beginning or continuing expectant management
- INITIAL MANAGEMENT
- COMPONENTS OF EXPECTANT MANAGEMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS