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.)
Subscribers log in hereLiterature review current through: Sep 2017. | This topic last updated: Jul 25, 2017.References
- American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
- Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy 2003; 22:203.
- Hnat MD, Sibai BM, Caritis S, et al. Perinatal outcome in women with recurrent preeclampsia compared with women who develop preeclampsia as nulliparas. Am J Obstet Gynecol 2002; 186:422.
- Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med 1993; 329:1213.
- Publications Committee, Society for Maternal-Fetal Medicine, Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks' gestation. Am J Obstet Gynecol 2011; 205:191.
- Magee LA, Yong PJ, Espinosa V, et al. Expectant management of severe preeclampsia remote from term: a structured systematic review. Hypertens Pregnancy 2009; 28:312.
- Hauth JC, Ewell MG, Levine RJ, et al. Pregnancy outcomes in healthy nulliparas who developed hypertension. Calcium for Preeclampsia Prevention Study Group. Obstet Gynecol 2000; 95:24.
- Bombrys AE, Barton JR, Nowacki EA, et al. Expectant management of severe preeclampsia at less than 27 weeks' gestation: maternal and perinatal outcomes according to gestational age by weeks at onset of expectant management. Am J Obstet Gynecol 2008; 199:247.e1.
- Jenkins SM, Head BB, Hauth JC. Severe preeclampsia at <25 weeks of gestation: maternal and neonatal outcomes. Am J Obstet Gynecol 2002; 186:790.
- Belghiti J, Kayem G, Tsatsaris V, et al. Benefits and risks of expectant management of severe preeclampsia at less than 26 weeks gestation: the impact of gestational age and severe fetal growth restriction. Am J Obstet Gynecol 2011; 205:465.e1.
- van Oostwaard MF, van Eerden L, de Laat MW, et al. Maternal and neonatal outcomes in women with severe early onset pre-eclampsia before 26 weeks of gestation, a case series. BJOG 2017; 124:1440.
- Odendaal HJ, Pattinson RC, Bam R, et al. Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial. Obstet Gynecol 1990; 76:1070.
- Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial. Am J Obstet Gynecol 1994; 171:818.
- Vigil-De Gracia P, Reyes Tejada O, Calle Miñaca A, et al. Expectant management of severe preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter clinical trial. Am J Obstet Gynecol 2013; 209:425.e1.
- van Wassenaer AG, Westera J, van Schie PE, et al. Outcome at 4.5 years of children born after expectant management of early-onset hypertensive disorders of pregnancy. Am J Obstet Gynecol 2011; 204:510.e1.
- Spong CY, Mercer BM, D'alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118:323.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121:908. Reaffirmed 2017.
- Churchill D, Duley L, Thornton JG, Jones L. Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation. Cochrane Database Syst Rev 2013; :CD003106.
- Sibai BM. Treatment of hypertension in pregnant women. N Engl J Med 1996; 335:257.
- Sibai BM, Barton JR, Akl S, et al. A randomized prospective comparison of nifedipine and bed rest versus bed rest alone in the management of preeclampsia remote from term. Am J Obstet Gynecol 1992; 167:879.
- Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007; 196:514.e1.
- Visser W, Wallenburg HC. Temporising management of severe pre-eclampsia with and without the HELLP syndrome. Br J Obstet Gynaecol 1995; 102:111.
- van Pampus MG, Wolf H, Westenberg SM, et al. Maternal and perinatal outcome after expectant management of the HELLP syndrome compared with pre-eclampsia without HELLP syndrome. Eur J Obstet Gynecol Reprod Biol 1998; 76:31.
- Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004; 103:981.
- Shah DM, Shenai JP, Vaughn WK. Neonatal outcome of premature infants of mothers with preeclampsia. J Perinatol 1995; 15:264.
- Carvalho MA, Faúndes A, Santos LC. Pregnancy-induced hypertension and hyaline membrane disease. Int J Gynaecol Obstet 1997; 58:197.
- Perlman JM, Risser RC, Gee JB. Pregnancy-induced hypertension and reduced intraventricular hemorrhage in preterm infants. Pediatr Neurol 1997; 17:29.
- Effect of antenatal steroids for fetal maturation on perinatal outcomes. NIH Consensus Statement 1994; 12:1.
- American College of Obstetricians and Gynecologists. Antenatal corticosteroid therapy for fetal maturation. ACOG Committee Opinion No. 210, American College of Obstetricians and Gynecologists, Washington DC 1998.
- Roberts D, Brown J, Medley N, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2017; 3:CD004454.
- Barrilleaux PS, Martin JN Jr, Klauser CK, et al. Postpartum intravenous dexamethasone for severely preeclamptic patients without hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome: a randomized trial. Obstet Gynecol 2005; 105:843.
- Fonseca JE, Méndez F, Cataño C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2005; 193:1591.
- Working group report on high blood pressure in pregnancy. National Instititutes of Health, Washington, DC 2000.
- Ganzevoort W, Rep A, de Vries JI, et al. Prediction of maternal complications and adverse infant outcome at admission for temporizing management of early-onset severe hypertensive disorders of pregnancy. Am J Obstet Gynecol 2006; 195:495.
- Coppage KH, Polzin WJ. Severe preeclampsia and delivery outcomes: is immediate cesarean delivery beneficial? Am J Obstet Gynecol 2002; 186:921.
- Nassar AH, Adra AM, Chakhtoura N, et al. Severe preeclampsia remote from term: labor induction or elective cesarean delivery? Am J Obstet Gynecol 1998; 179:1210.
- Alexander JM, Bloom SL, McIntire DD, Leveno KJ. Severe preeclampsia and the very low birth weight infant: is induction of labor harmful? Obstet Gynecol 1999; 93:485.
- Alanis MC, Robinson CJ, Hulsey TC, et al. Early-onset severe preeclampsia: induction of labor vs elective cesarean delivery and neonatal outcomes. Am J Obstet Gynecol 2008; 199:262.e1.
- Blackwell SC, Redman ME, Tomlinson M, et al. Labor induction for the preterm severe pre-eclamptic patient: is it worth the effort? J Matern Fetal Med 2001; 10:305.
- Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003; 102:181.
- American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843.
- Visalyaputra S, Rodanant O, Somboonviboon W, et al. Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study. Anesth Analg 2005; 101:862.
- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS