Expectant management of preeclampsia

In cases that begin with outpatient management, prompt hospitalization is indicated if there is clinical evidence that the disease is progressing (ie, new symptoms, labor or rupture of membranes, vaginal bleeding, or increased blood pressures or proteinuria) or IUGR and/or oligohydramnios.

Instruct all women to report symptoms and changes in fetal movement.

When to deliver

Whether the gravida is hospitalized or an outpatient, delivery is indicated at 37 weeks. Earlier delivery may be warranted if nonreassuring maternal or fetal conditions develop. (FIGURE 1 summarizes management of mild preeclampsia.)

Severe preeclampsia

Expectant management is safe in properly selected women with severe disease, although maternal and fetal conditions can deteriorate. Hospitalization and daily monitoring are required.

Preeclampsia is severe when any of the following are present:

• systolic blood pressure of 160 mm Hg or higher or diastolic pressure of 110 mm Hg or above on 2 occasions at least 6 hours apart while the patient is on bed rest
• proteinuria of 5 g or more in a 24-hour urine specimen,
• oliguria of less than 500 mL in 24 hours,
• cerebral or visual disturbances,
• pulmonary edema or cyanosis,
• severe epigastric or right upper-quadrant pain, or
• thrombocytopenia.

When gestational hypertension or preeclampsia is severe, hospitalization in the labor and delivery suite is warranted. These women should receive intravenous (IV) magnesium sulfate to reduce the risk of convulsions and antihypertensive drugs to treat severe levels of hypertension, if present. The aim of antihypertensive treatment is to keep diastolic blood pressure between 90 and 105 mm Hg and systolic blood pressure below 160 mm Hg.

During observation, assess maternal and fetal conditions and decide whether delivery is indicated (FIGURE 2).

Expectant management is warranted only for gestations between 23 and 32 weeks’ gestation, provided maternal and fetal conditions are stable (FIGURE 2).

Keep in mind that both maternal and fetal conditions may progressively deteriorate. Thus, these pregnancies involve higher rates of maternal morbidity and significant risk of neonatal morbidity. For this reason, expectant management should proceed only in a tertiary-care center with adequate maternal and neonatal facilities.

Recommended counseling

Advise these patients of the potential risks and benefits of expectant management, which requires daily monitoring of maternal and fetal conditions. Also explain that the decision to continue expectant management will be revisited on a daily basis and that the median number of days pregnancy is prolonged in these cases is 7 (range 2 to 35).

Another important fact to relay: Only 2 randomized trials involving 133 women have compared expectant management to aggressive management in early-onset preeclampsia. However, retrospective and observational studies involving more than 700 women suggest expectant management reduces short-term neonatal morbidity with minimal risk to the mother.

Superimposed preeclampsia

Women who develop preeclampsia on top of chronic hypertension, renal disease, or type 1 diabetes have a markedly higher risk of morbidity, including perinatal morbidity, than women without preexisting conditions.

Women with superimposed preeclampsia may be managed in the hospital, since these pregnancies are associated with higher rates of abruptio placentae (2% to 5%), preterm delivery (56%), IUGR (13% to 15%), and perinatal death (8%). Thus, these women benefit from very close maternal and fetal monitoring.

Superimposed preeclampsia is not classified according to severity.

In general, maternal and perinatal morbidities are substantially higher in women who have preexisting conditions than in healthy women who develop preeclampsia.

Chronic hypertension

Indications for delivery are similar to those described for healthy women with preeclampsia, as is antihypertensive therapy.

If the woman develops preeclampsia while using antihypertensive drugs, delivery should be considered beyond 34 weeks’ gestation.

How preeclampsia affects renal function

Women with renal disease or dysfunction (serum creatinine ≥1.2 mg/dL) prior to or early in pregnancy face an increased risk of adverse neonatal outcomes, regardless of whether preeclampsia also develops. These women also face an increased risk of deteriorating renal function during pregnancy (particularly if preeclampsia or severe hypertension develops) and beyond (more than 6 months postpartum).

Start antihypertensive medications as soon as possible, with the goal of keeping systolic blood pressure below 140 mm Hg and diastolic blood pressure below 90 mm Hg throughout gestation.

Delivery is indicated with the onset of preeclampsia or significant deterioration in renal function.

Diabetes warrants aggressive therapy

Women with type 1 diabetes have a higher risk of preeclampsia, maternal and fetal morbidity, and perinatal mortality. These risks multiply in women who have hypertension and/or diabetic nephropathy. Worsening of retinopathy and nephropathy also is more likely in women who have hypertension. Thus, aggressive management of blood sugars with insulin should be accompanied by aggressive control of blood pressure, with the goal of keeping systolic pressure below 130 mm Hg and diastolic pressure below 85 mm Hg.