7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

1/15SEPTEMBER 2011 American Journal of Obstetrics& Gynecology 191191 American Journal of Obstetrics& Gynecology SEPTEMBER 2011

SMFM Clinical Opinionwww.AJOG.org

Evaluation and management of severe preeclampsiabefore 34 weeks gestationPublications Committee, Society or Maternal!Fetal Me"icine, wit# t#e assistance o $a#a M. Sibai, M%

!ntroduction

Preeclampsia is a multisystem "isor"er

t#at can maniest clinically wit# #yper!

tension an" proteinuria wit# or wit#!

out accompanying symptoms, abnormal

maternal laboratory test results, intra!

uterine growt# restriction, or re"uce"

amniotic lui" &olume.1

'#e inci"ence ose&ere preeclampsia ranges rom (.)!1.*+

o pregnancies in estern countries.*!-

Preeclampsia /wee0s

an"se&ere

pre!eclampsia 2 wee0s gestation compli!cates (.)!1.-+ an" (.+ o pregnancies,

respecti&ely.,)

'#e li0eli#oo" o se&ere

an" preterm preeclampsia is substantially

increase" in women wit# a #istory o

pre! eclampsia, an" in t#ose wit# "iabetesmel! litus, c#ronic #ypertension, or a

multietal gestation.1,,/!1(

Publis#e"

reports use "iering criteria or t#e

"iagnoses o preeclampsia, se&ere an"

superimpose" preeclampsia, an" 3455P

6#emolysis, ele! &ate" li&er en7ymes, low

platelets8 syn! "rome. Commonly use"

"einitions are presente" in t#e 'able.11!

12For women wit# preeisting

#ypertension or pro! teinuria, t#e"iagnosis o se&erepre!

O"JE#$!%E& We sought to review the risks and benefits of expetant !anage!ent of

severe pree"a!psia re!ote fro! ter!# and to provide reo!!endations for expetant

!anage!ent# !aterna" and feta" eva"uation# treat!ent# and indiations for de"iver$%

'E$(O)*& Studies were identified through a searh of the ME&'()E database for re"evant

peer*reviewed arti"es pub"ished in the Eng"ish "anguage fro! +anuar$ 1,-0 through

&ee!ber 2010% .dditiona""$# the /ohrane 'ibrar$# guide"ines b$ organiations# and

studies identified through review of the above dou!ents and review arti"es were uti"iedto identif$ re"evant arti"es% Where re"iab"e data were not avai"ab"e# opinions of respeted

authorities were used%

+E*,-$* A.) +E#O''E.)A$!O.*& Pub"ished rando!ied tria"s and observationa"

studies regarding !anage!ent of severe pree"a!psia ourring weeks ofgestation suggest that expetant !anage!ent of se"eted patients an i!prove neonata"

outo!es but that de"iver$ is often re3uired for worsening !aterna" or feta" ondition%

Patients who are not andidates for expetant !anage!ent in"ude wo!en with

e"a!psia# pu"!onar$ ede!a# disse!inated intravasu"ar oagu"ation# rena" insuffiien$#

abruptio p"aentae# abnor!a" feta" testing# 4E''P s$ndro!e# or persistent s$!pto!s of

severe pree"a!psia% 5or wo!en with severe pree"a!psia before the "i!it of viabi"it$#

expetant !anage!ent has been assoiated with fre3uent !aterna" !orbidit$ with

!ini!a" or no benefits to the newborn% Expetant !anage!ent of a se"et group of

wo!en with severe pree"a!psia ourring weeks6 gestation !a$ i!prove

newborn outo!es but re3uires arefu" in*hospita" !aterna" and feta" survei""ane%

7e$ words8 expetant !anage!ent# feta" growth restrition# 4E''P s$ndro!e# severe

pree"a!psia

eclampsia can be more "iicult, but

new!onset se&ere #ypertension or pro!

teinuria, or "e&elopment o ot#er clin!

ical or laboratory in"ings o se&ere

preeclampsia are suggesti&e o pre!

eclampsia in t#is setting.Se&erepreeclampsia occurringpreterm

can result in bot# acute1,*,2,/!1( an" long!

From t#e Society or Maternal!Fetal

Me"icine, as#ington, %C 6Publications

Committee8: an" %i&ision o Maternal

Fetal Me"icine, %epartment o Obstetrics

an" Gynecology, Clinical Perinatal

;esearc#, %a>og%2011%0:%01:

term complications or bot# t#e mot#er

an" #er newborn.1-,1)

Maternal compli!

cations o se&ere preeclampsia 6'able86as well as myocar"ial inarction, stro0e,

acute respiratory "istress syn"rome, co!

agulopat#y, se&ere renal ailure, retinalin=ury8 occur more commonly in t#e

presence o preeistent me"ical "isor!

"ers, an" wit# acute maternal organ "ys!

unction relate" to preeclampsia.1(,1/

Ma!

ternal morbi"ities rarelypersistaterse&ere

preeclampsia, alt#oug# car"io&ascular

"isease later in lie is more common re!

gar"less o clinical presentation.1-,1)

Fetal

an" newborn complications o se&erepre!eclampsia result rom eposure to utero!

placental insuiciency an">or rom pre!

termbirt#.1,1(

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7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

2/15SEPTEMBER 2011 American Journal of Obstetrics& Gynecology 19/19* American Journal of Obstetrics& Gynecology SEPTEMBER 2011

3istorically, women wit# se&ere pre!

eclampsia #a&e #a" "eli&ery initiate" upon

"iagnosis in or"er to limit maternal com!

clinical course o se&ere preeclampsia

is oten c#aracteri7e" by progressi&e

"eteri! oration i "eli&ery is not

pursue".1(,1/

3owe&er, some #a&e c#allenge" t#e

&iew t#at all patients wit# se&ere

preeclampsia must be "eli&ere"

epe"itiously./

'#e irst attempts at

epectant management were aime" at

pro&i"ing brie pregnancy prolongation

to allow or antenatal corti! costeroi"

a"ministration, but t#e potential or

longer epectant management was en!

tertaine" because some patients remaine"

stable or impro&e" "uring initial

obser&a! tion. Furt#er stu"y #as s#own

t#at me! "ian latency wit# epectant

manage! ment ranges rom /?12

"ays.1@

n t#is report, t#e ris0s an"beneits o

epectant management o se&erepre!

eclampsia remote rom term are re!

&iewe", an" recommen"ations regar"!

ing epectant management, maternal plications rom worsening "isease.

1,1*'#e an" etal e&aluation, an" in"ications

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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www . AJOG.orgwww. AJOG.org SMFM Clinical Opinion

$A"-E

)iagnostic criteria for preeclampsia0 severepreeclampsia0 and (E--1 syndrome

11214

Pree"a!psiaB B"ood pressure 10 !! 4g or ,0 !! 4g diasto"i that ours 20 wk6 gestation

in wo!an with previous"$ nor!a" b"ood pressure p"us proteinuria defined as urinar$exretion 0% g protein in 2*h urine spei!en

Severe pree"a!psia ?

1 of fo""owing riteria is re3uired@B B"ood pressure 1=0 !! 4g s$sto"i or 110 !! 4g diasto"i on 2 oasions at

"east = h apart whi"e patient is on bed restB Proteinuria A g in 2*h urine spei!en on 2 rando! urine sa!p"es o""eted

at "east h apart

me"ical 6eg, renal "isease, insulin!"e!

pen"ent "iabetes, connecti&e tissue "is!

ease8 or obstetric 6eg, &aginal blee"ing,

premature rupture o membranes, mul!

tietal gestation, preterm labor8 compli!

cations at *@!* wee0s gestation. '#ose

ran"omi7e" to epectant management

"eli&ere" at a more a"&ance" gesta!tional age 6*.9 &s (.@ wee0s: P .

(18, an" #a" newborns wit# #ig#er

birt#! weig#ts 61)** &s 1* g: P .

(18 w#o

careunita"mission6/)+ &s1((+:P

B Thro!bo$topeniaB 5eta" growth restrition

Superi!posed pree"a!psia ? 1 of fo""owing riteria is re3uired@

B )ew*onset proteinuria 0% g protein in wo!an with h$pertension 20 wk6 gestation

B (f h$pertension and proteinuria present 20 wk6 gestation

Sudden inrease in proteinuria if both h$pertension and proteinuria are present20 wk6 gestation

Sudden inrease in h$pertension in wo!an whose h$pertension has previous"$ beenwe"" ontro""ed

Thro!bo$topenia ?p"ate"et ount 100#000 e""s;!!1@ (nrease in a"anine a!inotransferase or aspartate a!inotransferase to abnor!a"

"eve"sWo!en with hroni h$pertension who deve"op persistent headahe# soto!a# orepigastri pain a"so !a$ have superi!posed pree"a!psia

4E''P s$ndro!e ?differing diagnosti riteria have been reported# 2 o!!on"$ usedriteria fo""ow@B Sibai et a"1 ?eah of fo""owing re3uired@

?1@ 4e!o"$sis on periphera" s!ear# "atate deh$drogenase =00 ;'# or tota" bi"irubin1%2 !g;d'

?2@ .spartate a!inotransferase :0 ;'?@ P"ate"et ount 100#000 e""s;!!

B Martin et a"1 ?eah of fo""owing re3uired@?1@ 'atate deh$drogenase =00 ;'?2@ .spartate a!inotransferase or a"anine a!inotransferase 0 (;'?@ P"ate"et ount 1A0#000 e""s;!!

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

SMFM. Severe preeclampsia.Am J Obstet Gynecol 2011.

P .((*8 an" necroti7ing enterocolitis

6(+ &s 1(.9+:P .(*8, but were more

reuently small or gestational age at

birt# 6(.1 &s 1(.9:P .(28. '#ere wereno cases o maternal eclampsia or pul!

monary e"ema in eit#er trial. Abruptio

placentae was similar in reuency be!

tween t#e ran"omi7e" groups in bot#stu"ies, but was more common in bot#

t#e epectantly an" nonepectantly

manage" groups rom t#e O"en"aal et

al19

trial 6**+ &s 1-+8 t#an in t#e Sibai

et al*(

stu"y 62.1+ &s 2.+8. 3455P

syn! "rome complicate" only *

epectantly manage" cases an" 1

aggressi&ely man! age" case in t#elatter stu"y 62.1+ &s

*.1+8.

'wo a""itional ran"omi7e" trials

e&aluate" t#erapeutic inter&entions "ur!ing epectant management. Fena0el et

al*1

"escribe" 29 women wit# se&ere

pre! eclampsia at *)!) wee0s w#owere ran! "omly assigne" to recei&e

eit#ersublingual

or "eli&ery are oere". For t#e pur!

pose o t#is "ocument, epectant man!

agement is "eine" as any attempt to"elay "eli&ery or antenatal corticoste!

roi" a"ministration or longer.

at are te benefits and risks ofe5pectant management of severepreeclampsia

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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SMFM Clinical Opinionwww. AJOG.org SMFM Clinical Opinionan" oral nie"ipine or intra&enous an"

oral #y"rala7ine treatments or se&ere

#yper! tension "uring epectant

management. '#ose assigne" to

nie"ipine t#erapy "eli&! ere" more

reuently at ) wee0s, were less

reuently "iagnose" wit# acute etal

"istress, an" t#eir inants #a" a

s#orter mean "uration o neonatal

intensi&e care unit stay t#an t#ose

assigne" to #y"ral! a7ine t#erapy 6P

.(1 or eac#8. 3ow! e&er, mean

gestational age at "eli&ery 62.) &s

.) wee0s:P .*(8 an" preg! nancy

prolongation 61-.- &s 9.- "ays:P .

(/8 were not impro&e", an" no "i!

erences in t#e reuencies o Ema=or

or Eminor newborn complications

were seen between groups. n

multicenter

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7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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comparison o anti#ypertensi&e t#erapy

alone &s anti#ypertensi&e t#erapy plus

plasma &olume epansion, Gan7e&oort

et al**

oun" t#at &olume epansion

ga&e no a""itional beneit among

women e! pectantly manage" wit#

se&erepre! eclampsia at *2! wee0s )

"ays.

Observational studies

Obser&ational stu"ies regar"ing epect!

ant management o se&ere preeclampsia

#a&e &arie" in t#eir inclusion criteria an"

in"ications or "eli&ery.-,/,1(,1@,*!-

Some

inclu"e" only t#ose women w#o

remaine" stable ater *2!2@ #ours o

obser&ation, w#ile ot#ers inclu"e"

women epectantly manage" rom t#e

time o "iagnosis. A re! cent systematic

re&iew summari7e" t#e reuency ocomplications relate" to se! &ere

preeclampsia remote rom term.1@

Presente" as 6me"ian: interuartile range

H;I8, complications o epectant man!

agement inclu"e" intensi&e care unit a"!

mission 6me"ian, */.)+: H;, 1.-?

-*.)8, #ypotension 6me"ian, 1/.(+: H;,

1*.(?

*1.(8, 3455P syn"rome 6me"ian, 11.(+:

H;, -.?1/.)I8, recurrent se&ere #yper!

tension 6me"ian, @.@+: H;, .?*/.-8,

abruption placentae 6me"ian, -.1+: H;,*.*?@.-8, pulmonary e"ema 6me"ian,

*.9+: H;, 1.-?-*.)8, eclampsia 6me"ian,

1.1+: H;, ( ?*.(8, subcapsular li&er

#e! matoma 6me"ian, (.-+: H;, (.*?

(./8, stro0e 6me"ian, (.2+: H;, ( ?

.18, still! birt# 6me"ian, *.-+: H;, (?

11.8, an" neonatal "eat# 6me"ian,

/.+: H;,

-.( ?1(./8. Small or gestational age

in! ants were common 6me"ian,

).@+: H;, *(.-?-.@8 ater epectant

manage! ment. %eli&ery or etal 62)+8or maternal 62(+8 in"ications was

similarly reuent.

n summary, epectant management

o se&ere preeclampsia occurring 2

wee0s gestation aime" at increasing

ges! tational age at "eli&ery an" birt#

weig#t, an" "ecreasing neonatal

complications is appropriate in selecte"

cases,but care! ul in!#ospital maternal

an" etal sur! &eillance are

recommen"e".

at is te initial evaluation andmanagement of severe preeclampsiamm, i li&er en7ymes are ele!

&ate", or i t#ere are in"ings suggesti&e o

abruptio placentae.

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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preeclampsia are limite", ran"omi7e"

controlle" trials in&ol&ing pregnancies

complicate" by #ypertension syn"romes

#a&e oun" antenatal corticosteroi" treat!

ment to result in less reuent respiratory

"istress syn"rome 6ris0 ratio ;;I, (.-(:

9-+ coni"ence inter&al CI, (.-?

(./*8, neonatal "eat# 6;;, (.-(: 9-+ C,

(.*9?(.@/8, an" intra&entricular #emorr#age

6;;, (.@: 9-+ C, (.1/? (.@/8.)

n a

sin! gle placebo!controlle" stu"y o

wee0ly betamet#asone or women wit#

se&ere preeclampsia between *)!2

wee0s gesta! tion, treatment 6mean

eposure 1./ "oses8 re"uce" t#e

reuencies o respiratory "is! tress

syn"rome 6;;, (.-: 9-+ C, (.-?

(.@*8 an" intra&entricular #emorr#age

6;;, (.-: 9-+ C, (.1-?(.@)8, among

ot#er complications./

n t#is stu"y, t#ere

were * maternal "eat#s among *1@

pregnancies.

not pre&iously gi&en, an" i it is

an! ticipate" t#at t#ere willbe time or

etal beneit rom t#is inter&ention,

antenatal corticosteroi"

a"ministration s#oul"be consi"ere"

regar"less o a plan or epectant

management. '#ose w#o "e! &elopnew!onset contrain"ications to

epectant management beore or

ater completion o antenatal

corticosteroi" treatment s#oul" be

"eli&ere" 6Figure8. t#e maternal an"

etal con"itions re! main stable"uring

initial inpatient mon! itoring,

continue" epectant manage! ment o

women 2 wee0s gestational age is

appropriate. Continuous etal

monitoring, an" magnesium sulate

sei! 7ure prop#ylais i initiate", can

be "is! continue". omen wit#

suspecte" etal growt# restriction an">or

oligo#y"ram! nios are not typically

consi"ere" to be can"i"ates or

epectant management beyon"

completion o antenatal cortico! steroi"

t#erapy "ue to t#e increase" ris0 o

a"&erse outcomes inclu"ing perinatal

"eat#.-,1/,*(,**,*)

Management in t#esecases s#oul" be in"i&i"uali7e" an"

base" on t#e se&erity o etal growt#

restriction, t#e presence o coeisting

oligo#y"ram! nios, an" results o etal

sur&eillance. For t#e remaining women,

t#e potential ma! ternal ris0s an"

perinatal beneits o con! tinue"

epectant management ater an! tenatal

corticosteroi" treatment s#oul" be

"etermine" ater consi"eration o

clinical actors suc# as gestational age,

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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7!G,+E

#linical algoritm for management of suspected severe preeclampsia

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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maternal status, an" li0eli#oo" o

signi! icant pregnancyprolongation.

$ecause o t#e potential or rapi"

"eteri! oration o t#e maternal an">or

etal con! "ition "uring epectant

management o se&ere preeclampsia,

suc# women are optimally care" or in

a #ospital wit# ser&ices capable omanaging compli! cate" obstetric cases

an" preterm new! borns.1(

Maternal

e&aluation s#oul" in! clu"e monitoringo bloo" pressure, urine output, an" signs

or symptoms o concern 6persistent

#ea"ac#e, &isual c#anges, epi! gastric

pain, ab"ominal ten"erness, or &aginal

blee"ing8. '#e reuency an" na! ture o

etal monitoring s#oul" be base" on

gestational age an" etal status. %ur!

ing initial epectant management, at

least "aily assessment o t#e completebloo" cell count wit# platelet count, as

well as li&er an" renal unctions can

#elp i"entiy t#ose in w#om t#e

"isease is progressing an" reuires

"eli&ery. 4&al! uation o maternal

coagulation parame! ters is not

typically necessary. '#e re! uency o

subseuent laboratory testing can be

"etermine" base" on t#e se&erity o

illness an" "isease progression. *2 #8, signiicant

pregnancy prolonga! tion occurre",

maternal complications were not

increase", an" resolution o re!

"iagnostic criteria use" or 3455P syn!

"rome #a&e &arie" between publica!

tions.2*

n a systematic re&iew o 1* stu"!

ies, Magee et al1@

e&aluate" t#e reuency

o complications t#at can occur w#en e!

pectant management is un"erta0en in t#e

setting o 3455P syn"rome 2 wee0s

gestation. Me"ian H;I latency to "eli&!

ery was -.@ "ays (.@?1(.I an" "eli&ery

or etal in"ication was common6me"ian,

/(.@+: H;, -.9? @9.(8. Complications

6me"ian interuartile rangeI8 inclu"e"

recurrent se&ere #ypertension 6me"ian,

2).*+: H;, .)?-@.@8, abruptio pla!

centae 6me"ian, -.1+: H;, .?).28, ec!

lampsia 6me"ian, (.@+: H;, (? 2.98,

subcapsular li&er #ematoma 6me"ian,

.1+: H;, 1.)? 2./8, stro0e 6).+8,

stillbirt# 6me"ian, 1(.-+: H;, .2?

19.18, an" neonatal "eat# 6me"ian,

-.-+: H;, 2.?@.98. %eli&ery o a smallor gestational age inant was common

6-).+8. Maternal "eat# #as also occurre"

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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"uring epectant management o 3455P

syn"rome.2

pursue" i t#e maternal or etal

con"ition worsens, or upon completion

o t#istreatment.

-,1(,*(,*1,*/

*ould e5pectantmanagement be offered wenfetal growt restriction issuspected6

#ile no prospecti&e trials #a&e

e&alu! ate" t#e beneits an" ris0s o

epectant management w#en etal

growt# restric! tion is suspecte" in t#e

setting o preterm se&ere preeclampsia,

* retrospecti&e obser! &ational stu"ies

#a&e "escribe" outcomes or suc#

pregnancies.**,*)

n one stu"y o &olume

epansion "uring epectant man!

agement o se&ere preeclampsia, t#ose

wit# suspecte" etal growt# restriction

6"eine" as ultrasoun" estimate" weig#t

1(t# percentile or ab"ominal

circumer! ence -t# percentile8 #a" a

me"ian preg! nancy prolongation o /"ays, an" t#e re! uency o a"&erse

outcome 6perinatal "eat#, c#ronic lung

"isease, gra"e in! tra&entricular

#emorr#age, or gra"e * peri&entricular

leu0omalacia8 or t#is

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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group wassimilar to t#e o&erallco#ort.**

A secon" stu"y compare" 12 women

wit# se&ere preeclampsia an" estimate"

etal weig#t 1(t# percentile wit#

women wit#out etal growt#

restriction.*)

Only brie pregnancy

prolongation 6.1 "ays8 was seen wit#

epectant management, an" t#einci"ences o abruption an" neonatal

morbi"ities were similar between t#ose

wit# or wit#out etal growt# restriction.

'#ese in&estigators recommen"e" "eli&!

ery ater antenatal corticosteroi" a"minis!

tration in suc# cases. #ile publis#e"

stu"ies ail to "emonstrate beneits rom

epectant management o se&ere pre!

eclampsia wit# concurrent suspecte" etal

growt# restriction, t#e number o

sub=ects stu"ie" is small an" t#ere is a

wi"e spec! trum o se&erity o etalgrowt# restriction. '#e "ecision

regar"ing epectant man! agement o

t#ese patients s#oul" be

in"i&i"uali7e".

*ould severe preeclampsiaoccurring before te limit of viabilitybe treated e5pectantly6Se&erepreeclampsia t#at "e&elops near

t#e limit o etal &iability is associate"

wit# a #ig# li0eli#oo" o perinatal

morbi"ities an" mortality, regar"less oepectant management.-,/,@,1,,2-!-(

3owe&er, "ata regar"ing outcomes wit#

epectant man! agement categori7e" by

gestational wee0at "iagnosis are limite".

Sur&i&al rates o (>2 6(+8, 2>**

61@.*+8, an" 1->*) 6-/./+8 #a&e been

reporte" ater epectant man! agement

o se&ere preeclampsia initiate"

* wee0s, at * wee0s, an" at *2

wee0s gestation, respecti&ely.-,1,29,-(

Ot#er re! ports #a&ealsosuggeste" rare

sur&i&al wit# epectant management ose&ere pre! eclampsia *!*2 wee0s

gestation./,2@

4! plicit counseling

regar"ing t#e li0eli#oo" opoor perinatal

outcomes wit# epectant management

s#oul" be pro&i"e". %eli&ery s#oul" beconsi"ere" w#en se&ere pre! eclampsia

occurs beore t#e limit o &iabil!ity

6Figure8.-,/,1(,1,2@!-(

at is te role of antiypertensive

terapy during e5pectantmanagement6

n women wit# se&ere preeclampsia,

control o maternal bloo" pressure is

necessary to "ecrease t#e ris0s o

acute #ypertension 6eg, maternal

cerebro&as!

cular acci"ent, myocar"ial isc#emia8, but

a "ramatic "ecrease may also impair

uteroplacental perusion. Anti#yperten!

si&e me"ications s#oul" be consi"ere" i

systolic bloo" pressure remains persis!

tently 1)( mm 3g, or i "iastolic bloo"

pressure persists 11( mm 3g.1(

Once

treate", t#e target range s#oul" be a sys!tolic bloo" pressure o 12(!1-- mm 3g

an" a "iastolic bloo" pressure o 9(!1(-

mm 3g.

Alt#oug# parenteral anti#ypertensi&e

t#erapy may be nee"e" initially or acute

control o bloo" pressure, oral me"ica!

tions can be utili7e" as epectant manage!

ment is continue". Oral labetalol an"calcium c#annel bloc0ers #a&e been com!

monly use".1(

One approac# is tobegin aninitial regimen o labetalol at *(( mg orally

e&ery 1* #ours, an" increase t#e "ose up to@(( mg orally e&ery @!1* #ours as nee"e"

6maimum total *2(( mg>"8. t#e mai!

mum "ose is ina"euate to ac#ie&e t#e "e!

sire" bloo" pressure goal, t#en s#ort!act!

ing oral nie"ipine can be a""e" at an

initial "ose o 1( mg orally e&ery ) #ours

an" increase" as nee"e" up to *( mg e&ery

2 #ours 62(!1*( mg>"8. An alternati&e

regimen is a long!acting preparation o ni!

e"ipine 6up to (!)( mg>"8. Follow!

ing initial control ose&ere #ypertension,

bloo" pressure s#oul"bemeasure" at leaste&ery)!@#ours. t#ere isrecurrent persis!

tent se&ere #ypertension "espite a"euate

oral or intra&enous anti#ypertensi&e t#er!

apy, "eli&ery s#oul" be pursue" ater ma!

ternal stabili7ation.

at strategies are available for fetalassessment during e5pectantmanagement6

Do ran"omi7e" trials #a&e i"entiie" an

optimal met#o" o etal assessment "ur!

ingepectant management ose&erepre!eclampsia, #owe&er t#ere is agreement

t#at etal testing is in"icate" i t#e preg!

nancy is consi"ere" &iable.-,19!

Don!

stress testing 6DS'8 is recommen"e",

but t#e optimal reuency o testing an"

t#e a""itional &alue o biop#ysical pro!

ile testing #a&e not been "etermine".

One approac# or etal sur&eillance in!

&ol&es at least "aily DS's, wit# biop#ysi!

calproiletestingperorme" s#oul" anon!

reacti&e DS' result be encountere".

Follow!up etal growt# e&aluation an"

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

11/15

amniotic lui" &olume estimation s#oul"

also be perorme". etal growt#

restric! tion is suspecte", an" epectant

man! agement is un"erta0en, t#en

incorpo! ration o %oppler bloo"

low stu"ies into an in"i&i"uali7e"

management sc#eme is appropriate.

at are te indications for deliveryafter e5pectant management6n t#e publis#e" stu"ies o preterm se!

&ere preeclampsia manage" epectantly,

"eli&ery #as typically been pursue" at

ap! proimately 2 complete" wee0s

gesta! tion. 3owe&er, "eterioration o

maternal an">or etal con"itions prior

to t#is ges! tational age is t#e most

common reason or "eli&ery.1@

Maternal

in"ications or "eli&ery are "elineate" in

Figure. %eli&! ery s#oul" also be

consi"ere" or women "eclining or

noncompliant to ongoing inpatient

obser&ation: t#ose "e&eloping

persistent epigastric or rig#t upper

ua"! rant pain, nausea, or &omiting:

an" or t#ose w#o "e&elop preterm

labor or pre! mature rupture o

membranes 6Fig! ure8.-,11,1*,19,*(,*)!

#en "eli&ery is in! "icate", &aginal

"eli&ery can oten be accomplis#e",

but t#is is less li0ely wit# "ecreasinggestational age. it# labor in"uction,

t#e li0eli#oo" o cesarean "e! li&ery

increases wit# "ecreasing gesta!

tional age in t#is setting 6range, 9?

9/+

*@ wee0s, -?)-+ at *@!* wee0s,

an"

1?@+ at *!2 wee0s gestation8.-1!

-2

+E#O''E.)A$!O.

*

Levels I and II evidence,

level A recommendation

1. 4pectant management o se&erepre!

eclampsia remote rom term is

appro!priate in selecte"cases, an" is

associate" wit# pregnancy

prolongation an" im! pro&e"

newborn outcomes.

Levels II and III

evidence, level B

recommendation

*. omen wit# persistent symptoms o

se&ere preeclampsia, uncontrollable se!

&ere #ypertension, eclampsia,pulmo!

nary e"ema, abruptio placentae, "is!

seminate" intra&ascular coagulation,

signiicant an" new!onset renal "ys!

unction, an" t#ose w#o #a&e abnor!

mal etal sur&eillance results, s#oul"

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

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8uality of evidence

The 3ua"it$ of evidene for eah in"udedarti"e was eva"uated aording to theategories out"ined b$ the SPreventative Servies Task 5ore8

! Proper"$ powered and ondutedrando!i0ed ontro""ed tria"9 we""*onduted s$ste!ati review or!etaana"$sis of ho!ogeneous ran*do!i0ed ontro""ed tria"s%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

!!21 We""*designed ontro""ed tria" withoutrando!iation%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

!!2/ We""*designed ohort or ase*ontro"ana"$ti stud$%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

!!23 Mu"tip"e ti!e series with or withoutthe intervention9 dra!ati resu"tsfro! unontro""ed experi!ents%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

!!! Cpinions of respeted authorities#based on "inia" experiene9 desrip*

tive studies or ase reports9 reports ofexpert o!!ittees%

+ecommendations are gradedin te following categories&

-evel AThe reo!!endation is based on good andonsistent sientifi evidene%

-evel "The reo!!endation is based on "i!ited orinonsistent sientifi evidene%

-evel #The reo!!endation is based on expert

opinion or onsensus%

typicallybe"eli&ere"aterinitial

mater! nal stabili7ation.

Level I evidence,

level A recommendation

. not pre&iously gi&en, an" i it is

an! ticipate" t#at t#ere will be time

or e! tal beneit rom t#is

inter&ention be! ore "eli&ery,

antenatal corticosteroi"

a"ministration s#oul" be consi"ere"

regar"less o a plan or epectant

management.

Level III evidence,

level C recommendation

2. $ecause o t#e ongoing ris0s to t#e

mot#er an" etal ris0s "uring contin!

ue" epectant management, "eli&ery

or se&erepreeclampsia s#oul" be un!

"erta0en at 2 wee0s gestation or

t#ose w#o remain pregnant to t#is

ges! tational age.

Level II

evidence,

level A recommendation

-. Se&ereproteinuria alone an" t#e "e!

gree o c#ange in proteinuria s#oul"

not be consi"ere" criteria to a&oi" or

terminate epectant management.

Levels I and II evidence,

level A recommendation

). omen wit# 3455P syn"rome

s#oul" not typically be manage"

epectantly. Kaginal or cesarean

"eli&ery s#oul" be pursue" as

appropriate.

Level II and III

evidence, level B

recommendation

/. '#e "ecision regar"ing epectantman! agement o se&ere

preeclampsia wit# concurrent

suspecte" etal growt# re! striction

s#oul" be in"i&i"uali7e".

Levels I and II evidence,

level B recommendation

@. 4plicit counseling regar"ing t#e po!

tential maternal ris0s s#oul" be pro!

&i"e" an" "eli&ery s#oul" be consi"!

ere" w#en se&erepreeclampsia occurs

beore t#e limit o &iability.

This opinion was deve"oped b$ the

Pub"iations /o!!ittee of the Soiet$ for

Materna"*5eta" Mediine with the assistane of

Baha M% Sibai# M and was approved b$ the

exeutive o!* !ittee of the soiet$ on +une

0# 2011% &r Sibai and eah !e!ber of the

pub"iations o!!it* tee ?Brian Merer# M&

D/hair# Fineno Ber* ghe""a# M Sean

B"akwe""# M +oshua /ope"# M Wi""ia!

Grob!an# M MB.# /$nthia G$* a!fi# M

&onna +ohnson# M Sarah 7i"pat* rik# M

Ph George Maones# M George Saade#

M 4$agriv Si!han# M '$nn Si!p* son#

M +oanne Stone# M Mihae" Farner# M

Ms &eborah Gardner@ have sub!itted a

onf"it of interest dis"osure de"ineating per*

sona"# professiona"# and;or business

interests that !ight be pereived as a rea" or

potentia" onf"it of interest in re"ation to this

pub"iation%

+E7E+E.#E*

1 Sibai B# &ekker G# 7upfer!i M%

Pree"a!p* sia% 'anet 200A9=A8:-A*,,%

'eve" (((%

/ 7uk"ina EF# .$a /# /a""aghan WM% 4$perten*

sive disorders and severe obstetri !orbidit$

in the nited States% Cbstet G$neo"

200,9118

12,,*0=% 'eve" ((*%

3 /atov +M# )ess RB# 7ip 7E# C"sen +% Risk of

ear"$ or severe pree"a!psia re"ated to preex*

isting onditions% (nt + Epide!io" 200:9=8

12*,% 'eve" ((*%

4 Hhang +# Meik"e S# Tru!b"e.% Severe !ater*

na" !orbidit$ assoiated with h$pertensive dis*

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

13/15

orders in pregnan$ in the nited States%

4$pertens Pregnan$ 200922820*12% 'eve"

((*%

: 4addad B# &eis S# Goffinet 5# &anie" B+# /a*

bro" Sibai BM% Materna" and perinata" out*

o!es during expetant !anage!ent of 2,

severe pree"a!pti wo!en between 2 and

weeks6 gestation% .! + Cbstet G$neo"

20091,081A,0*A% 'eve" ((*2%

; Gupta 'M# Gaston '# /hauhan SP% &ete*

tion of feta" growth restrition with preter!severe pree"a!psia8 experiene at two ter*

tiar$ enters% .! + Perinato" 200-92A82:*,%

'eve" ((*%

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

14/15

1= Magee '.# Iong P+# Espinosa F# /JtK .M#

/hen (# von &ade"s0en P% Expetant !anage*

!ent of severe pree"a!psia re!ote fro!

ter!8 a strutured s$ste!ati review%

4$pertens Pregnan$ 200,92-812*:% 'eve"

(%

19 Cdendaa" 4+# Pattinson R/# Ba! R#

Grove 7ote T+% .ggressive or expetant

!anage* !ent for patients with severe

pree"a!psia be* tween 2-* weeks6gestation8 a rando!ied ontro""ed tria"%

Cbstet G$neo" 1,,09:=810:0*

A% 'eve" (%

/> Sibai BM# Merer BM# Shiff E#

5ried!an S.% .ggressive versus expetant

!anage!ent of severe pree"a!psia at 2- to

2 weeks6 ges* tation8 a rando!i0ed

ontro""ed tria"% .! + Cb* stet G$neo"

1,,91:18-1-*22% 'eve" (%

/1 5enake" 7# 7enake" G# .pp"e!an H# et a"%

)ifedipine in treat!ent of severe

pree"a!psia% Cbstet G$neo" 1,,19::81*

:% 'eve" (%

// Gan0evoort W# Rep .# Bouse" G+# et a"% .rando!i0ed ontro""ed tria" o!paring two te!*

pori0ing !anage!ent strategies# one with and

one without p"as!a vo"u!e expansion# for se*

vere pree"a!psia% B+CG 200A911281A-*=-%

'eve" (%

/3 /hua S# Red!an /W% Prognosis for pre*

e"a!psia o!p"iated b$ A g or !ore of pro*

teinuria in 2 hours% Eur + Cbstet G$neo"

Re* prod Bio" 1,,298,*12% 'eve" ((*%

/4 C"ah 7S# Red!an WG# Gee 4% Manage*

!ent of severe# ear"$ pre*e"a!psia8 is

onser* vative !anage!ent >ustifiedL Eur +

Cbstet G$* neo" Reprod Bio" 1,,9A181:A*

-0% 'eve" ((*2%

/: van Pa!pus MG# Wo"f 4# Westenberg SM#der Post F# Bonse" G+# Treffers PE% Materna"

and perinata" outo!e after expetant

!anage* !ent of 4E''P s$ndro!e o!pared

with pre* e"a!psia without 4E''P s$ndro!e%

Eur + Cb* stet G$neo" Reprod Bio"

1,,-9:=81*=% 'eve" ((*2%

/; /ha!!as M5# )gu$en TM# 'i M.#

)uwa$* hid BS# /astro '/% Expetant

!anage!ent of severe preter!

pree"a!psia8 is intrauterine growth

restrition an indiation for i!!ediate

de"iver$L .! + Cbstet G$neo" 200091-8

-A*-% 'eve" ((*%

/es .+M# 5raux

.# 7oop!an /# Bots M'# Bruinse 4W% . ran*

do!ied p"aebo*ontro""ed tria" of pro"onged

predniso"one ad!inistration to patients with

4E''P s$ndro!e re!ote fro! ter!% Eur + Cb*

stet G$neo" Reprod Bio" 200=912-81-:*,%

'eve" (%

7/25/2019 (688850069) Evaluatioan and Management of Severe Preeklamsia

15/15

44 Woudstra &M# /handra S# 4of!e$r G+#

&owswe"" T% /ortiosteroids for 4E''P ?he!o*

"$sis# e"evated "iver en0$!es# "ow p"ate"ets@

s$n* dro!e in pregnan$% /ohrane &atabase

S$st Rev 20109,8/&00-1-% 'eve" (%

4: Mood"e$ +# 7oranteng S.# Rout /%

Expet* ant !anage!ent of ear"$ onset of

severe pre* e"a!psia in &urban% S .fr

Med + 1,,9

-8A-*:% 'eve" ((*

%4; 4a"" &R# Cdendaa" 4+# Ste$n &W%

Expet* ant !anage!ent of severe pre*

e"a!psia in the !id*tri!ester% Eur + Cbstet

G$neo" 20019,=8

1=-*:2% 'eve" ((*%

4 Seik M# Cka$a C# Seik 4T# IaparEG% Expetant !anage!ent of severe

pree"a!p* sia presenting before 2A

weeks of gestation% Med Si Monit

200:918A2*:% 'eve" ((*%

:1 )assar .4# .dra ..# /hakhtoura )#

Be$* doun S% Severe pree"a!psia re!ote

fro! ter!8 "abor indution or e"etive

esarean de"iver$L .! + Cbstet G$neo"

1,,-91:,81210*% 'eve" (((%

:/ ."exander +M# B"oo! S'# M(ntire &

'ev* eno 7+% Severe pree"a!psia and the

ver$*"ow birth weight infant8 is indution of

"abor har!fu"L Cbstet G$neo"

1,,,9,8-A*-% 'eve" (((%

:3 B"akwe"" S/# Red!an ME# To!"inson M#

et a"% 'abor indution for the preter! severe

pre*e"a!pti patient8 is it worth the effortL +

Matern 5eta" Med 200191080A*11% 'eve" (((%

:4."anis M/# Robinson /+# 4u"se$ T/# Ebe"*

ing M# +ohnson &+% Ear"$*onset severe pre*

e"a!psia8 indution of "abor vs e"etive

esar* ean de"iver$ and neonata" outo!es%

.! + Cbstet G$neo" 200-91,,82=2%e1*=%

'eve" ((*%

The pratie of !ediine ontinues to

evo"ve# and individua" iru!stanes wi""var$% This opinion ref"ets infor!ation

avai"ab"e at the ti!e of its sub!ission forpub"iation and is neither designed nor

intended to estab"ish an ex"usive stan*dard of perinata" are% This pub"iation is

not expeted to ref"et the opinions of a""

!e!bers of the Soiet$ for Materna"*

5eta" Mediine%