NEW YORK (Reuters Health) – A new report concludes that expectant management of severe preeclampsia occurring before 34 weeks gestation is appropriate in selected cases. It can prolong pregnancy and improve newborn outcomes, but requires careful in-hospital maternal and fetal surveillance.
The report, from Dr. Baha M. Sibai, director of Clinical Perinatal Research, University of Cincinnati College of Medicine in Ohio and the Society for Maternal-Fetal Medicine (SMFM) Publications Committee, is published in the American Journal of Obstetrics and Gynecology.
Historically, delivery was initiated as soon as severe preeclampsia was diagnosed with the aim of limiting maternal complications from worsening disease, the authors note in the report. However, the view that all patients with severe preeclampsia must be delivered right away was subsequently challenged and the first attempts at expectant management soon followed.
These first attempts were aimed at prolonging pregnancy just long enough to allow for antenatal corticosteroid administration, “but the potential for longer expectant management was entertained because some patients remained stable or improved during initial observation,” the authors note. Studies have shown that median latency with expectant management ranges from 7 to 14 days.
In their report, the SMFM Committee reviews the current state of knowledge about the risks and benefits of expectant management of severe preeclampsia remote from term and provides recommendations, when possible, for expectant management, maternal and fetal evaluation and indications for delivery.
Their guidance is based on relevant peer reviewed randomized trials and observational studies published in English between 1980 and 2010. Expectant management is defined as any attempt to delay delivery for antenatal corticosteroid administration or longer.
Overall, they say, the literature provides evidence that expected management of selected patients can improve neonatal outcomes but that delivery is often required for worsening maternal or fetal condition.
“If not previously given, and if it is anticipated that there will be time for fetal benefit from this intervention before delivery, antenatal corticosteroid administration should be considered regardless of a plan for expectant management,” the Committee concludes.
Due to the ongoing risks to the mother and fetal risks during continued expectantmanagement, “delivery for severe preeclampsia should be undertaken at 34 weeks’ gestation for those who remain pregnant to this gestational age,” they advise.
“The decision regarding expectant management of severe preeclampsia with concurrent suspected fetal growth restriction should be individualized,” the report states.
The Committee emphasizes that patients who are not candidates for expectant management include women with eclampsia, pulmonary edema, disseminated intravascular coagulation (DIC), renal insufficiency, abruptio placentae, abnormal fetal testing, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, or persistent symptoms of severe preeclampsia. These women, as well as those who have abnormal fetal surveillance results, “should typically be delivered after initial maternal stabilization,” the Committee concludes.
They note that severe proteinuria alone and the degree of change in proteinuria should not be considered criteria to avoid or terminate expectant management.
“For women with severe preeclampsia before the limit of viability, expectant management has been associated with frequent maternal morbidity with minimal or no benefits to the newborn,” the authors note.
“Explicit counseling regarding the potential maternal risks should be provided and delivery should be considered when severe preeclampsia occurs before the limit of viability,” they advise.
Am J Obstet Gynecol 2011.
