Expectant Management of Severe Preeclampsia

4/5/2014
Expectant management of severe preeclampsia
Official reprint from UpToDate

www.uptodate.com 2014 UpToDate
Authors
Errol R Norwitz, MD, PhD
Edmund F Funai, MD
Section Editor
Charles J Lockwood, MD
Deputy Editor
Vanessa A Barss, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2014. | This topic last updated: Nov 08, 2013.
INTRODUCTION 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 disease is considered
severe when any of the features listed in the following table are present (table 2) [1].
A database of hospital discharge data from approximately 300,000 deliveries in the United States found the
overall incidence of severe preeclampsia was about 1 percent of all pregnancies [2]. Studies limited to
nulliparous women report that about 5 percent develop preeclampsia and 40 to 50 percent of these women
develop severe disease [3,4]. The incidence of severe preeclampsia at <34 weeks is 0.3 percent [5]. However,
these studies used the pre-2013 definition of severe preeclampsia, which involved different criteria for severe
disease (eg, inclusion of fetal growth restriction and proteinuria >5 grams/day as features of severe disease).
(See "Preeclampsia: Clinical features and diagnosis".)
Women with severe preeclampsia 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 severe preeclampsia for
prompt delivery versus expectant management. The general management of pregnancies complicated by
preeclampsia is reviewed separately. (See "Preeclampsia: Management and prognosis".)
OUTCOME OF PREGNANCIES COMPLICATED BY SEVERE PREECLAMPSIA A literature review including
72 publications reported the following serious maternal complications of severe preeclampsia: seizures,
pulmonary edema, hypertensive encephalopathy, stroke, renal failure, hepatic failure or rupture, retinal
detachment or cortical blindness, disseminated intravascular coagulation, placental abruption, and death [6].
The magnitude of increased morbidity associated with preeclamptic pregnancies was best illustrated in a
controlled study that compared the pregnancy outcome of 319 women with mild or severe preeclampsia
delivering their first baby to that of 3229 similar women whose blood pressure remained normal during the
pregnancy (table 3) [7]. The major consequences of severe preeclampsia were increased rates of maternal liver
and kidney dysfunction, induced labor, cesarean delivery, preterm birth, fetal growth restriction, and neonatal
respiratory problems. The highest risk of maternal and neonatal morbidity was in pregnancies complicated by
severe second trimester preeclampsia. In this series, there was no significant increase in the rate of fetal or
neonatal death, but others have found that earlier onset of severe preeclampsia and severely restricted fetal
growth are associated with a dismal neonatal prognosis [8].
Onset at less than 24.0 weeks Both maternal and fetal outcomes are poor with expectant management of
severe preeclampsia with onset in the second trimester [8-10]. Twenty-five to 63 percent of mothers managed
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expectantly had serious complications, including HELLP syndrome, renal insufficiency, abruptio placentae,
pulmonary edema, and eclampsia.
The following perinatal survival rates by week of gestation were derived from combined data from several series
[8]:
less than 23 and 0/7ths weeks (28 fetuses, 0 survivors)
23 and 0 to 6/7ths weeks (22 fetuses, 18 percent survival)
Survivors are at high risk of short-term complications and long-term disability. However, the limits of viability vary
among hospitals and are impacted by factors other than gestational age, such as gender, birthweight, and
administration of antenatal corticosteroids, and these factors should be taken into account when counseling
individual patients. (See "Limit of viability".)
Randomized trials involving pregnancies 28 weeks The outcome of various management approaches of
early third trimester severe preeclampsia was evaluated in two small randomized trials that assigned women
with severe preeclampsia to aggressive or expectant management [11,12]. The pregnancies were at 28 to 32
[12] and 28 to 34 [11] weeks of gestation and the diagnosis of severe preeclampsia was based on blood
pressure criteria alone.
Both trials reported significant prolongation of pregnancy and improvement in neonatal outcome with expectant
management, with no increase in the rate of maternal complications. Prolongation of pregnancy averaged 15.4
days (range 4 to 36 days) in the larger of these trials (n = 95) [12] and 7.1 days in the smaller series (n = 38)
[11]. In the larger trial, there were no cases of eclampsia or perinatal death and no increase in the frequency of
abruptio placentae with expectant management (incidence of abruption: 4 percent) [12]. Importantly, infants in
the expectantly managed group had a significantly higher gestational age at delivery (32.9 versus 30.8 weeks)
and birth weight, lower incidence of admission to the neonatal intensive care unit (76 versus 100 percent), and
lower incidence of neonatal complications (respiratory distress 22 versus 50 percent; necrotizing enterocolitis 0
versus 11 percent).
A larger third randomized trial (MEXPRE Latin Study) included 267 women at 28 to 33 weeks of gestation with
severe preeclampsia based on blood pressure criteria plus proteinuria >5 grams or end-organ symptoms
(headache, visual disturbances, epigastric pain, tinnitus), but excluded those with HELLP, renal failure,
pulmonary edema, and other comorbidities [13]. Despite the exclusions, these patients had more signs and
symptoms of severe disease than those in the two trials discussed above (patients had only severe
hypertension). In this trial, expectant management resulted in prolongation of pregnancy (10.3 days versus 2.2
days for pregnancies treated with a course of antenatal corticosteroids followed by delivery in 24 to 72 hours);
however, this did not result in significant neonatal benefit. Perinatal mortality was similar in the expectantly
managed and prompt delivery after steroids groups (9.4 versus 8.7 percent), as was composite neonatal
morbidity (56.4 versus 55.6 percent). Furthermore, small for gestation age (SGA) and abruption outcomes were
statistically more common with expectant management (SGA 21.7 versus 9.4 percent; abruption RR 5.07, 95%
CI 1.13-22.7). The lack of benefit from expectant management compared with the previous two trials may have
been due to selection of patients at the more severe spectrum of severe preeclampsia. In addition, 40 percent of
patients in the expectant management group were delivered for uncontrollable hypertension (compared to 6
percent in the Sibai trial [12]), which suggests that more aggressive attempts at blood pressure control might
have resulted in greater prolongation of pregnancy and, in turn, less morbidity from preterm delivery.
Systematic review of studies of pregnancies <34 weeks A systematic review of randomized trials and
studies of severe preeclampsia <34 weeks of gestation (39 cohorts, 4650 women) concluded expectant
management was associated with pregnancy prolongation of 7 to 14 days and a median serious maternal
complication rate of <5 percent, which is similar to the rate with prompt intervention (2 studies, 42 women) [6].
Onehalf of expectantly managed patients delivered for maternal indications and the other half delivered for fetal
indications.
Approximately 40 percent of women with severe preeclampsia at <34 weeks of gestation were appropriate
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candidates for expectant management rather than delivery [6]. (See 'Candidates for expectant management of
severe preeclampsia' below.)
Long-term outcome The long-term outcome of pregnancies complicated by severe preeclampsia, growth
restriction, and preterm birth was illustrated by the Pre-eclampsia Eclampsia Trial Amsterdam (PETRA) study
[14]. This study assessed neurodevelopmental outcome at age 4.5 years in 216 children born after expectant
management of severe hypertensive complications of pregnancy with onset between 24 and 34 weeks of
gestation. All of the children were products of singleton gestations complicated by pregnancy-induced
hypertension, severe preeclampsia, HELLP, or eclampsia; 91 percent were small for gestational age at birth;
and the mean gestational age at delivery was 31.4 weeks. At 4.5 years corrected age, there was an increased
frequency of IQ that was subnormal (78 to 93) or abnormal (<78) (30 percent versus 16 percent in the general
population). Fifty-four percent of the children had normal results on all tests of developmental outcome. Seven
percent of the children were attending special education classes, which is about seven times as many as the
nationwide rate of 1 percent at that age in The Netherlands. There were no blind or deaf children in the cohort.
GESTATIONAL AGE BASED APPROACH TO MANAGEMENT OF SEVERE PREECLAMPSIA Based on
the outcome data presented above, if a woman develops severe preeclampsia before 24 weeks of gestation, we
often recommend termination of pregnancy to reduce the mother's risk of developing life-threatening morbidity
(eg, cerebrovascular hemorrhage) and to prevent the birth of an infant at the limit of viability, and thus at high risk
of death or severe permanent disability. Factors critical in making this decision are the estimated fetal weight,
presence or absence of growth restriction, and the neonatologist's judgment of the neonatal prognosis. If the
fetus is deemed nonviable, we recommend delivery [1]. (See "Limit of viability".)
At 24 to 25 weeks of gestation, the decision making process is exceptionally complex; the clinician and patient
should carefully weigh the risks and benefits of expectant management, taking into account individual clinical
factors such as the estimated fetal weight and whether a full course of corticosteroids can be/has been
administered.
Between 25 and 34 weeks of gestation, we offer expectant management to appropriately selected women, as
described below. (See 'Candidates for expectant management of severe preeclampsia' below.)
We suggest delivery for all women with severe preeclampsia who have reached a favorable gestational age (34
or more weeks of gestation), as prolonging the pregnancy at this gestational age subjects the mother and fetus
to significant risks with relatively small potential benefits. This is consistent with recommendations by expert
groups [1,15,16].
CANDIDATES FOR EXPECTANT MANAGEMENT OF SEVERE PREECLAMPSIA Expectant management
of severe preeclampsia is a reasonable approach for some patients. It should be emphasized that expectant
management of severe preeclampsia is not associated with any direct maternal benefits. The mother is taking
on a small but significant risk to her own health, in order to delay delivery until an older gestational age with a
more favorable neonatal prognosis is reached for her child [17]. These patients should be hospitalized and cared
for by, or in consultation with, a maternal-fetal medicine specialist. Such an approach should be undertaken
only at facilities with adequate maternal and neonatal intensive care resources [1]. In this environment, we offer
expectant management for patients with severe preeclampsia presenting between 24 and 34 weeks of gestation
in the following circumstances:
Transient laboratory abnormalities Asymptomatic women with severe preeclampsia by laboratory criteria
alone (ALT or AST twice the upper limit of normal, platelet count of less than 100,000 cells/microL) may be
managed expectantly if the abnormalities resolve within 24 to 48 hours of hospitalization [11,12]. In otherwise
asymptomatic or mildly hypertensive women, it is reasonable to delay delivery, administer antenatal
glucocorticoids, and repeat the laboratory tests (AST, ALT, platelet count) every 6 to 12 hours to see if they
improve.
We would promptly deliver patients with worsening of liver function tests or platelet counts over a period of 6 to
12 hours, and those who develop other signs of severe preeclampsia.
Severe preeclampsia based solely on blood pressure criteria Two trials have established a precedent
for expectant management of patients with severe preeclampsia by blood pressure criteria alone in pregnancies
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28 to 34 weeks with reassuring fetal testing [11,12]. Antihypertensive agents are given to control severe
hypertension.
The use of antihypertensive drugs does not alter the course of preeclampsia or reduce perinatal morbidity or
mortality, and their use may diminish uteroplacental perfusion or mask an increase in blood pressure, which can
be a sensitive measure of worsening disease [18,19]. For these reasons, treatment of mild hypertension during
pregnancy is not generally recommended; however, antihypertensive agents should be used in women with
severe hypertension to prevent a cerebrovascular accident. (See "Management of hypertension in pregnant and
postpartum women".)
CONTRAINDICATIONS TO EXPECTANT MANAGEMENT OF SEVERE PREECLAMPSIA In some clinical
situations, we feel the risks associated with expectant management outweigh any potential benefits. Under
these circumstances, we intervene regardless of gestational age and even if the second corticosteroid dose has
not been given or the maximum therapeutic effect has not been achieved.
Strong consideration should be given to abandoning expectant management and proceeding with prompt
delivery if any of the following conditions are present [5,20]:
Maternal hemodynamic instability (shock)
Nonreassuring fetal testing (nonreassuring nonstress test or biophysical profile score, estimated fetal
weight less than the fifth percentile for gestational age, oligohydramnios with AFI <5.0 cm or maximal
vertical pocket <2.0 cm, and/or persistent absent or reversed diastolic flow on umbilical artery Doppler
velocimetry)
Intrapartum fetal demise
Persistent severe hypertension unresponsive to medical therapy
Severe headache (ie, incapacitating, "the worst headache of my life") or persistent progressive headache
(despite analgesia), visual aberrations, or epigastric/right upper quadrant pain
Eclampsia (See "Eclampsia".)
Pulmonary edema
Renal failure with a marked rise in serum creatinine (eg, rise in serum creatinine concentration by 1
mg/dL over baseline) and/or urine output less than 0.5 mL/kg/hour for two hours unresponsive to hydration
with two intravenous boluses of 500 mL fluid
Abruptio placentae
Laboratory abnormalities, such as:
Aminotransferases increasing over 6 to 12 hours and reaching levels twice the upper limit of normal
Progressive decrease in platelet count to less than 100,000 cells/microL
Coagulopathy in the absence of an alternative explanation
Preterm labor
Preterm premature rupture of membranes
Maternal request for immediate delivery
HELLP syndrome Although some studies have reported that serious maternal complications in the
setting of expectant management of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low
Platelets) are uncommon with careful maternal monitoring, the benefit of expectant management in this
setting has not been demonstrated [21,22]. The aim of expectant management is to improve neonatal
morbidity and mortality; there is no evidence that overall perinatal outcome is improved with expectant
management of HELLP compared to pregnancies delivered after a course of glucocorticoids. We consider
expectant management in this setting an investigational approach [23]. (See "HELLP syndrome".)
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INITIAL MANAGEMENT OF SEVERE PREECLAMPSIA Women with suspected preeclampsia should be

admitted to the hospital to confirm the diagnosis, assess severity, monitor maternal and fetal status, and initiate
supportive therapy or perform delivery. (See "Preeclampsia: Clinical features and diagnosis" and "Preeclampsia:
Management and prognosis".)
Our initial management of these pregnancies involves:
Admission to the Labor and Delivery Unit. The patient may need to be monitored in this intensive setting
for as long as 48 hours. She can be transferred to less intensive care when her blood pressure is stable
without labile elevations into the severe range, her laboratory tests are stable or improving, and fetal testing
is reassuring.
Administration of a course of antenatal corticosteroids Reasonable efforts should be made to delay
delivery for 48 hours to complete a full course of steroids. However, intervention will be necessary if there
is deterioration in maternal or fetal status.
Although some studies [24], but not all [25], have reported that neonates from preeclamptic pregnancies
have a reduced incidence of respiratory distress syndrome and intraventricular hemorrhage [26] compared
to infants from normotensive pregnancies, this is not sufficient justification to withhold antenatal
corticosteroid therapy if indicated by gestational age because corticosteroid therapy significantly reduces
neonatal morbidity and mortality in these neonates [27,28]. A meta-analysis of randomized trials of
antenatal corticosteroid treatment versus no antenatal corticosteroid treatment of pregnancies complicated
by hypertension syndromes showed that treatment significantly reduced the risks of neonatal death (RR
0.50, 95% CI 0.29-0.87, two studies, 278 infants), respiratory distress syndrome (RR 0.50, 95% CI 0.350.72, five studies, 382 infants) and intraventricular hemorrhage (RR 0.38, 95% CI 0.17-0.87, two studies,
278 infants) [29]. (See "Antenatal corticosteroid therapy for reduction of neonatal morbidity and mortality
from preterm delivery".)
Antepartum or postpartum administration of corticosteroids does not reduce the severity or duration of
severe preeclampsia [30,31].
Seizure prophylaxis with magnesium sulfate. (See "Preeclampsia: Management and prognosis", section
on 'Seizure prophylaxis'.)
Blood pressure monitoring at least every one to two hours. Severe hypertension should be treated to
reduce the risk of maternal cardiovascular complications. There is no consensus on what the threshold for
treatment should be or how the threshold should vary by patient specific factors. We treat patients with
systolic blood pressure 150 mm Hg or the diastolic blood pressure 95 to 100 mmHg. (See
"Management of hypertension in pregnant and postpartum women", section on 'Preeclampsia'.)
Accurate recording of fluid intake and urine output.
Laboratory studies We obtain a complete blood count (including platelet count and smear),
electrolytes, creatinine, alanine and aspartate aminotransferase (ALT, AST), and lactic acid
dehydrogenase (LDH) [32]. Albumin can be useful to help guide nutritional replacement in cases of severe
proteinuria. A coagulopathy profile (PT, PTT, fibrinogen) is sent if the ALT and AST are more than twice
normal, if the platelet count is less than 100,000 cells/microL, or if placental abruption is suspected. (See
"Preeclampsia: Clinical features and diagnosis".)
Assessment of fetal well-being, including a nonstress test, amniotic fluid volume determination, and
estimation of fetal growth. We obtain umbilical artery Doppler velocimetry if fetal growth restriction or
oligohydramnios is present.
COMPONENTS OF EXPECTANT MANAGEMENT OF SEVERE PREECLAMPSIA If there are no
contraindications to expectant management, we suggest the following regimen to minimize the risk of maternal
and fetal complications. Close supervision of mother and fetus is crucial, as it is impossible to predict the
clinical course the disease will take after admission, and clinical deterioration can occur rapidly [33]. After initial
assessment and stabilization on the Labor and Delivery Unit, these patients are monitored and medically
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managed on an antepartum unit. There are no data from randomized trials on which to base an evidence-based
protocol for managing these patients. Our general approach to management on the antepartum unit is as
follows:
Hospitalize until delivery. Findings from frequent maternal and fetal assessment are reviewed throughout
the day and the ongoing risks of conservative management versus the benefit of further fetal maturation are
reevaluated frequently.
Monitor blood pressure every four hours. We do not awaken patients at night to check blood pressure if
they are asymptomatic and blood pressure has been well-controlled during the day. Antihypertensive
therapy is given to women with chronic hypertension and those being managed according to standard
protocols for severe preeclampsia by blood pressure criteria only remote from term [11,12].
Frequently assess maternal symptoms (eg, headache, vision changes, epigastric or abdominal pain,
decreased fetal activity, vaginal bleeding)
Accurately record fluid intake and urine output to identify oliguria.
Obtain a complete blood count, serum creatinine, and liver function tests at least twice weekly. Delivery
should be considered if laboratory abnormalities worsen after an initial improvement.
Finish the course of antenatal corticosteroids, if not already completed.
Regularly assess fetal well-being. There is no standardized protocol for fetal assessment in this setting.
We obtain fetal kick counts and nonstress tests at least daily, ultrasound assessment of amniotic fluid
volume once or twice per week, weekly Doppler velocimetry of the umbilical artery if growth is abnormal,
and ultrasound estimation of fetal growth every 7 to 14 days. (See "Antepartum fetal heart rate
assessment" and "Fetal growth restriction: Evaluation and management" and "Assessment of amniotic
fluid volume".)
Continue magnesium sulfate seizure prophylaxis until completion of the course of antenatal
corticosteroids. If the patient remains a candidate for expectant management at that time, the magnesium
sulfate can be discontinued until her status changes and preterm delivery becomes indicated.
Consultation with neonatology and anesthesiology services.
Several management strategies with no proven benefit in the setting of severe preeclampsia are commonly
recommended, but are best avoided because of potential morbidity, cost, and/or patient inconvenience. These
include: routine use of continuous fetal heart rate monitoring, routine initiation of antihypertensive therapy,
antepartum administration of magnesium sulfate seizure prophylaxis for over 48 hours, serial 24-hour urine
collections for protein quantitation, and routine assessment of fetal lung maturity. However, the latter may be
useful in delivery decisions between 30 and 34 weeks when there is contradictory or equivocal evidence of
maternal or fetal deterioration.
DELIVERY
Indications Delivery in the setting of severe preeclampsia will usually be initiated for the maternal indications
described above, which include persistent signs or symptoms of end-organ damage, such as severe headache,
epigastric pain, visual abnormality, uncontrollable hypertension, eclampsia, pulmonary edema, renal failure,
severe thrombocytopenia, HELLP syndrome, and altered mental state. (See 'Contraindications to expectant
management of severe preeclampsia' above.)
In our opinion, fetal indications for intervention include nonreassuring fetal heart rate or biophysical testing,
estimated fetal weight less than the fifth percentile for gestational age, oligohydramnios (defined as AFI <5.0 cm
or maximal vertical pocket <2.0 cm), and/or persistent absent or reversed diastolic flow on umbilical artery
Doppler velocimetry. (See "Fetal growth restriction: Evaluation and management".)
Obstetrical indications for delivery in patients with severe preeclampsia include preterm labor, preterm premature
rupture of membranes, abruptio placentae, and fetal demise.
In the absence of any of these maternal or fetal indications for earlier intervention, we deliver women hospitalized
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for expectant management of severe preeclampsia at 34 weeks of gestation. We do not assess fetal lung
maturity prior to delivery.
Route Cesarean delivery is reserved for standard obstetrical indications [1]. A decision to expedite delivery in
the setting of severe preeclampsia does not mandate immediate cesarean birth [34]. Cervical ripening agents
may be used if the cervix is not favorable prior to induction [35]; however, a prolonged induction is best avoided.
The safety of induction was illustrated by two retrospective series that compared neonatal outcome of over 700
singleton, live born, premature infants of women with severe preeclampsia who underwent induction or
scheduled cesarean delivery [36,37]. Induction was not associated with a significant increase in the rate of any
major neonatal complication (respiratory distress syndrome, intraventricular hemorrhage, seizures, sepsis,
death).
At 32 weeks of gestation, the rate of vaginal delivery after labor induction exceeds 60 percent, but at 28
weeks, it falls to 0 to 32 percent because of the high frequency of nonreassuring fetal heart rate tracings and
failure of the cervix to dilate [35,37,38]. For this reason, some experts recommend scheduled cesarean delivery
for women with severe preeclampsia who are under 28 to 30 weeks of gestation, especially if they have a low
Bishop score [37,39]. We generally agree, but take parity and prior labor course into consideration, as well.
Anesthesia We agree with practice guidelines from the American Society of Anesthesiologists (ASA) and
the American College of Obstetricians and Gynecologists (ACOG) that neuraxial anesthetic techniques are
strongly preferred to general anesthesia for preeclamptic parturients with adequate platelet counts undergoing
cesarean deliveries [1,40]. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section
on 'Neuraxial analgesia and low platelets'.)
Spinal anesthesia is an option if an epidural catheter is not already in place. In a randomized multicenter center
trial that compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely
preeclamptic patients, spinal anesthesia was associated with a higher incidence of hypotension (systolic
arterial blood pressure 100 mm Hg: 51 versus 23 percent) and required more treatment with ephedrine than did
epidural anesthesia; however, hypotension was easily treated with ephedrine and resolved in 1 minute in both
groups [41]. Neonatal outcomes were similar for both groups.
The anesthesiologists choice of a particular neuraxial technique is based on many factors, including the
patients platelet count and the urgency and expected length of the procedure. The obstetrician and
anesthesiologist should discuss these factors prior to the administration of the anesthetic.
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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
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Beyond the Basics topics (see "Patient information: Preeclampsia (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Preeclampsia (table 1) is severe when any features from the following table are present (table 2). (See
'Introduction' above.)
After thorough initial assessment, expectant management with aggressive maternal and fetal monitoring of
appropriately selected women can improve perinatal outcome. (See 'Initial management of severe
preeclampsia' above and 'Candidates for expectant management of severe preeclampsia' above and
'Contraindications to expectant management of severe preeclampsia' above.)
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Women managed expectantly should be hospitalized and cared for by, or in consultation with, a maternalfetal medicine specialist. They should undergo daily maternal and fetal assessment with continual review
of the ongoing risks of conservative management. (See 'Components of expectant management of severe
preeclampsia' above.)
For pregnancies 34.0 weeks of gestation, we suggest prompt delivery (Grade 2B). At this gestational
age, the maternal and fetal risks of prolonging the pregnancy generally outweigh the benefits of further fetal
and cervical maturation. (See 'Outcome of pregnancies complicated by severe preeclampsia' above and
'Gestational age based approach to management of severe preeclampsia' above.)
For pregnancies between 24.0 and 34.0 weeks of gestation, we suggest expectant management in the
following settings: (See 'Outcome of pregnancies complicated by severe preeclampsia' above and
Laboratory abnormalities that are transient (Grade 2B)
Severe hypertension (Grade 2B) is the only criterion for severe disease.
Prompt delivery is indicated if maternal or fetal status deteriorates during expectant management.
(See 'Delivery' above and 'Contraindications to expectant management of severe preeclampsia'
above.)
For pregnancies <24.0 weeks of gestation, we suggest prompt delivery (Grade 2C). Expectant
management is associated with a high risk of severe maternal morbidity, perinatal mortality, and severe
neonatal morbidity. (See 'Outcome of pregnancies complicated by severe preeclampsia' above and
Severe hypertension should be treated with antihypertensive drugs. (See 'Initial management of severe
preeclampsia' above.)
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20. Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient selection,
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31. Fonseca JE, Mndez F, Catao 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
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101:862.
Topic 6791 Version 11.0
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GRAPHICS
Criteria for the diagnosis of preeclampsia
Systolic blood pressure 140 mmHg or diastolic blood pressure 90 mmHg on two
occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive
patient
If systolic blood pressure is 160 mmHg or diastolic blood pressure is 110 mmHg,
confirmation within minutes is sufficient
and
Proteinuria 0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL)
ratio 0.3
Dipstick 1+ if a quantitative measurement is unavailable
In patients with new onset hypertension without proteinuria, the new onset of any of
the following is diagnostic of preeclampsia:
Platelet count <100,000/microliter
Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other
renal disease
Liver transaminases at least twice the normal concentrations
Pulmonary edema
Cerebral or visual symptoms
Adapted from: Hypertension in pregnancy: Report of the American College of Obstetricians and
Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
Graphic 79977 Version 8.0
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The presence of one or more of the following criteria are features of

severe preeclamptic disease
Symptoms of central nervous system dysfunction:
New onset cerebral or visual disturbance, such as:
Photopsia, scotomata, cortical blindness, retinal vasospasm
Severe headache (ie, incapacitating, "the worst headache I've ever had") or headache that
persists and progresses despite analgesic therapy
Altered mental status
Hepatic abnormality:
Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not
accounted for by an alternative diagnosis or serum transaminase concentration twice normal,
or both
Severe blood pressure elevation:

Systolic blood pressure 160 mmHg or diastolic blood pressure 110 mmHg on two occasions at
least four hours apart while the patient is on bedrest (unless the patient is on antihypertensive
therapy)
Thrombocytopenia:
<100,000 platelets/microL
Renal abnormality:
Progressive renal insufficiency (serum creatinine >1.1 mg/dL or doubling of serum creatinine
concentration in the absence of other renal disease)
Pulmonary edema
In contrast to older criteria, the 2013 criteria do not include proteinuria >5 grams/24 hours
and fetal growth restriction as features of severe disease.
Adapted from: Hypertension in pregnancy: Report of the American College of Obstetricians and
Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
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Complications of preeclampsia
Outcome
Normal blood
measure
pressure, (percent)
Mild
Severe
preeclampsia
(percent)
preeclampsia
(percent)
Maternal
Liver
dysfunction
0.2
3.2
20.2
Kidney
dysfunction
0.3
5.1
12.8
Placental
abruption
0.7
0.5
3.7
Induced
labor
12.1
41.5
58.7
Cesarean
delivery
13.3
30.9
34.9
Delivery
<34 weeks
3.2
1.9
18.5
Fetal or neonatal
Growth
restriction
4.2
10.2
18.5
Admission
to NICU
12.9
27.3
42.6
Respiratory
difficulty
3.8
3.2
15.7
Brain
hemorrhage
0.2
0.5
Fetal death
0.9
0.5
0.9
Neonatal
0.5
0.5
0.9
death
Adapted from data in Hauth, JC, Ewell, MG, Levine, RJ, et al. Obstet Gynecol 2000; 95:24.
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Disclosures
Disclosures: Errol R Norw itz, MD, PhD Consultant/Advisory Boards: Hologic (prediction tests for preterm birth); Natera (prenatal
diagnosis using cell-free DNA). Patent Holder: use of urinary angiogenic factors to predict preeclampsia, purchased by Beyer
(prediction test for preeclampsia). Edm und F Funai, MD Nothing to disclose. Charles J Lockw ood, MD Nothing to disclose.
Vanessa A Barss, MD Employee of UpToDate, Inc. Equity Ow nership/Stock Options: Merck; Pfizer; Abbvie.
Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
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Expectant management of severe preeclampsia

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Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

INITIAL MANAGEMENT OF SEVERE PREECLAMPSIA Women with suspected preeclampsia should be

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

The presence of one or more of the following criteria are features of

Severe blood pressure elevation:

Expectant management of severe preeclampsia

Expectant management of severe preeclampsia

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