Evaluation and management of severe preeclampsia before 34 weeks’ gestation




Objective


We sought to review the risks and benefits of expectant management of severe preeclampsia remote from term, and to provide recommendations for expectant management, maternal and fetal evaluation, treatment, and indications for delivery.


Methods


Studies were identified through a search of the MEDLINE database for relevant peer-reviewed articles published in the English language from January 1980 through December 2010. Additionally, the Cochrane Library, guidelines by organizations, and studies identified through review of the above documents and review articles were utilized to identify relevant articles. Where reliable data were not available, opinions of respected authorities were used.


Results and Recommendations


Published randomized trials and observational studies regarding management of severe preeclampsia occurring <34 weeks of gestation suggest that expectant management of selected patients can improve neonatal outcomes but that delivery is often required for worsening maternal or fetal condition. Patients who are not candidates for expectant management include women with eclampsia, pulmonary edema, disseminated intravascular coagulation, renal insufficiency, abruptio placentae, abnormal fetal testing, HELLP syndrome, or persistent symptoms of severe preeclampsia. 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. Expectant management of a select group of women with severe preeclampsia occurring <34 weeks’ gestation may improve newborn outcomes but requires careful in-hospital maternal and fetal surveillance.


Introduction


Preeclampsia is a multisystem disorder that can manifest clinically with hypertension and proteinuria with or without accompanying symptoms, abnormal maternal laboratory test results, intrauterine growth restriction, or reduced amniotic fluid volume. The incidence of severe preeclampsia ranges from 0.6-1.2% of pregnancies in Western countries. Preeclampsia <37 weeks’ and severe preeclampsia <34 weeks’ gestation complicates 0.6-1.5% and 0.3% of pregnancies, respectively. The likelihood of severe and preterm preeclampsia is substantially increased in women with a history of preeclampsia, and in those with diabetes mellitus, chronic hypertension, or a multifetal gestation. Published reports use differing criteria for the diagnoses of preeclampsia, severe and superimposed preeclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. Commonly used definitions are presented in the Table . For women with preexisting hypertension or proteinuria, the diagnosis of severe preeclampsia can be more difficult, but new-onset severe hypertension or proteinuria, or development of other clinical or laboratory findings of severe preeclampsia are suggestive of preeclampsia in this setting.



Quality of evidence


The quality of evidence for each included article was evaluated according to the categories outlined by the US Preventative Services Task Force:



  • I

    Properly powered and conducted randomized controlled trial; well-conducted systematic review or metaanalysis of homogeneous randomized controlled trials.


  • II-1

    Well-designed controlled trial without randomization.


  • II-2

    Well-designed cohort or case-control analytic study.


  • II-3

    Multiple time series with or without the intervention; dramatic results from uncontrolled experiments.


  • III

    Opinions of respected authorities, based on clinical experience; descriptive studies or case reports; reports of expert committees.



Recommendations are graded in the following categories:


Level A


The recommendation is based on good and consistent scientific evidence.


Level B


The recommendation is based on limited or inconsistent scientific evidence.


Level C


The recommendation is based on expert opinion or consensus.




The practice of medicine continues to evolve, and individual circumstances will vary. This opinion reflects information available at the time of its submission for publication and is neither designed nor intended to establish an exclusive standard of perinatal care. This publication is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine.



TABLE

Diagnostic criteria for preeclampsia, severe preeclampsia, and HELLP syndrome







  • ➢

    Preeclampsia



    • ○

      Blood pressure ≥140 mm Hg or ≥90 mm Hg diastolic that occurs >20 wk’ gestation in woman with previously normal blood pressure plus proteinuria defined as urinary excretion ≥0.3 g protein in 24-h urine specimen



  • ➢

    Severe preeclampsia (≥1 of following criteria is required)



    • ○

      Blood pressure ≥160 mm Hg systolic or ≥110 mm Hg diastolic on 2 occasions at least 6 h apart while patient is on bed rest


    • ○

      Proteinuria ≥5 g in 24-h urine specimen ≥3+ on 2 random urine samples collected at least 4 h apart


    • ○

      Oliguria <500 mL in 24 h


    • ○

      Cerebral or visual symptoms


    • ○

      Pulmonary edema or cyanosis


    • ○

      Epigastric or right upper quadrant pain


    • ○

      Impaired liver function


    • ○

      Thrombocytopenia


    • ○

      Fetal growth restriction



  • ➢

    Superimposed preeclampsia (≥1 of following criteria is required)



    • ○

      New-onset proteinuria ≥0.3 g protein in woman with hypertension <20 wk’ gestation


    • ○

      If hypertension and proteinuria present <20 wk’ gestation



      • ■

        Sudden increase in proteinuria if both hypertension and proteinuria are present <20 wk’ gestation


      • ■

        Sudden increase in hypertension in woman whose hypertension has previously been well controlled


      • ■

        Thrombocytopenia (platelet count <100,000 cells/mm 3 )


      • ■

        Increase in alanine aminotransferase or aspartate aminotransferase to abnormal levels



      Women with chronic hypertension who develop persistent headache, scotoma, or epigastric pain also may have superimposed preeclampsia



  • ➢

    HELLP syndrome (differing diagnostic criteria have been reported, 2 commonly used criteria follow)



    • ○

      Sibai et al (each of following required)



      • (1)

        Hemolysis on peripheral smear, lactate dehydrogenase >600 U/L, or total bilirubin >1.2 mg/dL


      • (2)

        Aspartate aminotransferase >70 U/L


      • (3)

        Platelet count <100,000 cells/mm 3



    • ○

      Martin et al (each of following required)



      • (1)

        Lactate dehydrogenase >600 U/L


      • (2)

        Aspartate aminotransferase or alanine aminotransferase >40 IU/L


      • (3)

        Platelet count <150,000 cells/mm 3



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Jun 4, 2017 | Posted by in GYNECOLOGY | Comments Off on Evaluation and management of severe preeclampsia before 34 weeks’ gestation

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