1703OBGM_Article2

8/3/2019 1703OBGM_Article2

1/8

18 O B G M A N A G E M E N T M a r c h 2 0 0 5

Once you decide to expectantlymanage a patient with preeclamp-sia, the balancing act begins. That

means weighing fetal benefits againstmaternal risks, since the only justificationfor expectant management is to prolongpregnancy for fetal gainthere is noadvantage to the mother.

The best approach is to classify thewomans preeclampsia by the degree ofseverity and gestational age at the time ofdiagnosis, then follow recommendationstailored to that particular category.

This article offers guidelines forexpectant management of mild and severepreeclampsia, preeclampsia superimposedon a preexisting medical condition, andintrapartum and postpartum care.

Mild preeclampsia The earlier preeclampsia develops,

the greater the risk it will become

severe. The need for hospitalization

depends on gestational age, blood

pressure, proteinuria levels, maternal

symptoms, and reliability of the

patient.

Preeclampsia is mild when systolic blood

pressure reaches 140 to 159 mm Hg or

diastolic pressure measures 90 to 109 mmHg on at least 2 occasions more than 6hours apart after 20 weeks gestation in awoman who previously had normal bloodpressure. In preeclampsia, this hyperten-sion is accompanied by proteinuria of 0.3to 4.9 g in a 24-hour urine sample (1+ or2+ by dipstick on 2 occasions).

At or beyond 37 weeks gestationIn general, women diagnosed withpreeclampsia at this gestational age havepregnancy outcomes similar to those ofnormotensive gravidas. Thus, they bene-fit from induction of labor and delivery.

32 to 36 weeks gestationClose maternal and fetal evaluation isessential. (It is assumed these womenhave no labor or membrane rupture and

normal fetal testing; otherwise, deliveryis indicated at 34 weeks or beyond.)

In general, hospitalization is indicat-ed when any of the following circum-stances are present (FIGURE 1):

the patient is unreliable, 2 or more systolic blood pressure

readings exceed 150 mm Hg, 2 or more diastolic blood pressure

readings exceed 100 mm Hg, proteinuria occurs at a rate exceeding

1 g/24 hours, or

Expectant managementof preeclampsiaHow to maintain the precarious balance

between fetal benefit and maternal health

according to disease severity and gestational age.

C O N T I N U E D

N THIS ARTICLE

Algorithms for mildand severe diseasePages 23, 24

Hazards to the fetusPage 31

Incidenceof maternalcomplicationsPage 32

When to givemagnesium sulfatePage 32

Drug profiles:antihypertensivesin pregnancyPage 34

OBGOBGMANAGEMENT

Baha M. Sibai, MDProfessor and Chairman,

Department of Obstetrics

and Gynecology,

University of Cincinnati

College of Medicine

PART 2 OF 3

B E S T P R A C T I C E S F O R D I A G N O S I S A N D M A N A G E M E N T O F P R E E C L A M P S I A


2/8

www. o b g m a n a g e m e n t . c o m M a r c h 2 0 0 5 O B G M A N A G E M E N T 23

Criteria for mildpreeclampsia 140-159 mm Hg

systolic

or 90-109 mm Hg

diastolic

on 2 occasions,

6 hours apart

Proteinuria0.3-4.9 g in 24 hours

M a r c h 2 0 0 5 O B G M A N A G E M E N T 23

persistent maternal symptoms arepresent.

Before 32 weeks gestationThese women are at high risk of progress-

ing to severe disease. They also are morelikely to have adverse perinatal outcomessuch as intrauterine growth restriction(IUGR) (15% to 20%), preterm delivery(50%), and abruptio placentae (1% to2%), compared with women diagnosedwith preeclampsia at 32 to 36 weeks. Inaddition, they require more antenatal sur-veillance than women who developpreeclampsia later in pregnancy.

I recommend hospitalization at the

time of diagnosis when women developmild preeclampsia before 32 weeks.

What and when to monitorMaternal evaluation should include:

monitoring of blood pressure at leastdaily (at home or in the hospital),

daily urine dipstick evaluation to mon-itor changes in proteinuria,

twice-weekly platelet count and liverenzymes, and

documentation of symptoms. (Instructall women to report the onset of severeheadaches, visual changes, alteredmental status, epigastric or right upperquadrant pain, and any nausea orvomiting.)

Fetal evaluation should include: serial ultrasound every 3 weeks to esti-

mate fetal weight and amniotic fluidstatus,

nonstress testing every week, and daily fetal movement counts.

If a nonstress test is nonreactive, itshould be confirmed by biophysical profile.

All testing should be promptlyrepeated if the maternal clinical condi-tion deteriorates.

No need for bed rest, diuretics,or antihypertensive medicationsAlthough expectantly managed patientswith mild preeclampsia should beadvised to restrict daily activity, there is

no need for complete bed rest. Nor have

diuretics or other antihypertensive drugsbeen shown to prolong gestation. On thecontrary, these medications may mask

severe preeclampsia.Antihypertensive medications reducethe rate of severe hypertension but do notimprove perinatal outcome. If thesedrugs are used to treat mild diseaseremote from term, hospitalize the patientand manage her as though she has severepreeclampsia.

Hospitalization versusoutpatient managementAlthough she may be hospitalized at the time

of diagnosis, a woman with preeclampsiamay switch to outpatient management ifsystolic or diastolic blood pressuredeclines, proteinuria diminishes to 1 g/24hours or less, and there are no maternalsymptoms or evidence of severe IUGR.Otherwise, these women should remainhospitalized until delivery.

In cases that begin with outpatientmanagement, prompt hospitalization isindicated if there is clinical evidence that

the disease is progressing (ie, new symp-

F I G U R E 1

Treatment of mild preeclampsiain healthy women

No

Delivery

No

Yes

HospitalizationYes

Maternal-fetalevaluation

In-hospital or ambulatory

management

Any of the following present?

37 weeks gestation or more Nonreassuring fetal status Maternal indication for delivery Labor or membrane rupture

at 34 weeks or more


23-32 weeks gestation Unreliable patient Systolic pressure >150 mm Hg Diastolic pressure >100 mm Hg Proteinuria >1 g/24 hours Maternal symptoms

FAST TRACK

Expectant management of preeclampsia


3/8



n mildpreeclampsia,antihypertensivedrugs may maskdisease progression

FAST TRACKFAST TRACK

toms, labor or rupture of membranes,vaginal bleeding, or increased blood

pressures or proteinuria) or IUGR and/oroligohydramnios.

Instruct all women to report symp-toms and changes in fetal movement.

When to deliverWhether the gravida is hospitalized or anoutpatient, delivery is indicated at 37weeks. Earlier delivery may be warrantedif nonreassuring maternal or fetal condi-tions develop. (FIGURE 1 summarizes

management of mild preeclampsia.)

Severe preeclampsia

Expectant management is safein 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 fol-lowing 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

F I G U R E 2

Treatment of severe preeclampsia

No

Yes

Yes

No


HELLP syndrome (hemolysis, elevated liverenzymes, and low platelets)

Severe intrauterine growth restriction Thrombocytopenia Persistent symptoms


Eclampsia Pulmonary edema Acute renal failure Disseminated intravascular coagulation Suspected abruptio placentae

Nonreassuring fetal status Labor or rupture of membranes >34 weeks gestation

Magnesium sulfateand delivery

Admit to labor and delivery suite

Maternal-fetal evaluation for 24 hours Magnesium sulfate for 24 hours Antihypertensives if systolic pressure 160 mm Hg,

diastolic pressure 110 mm Hg, or mean arterialpressure >125 mm Hg

Terminatepregnancy

23-32 weeks 33-34 weeks

Steroids

Steroids Antihypertensives if needed Daily evaluation of maternal-fetal conditions Deliver at 34 weeks


4/8



n severe disease,expectantmanagements warranted only

between 23 and 32weeks, and only ifmother and fetus

are stable

FAST TRACKFAST TRACKFAST TRACK

6 hours apart while the patient is onbed rest

proteinuria of 5 g or more in a 24-hoururine specimen,

oliguria of less than 500 mL in 24 hours,

cerebral or visual disturbances, pulmonary edema or cyanosis, severe epigastric or right upper-quad-

rant pain, or thrombocytopenia.

When gestational hypertension orpreeclampsia is severe, hospitalization inthe labor and delivery suite is warranted.These women should receive intravenous(IV) magnesium sulfate to reduce the riskof convulsions and antihypertensive

drugs to treat severe levels of hyperten-sion, if present. The aim of antihyperten-sive treatment is to keep diastolic bloodpressure between 90 and 105 mm Hgand systolic blood pressure below 160mm Hg.

During observation, assess maternaland fetal conditions and decide whetherdelivery is indicated (FIGURE 2).

Expectant management is warrantedonly for gestations between 23 and 32

weeks gestation, provided maternal andfetal conditions are stable (FIGURE 2).Keep in mind that both maternal and

fetal conditions may progressively deteri-orate. Thus, these pregnancies involvehigher rates of maternal morbidity andsignificant risk of neonatal morbidity. Forthis reason, expectant managementshould proceed only in a tertiary-carecenter with adequate maternal andneonatal facilities.

Recommended counselingAdvise these patients of the potential risksand benefits of expectant management,which requires daily monitoring of mater-nal and fetal conditions. Also explain thatthe decision to continue expectant man-agement will be revisited on a daily basisand that the median number of days preg-nancy 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 man-agement to aggressive management inearly-onset preeclampsia. However, ret-rospective and observational studiesinvolving more than 700 women suggest

expectant management reduces short-term neonatal morbidity with minimalrisk 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 preeclampsiamay be managed in the hospital, sincethese pregnancies are associated with high-er rates of abruptio placentae (2% to 5%),preterm delivery (56%), IUGR (13% to15%), and perinatal death (8%). Thus,

these women benefit from very closematernal and fetal monitoring.Superimposed preeclampsia is not

classified according to severity.In general, maternal and perinatal mor-

bidities are substantially higher in womenwho have preexisting conditions than inhealthy women who develop preeclampsia.

Chronic hypertensionIndications for delivery are similar to thosedescribed for healthy women with

preeclampsia, as is antihypertensive therapy.If the woman develops preeclampsia

while using antihypertensive drugs, deliveryshould be considered beyond 34 weeksgestation.

How preeclampsiaaffects renal functionWomen with renal disease or dysfunction(serum creatinine 1.2 mg/dL) prior to orearly in pregnancy face an increased risk

of adverse neonatal outcomes, regardlessC O N T I N U E D


5/8


www. o b g m a n a g e m e n t . c o m M a r c h 2 0 0 5 O B G M A N A G E M E N T 31

Use calcium-channel blockersto controlblood pressurein pregnant womenwith diabetes

FAST TRACK


FAST TRACK


FAST TRACK

of whether preeclampsia also develops.These women also face an increased risk

of deteriorating renal function duringpregnancy (particularly if preeclampsia orsevere hypertension develops) and beyond(more than 6 months postpartum).Start antihypertensive medications as soon

as possible, with the goal of keeping sys-tolic blood pressure below 140 mm Hgand diastolic blood pressure below 90mm Hg throughout gestation.Delivery is indicated with the onset ofpreeclampsia or significant deteriorationin renal function.

Diabetes warrants aggressive therapyWomen with type 1 diabetes have a higherrisk of preeclampsia, maternal and fetalmorbidity, and perinatal mortality. Theserisks multiply in women who have hyper-tension and/or diabetic nephropathy.Worsening of retinopathy and nephropa-thy also is more likely in women who havehypertension. Thus, aggressive manage-ment of blood sugars with insulin should

be accompanied by aggressive control of

blood pressure, with the goal of keepingsystolic pressure below 130 mm Hg and

diastolic pressure below 85 mm Hg.Choosing antihypertensive drugs. Calcium-channel blockers are preferred to controlblood pressure during pregnancy in womenwith diabetes. Outside of pregnancy,angiotensin-converting enzyme (ACE)inhibitors are best to avert long-term com-plications, but avoid these drugs in preg-nancy (along with angiotensin-receptorblockers), particularly beyond 16 weeks.Delivery is indicated in all women withvascular diabetes mellitus beyond 34

weeks when preeclampsia is present.

Intrapartum management Close fetal heart rate and maternal

blood pressure monitoring are

mainstays, along with magnesium

sulfate and antihypertensive therapy.

All women with preeclampsia should

receive continuous monitoring of fetal

F I G U R E 3

Though prolonged gestation benefits the fetus, it is not risk-free

Fetal growth restrictionresults from impaired uteroplacentalblood flow and is especially likelywhen preeclampsia develops before32 weeks gestation (15% to 20%)

Oligohydramnioscan range as high as 10% to 30%in women with severe preeclampsia

Abruptio placentaeusually occurs in


6/8



Loweringblood pressuretoo rapidlyduring laborcan reducematernal organperfusion, including

uteroplacentalblood flow

FAST TRACKFAST TRACKFAST TRACK

heart rate and uterine activity, with spe-cial vigilance for hyperstimulation andonset of vaginal bleeding during labor.(For a description of potential maternalcomplications, see TABLE 1; fetal compli-cations are described in FIGURE 3.)

Uterine irritability, recurrent variable

or late decelerations, and the develop-ment of vaginal bleeding may be the firstsigns of abruptio placentae.

I recommend recording maternalblood pressure at least hourly to detectprogression from mild to severe hyper-tension and to determine the need forantihypertensive therapy.

Prevent progression to eclampsiaMagnesium sulfate is the drug of choice in

women with preeclampsia. Recent reviews

indicate that it reduces the rate of convul-sions from 2% to 0.6% in women withsevere preeclampsia. In women with mildpreeclampsia, the benefit of magnesiumsulfate remains unclear.

I recommend IV magnesium sulfateduring labor and postpartum when awoman has the indications listed in TABLE 2.

The dose of magnesium sulfate is 6 gIV loading over 20 minutes, followed by amaintenance dose of 2 g/hour.

Magnesium sulfate should be startedbefore surgery (elective cesarean delivery)and continued for at least 12 hours post-partum (I prefer 24 hours).

When treating hypertension in labor,avoid hypotensive overshootThe goal of intrapartum treatment is tolower maternal blood pressure withoutcausing precipitous hypotensive over-shoot that may lead to reduced maternalorgan perfusion, particularly uteropla-cental blood flow. Such acute loweringof maternal blood pressure is a commoncause of nonreassuring fetal heart ratepatterns during labor.

What blood pressure necessitates treat-ment? There is no doubt that severe levelsof hypertension should be treated to avoidpotential cerebrovascular and cardiovas-cular complications in healthy women.However, there is disagreement aboutwhat constitutes severe hypertension.

In previously healthy women, I rec-ommend antihypertensive therapy for sys-tolic pressures of 170 mm Hg or aboveand/or for diastolic pressures of 110 mmHg or above.

For women with thrombocytopenia,disseminated intravascular coagulation,or pulmonary edema, I recommend treat-ment for systolic pressures of 160 mm Hgor above and diastolic pressures of 105mm Hg or above. This latter groupshould also be given IV furosemide (20 to40 mg) to promote diuresis. I also recom-mend treatment at these levels in the post-partum period.

For women with diabetes, renal dis-

ease, or left ventricular cardiac disease,

T A B L E 2

When to give prophylacticmagnesium sulfate

Use intrapartumand for at least 12 hours postpartum

When the patient has:

Severe hypertension or preeclampsia

Mild preeclampsia with symptoms

Mild hypertension plus symptoms

or thrombocytopenia

HELLP syndrome

(Hemolysis, elevated liver enzymes,

and low platelets)

T A B L E 1

Likelihoodof maternal complications

Disease progresses during labor 10%

(from mild to severe)Eclampsia

Mild disease


7/8



antihypertensive medications should beused to keep systolic pressure below 140mm Hg and diastolic pressure below 90mm Hg during labor and postpartum.Further, patients in congestive heart fail-ure or with left ventricular diastolic dys-

function should receive furosemide inaddition to antihypertensive drugs.Choosing a drug. My drugs of choice areIV labetalol and oral nifedipine. These 2drugs, along with IV hydralazine, are themost commonly recommended medica-tions for severe hypertension in pregnan-cy (TABLE 3).

Although many authorities preferhydralazine, recent data indicate that,compared with IV labetalol and oral

nifedipine, IV hydralazine is associated

T A B L E 3

MEDICATION ONSET OF ACTION DOSE SIDE EFFECTS

Hydralazine 10-20 minutes 5-10 mg intravenously More maternal side effects and worse perinatal

every 20 minutes up to outcomes than labetalol or nifedipine.

maximum dose of 30 mg

Skin blisters; chest pain; general feeling of

discomfort, illness, or weakness; joint or muscle

pain; sore throat and fever; swollen lymph glands

Labetalol* 10-15 minutes 10-20 mg intravenously, Breathing difficulty and/or wheezing, cold hands

then 40-80 mg every 10 and feet, mental depression, shortness of breath,

minutes up to maximum slow heartbeat, swelling of lower extremities, back

dose of 220 mg/hour or or joint pain, chest pain, confusion, fever and sore

continuous infusion of throat, hallucinations, irregular heartbeat, unusual

1-2 mg/minute bleeding and bruising, yellow eyes or skin

Nifedipine 5-10 minutes 10-20 mg orally, repeated in Breathing difficulty, coughing, or wheezing;

30 minutes, up to maximum irregular or fast, pounding heartbeat; skin rash;

dose of 50 mg/hour swelling of lower extremities; chest pain; fainting;

painful, swollen joints; vision impairment

Sodium 0.5-5 minutes 0.25-5 g/kg/minute by Risk of fetal cyanide poisoning with prolonged

nitroprusside intravenous infusion treatment.

Maternal effects include symptoms of

hypothyroidism, headache, abdominal pain,

drowsiness, nausea, involuntary muscle

movements, perspiration, restlessness,

paraesthesia, palpitations, dizziness, retching,

tachycardia

*In women with asthma and congestive heart failure

Rarely needed except in hypertensive encephalopathy or cerebral hemorrhage

Drug profiles: Dosing and side effects of antihypertensives used in pregnancy

with more maternal side effects andworse perinatal outcomes (more fetal dis-tress in labor).

Postpartum management Because preeclampsia can worsen, or

first appear, in the postpartum period,

extra vigilance is important, and phar-

macotherapy may be appropriate.

Management of preeclampsia does notend with delivery of the fetus and the pla-centa. These events do signal the begin-ning of the curative process, but complica-tions can occur in the postpartum period.

Indeed, in some women, the disease


8/8


process worsens immediately postpartum.Therefore, women with diagnosedpreeclampsia or severe gestational hyper-tension require close monitoring of bloodpressure and maternal symptoms and

accurate measurement of fluid intake andurine output. Some of these women are atincreased risk for pulmonary edema; exac-erbation of severe hypertension; eclamp-sia; and hemolysis, elevated liver enzymes,and low platelets (HELLP) syndrome.

Treating postpartum hypertensionWomen who continue to have severehypertension (systolic pressure at or above155 mm Hg or diastolic pressure of 105

mm Hg or higher) will benefit from oralnifedipine (10 mg every 6 hours) or long-acting nifedipine (10 to 20 mg twicedaily), the drugs of choice because of theirfavorable effects on renal function.

Women with severe hypertension alsomay require diuretics for better control ofblood pressure, as may women with a his-tory of congestive heart failure or left ven-tricular dysfunction.

Start women with vascular diabetes

mellitus or diabetic nephropathy on ACEinhibitors immediately postpartum.Patients can be discharged home once

blood pressure is stable, provided there areno maternal symptoms of preeclampsia.

Postpartum preeclampsiacan develop even in healthy womenBecause severe hypertension or pre-eclampsia may develop for the first time inthe postpartum period, it is important toeducate all gravidas about the signs and

symptoms. All health-care providersshould be on the lookout for these symp-toms as well.

B I B L I O G R A P H Y

Abalos E, Duley L, Steyn DW, Henderson-Smart DJ.Antihypertensive drug therapy for mild to moderate hyper-

tension during pregnancy. Cochrane Database Syst Rev(England). 2001;(2)pCD002252.

Alfirevic Z, Roberts D, Martlew V. How strong is the asso-ciation between maternal thrombophilia and adversepregnancy outcome? A systematic review. Eur J ObstetGynecol Reprod Biol. 2002;101:614.

Amorim MMR, Santas LC, Faundes A. Corticosteroid ther-

apy for prevention of respiratory distress syndrome insevere preeclampsia. Am J Obstet Gynecol.1999;180:12831288.

Duley L, Galmezoglu AM, Henderson-Smart DJ.Magnesium sulfate and other anticonvulsants for womenwith preeclampsia. Cochrane Database Syst Rev(England). 2003;(2)pCD000025.

Friedman SA, Lubarsky S, Schiff E. Expectant manage-ment of severe preeclampsia remote from term. ClinObstet Gynecol. 1999;42:470478.

Haddad B, Deis S, Goffinet F, et al. Maternal and perinataloutcomes during expectant management of 239 severepreeclamptic women between 24 and 33 weeks gesta-tion. Am J Obstet Gynecol. 2004;190:15901597.

Hall DR, Odendaal HJ, Kirten GF, Smith J. Expectant man-agement of early onset, severe preeclampsia, perinatal

outcome. BJOG. 2000;107:12581264.Kupferminc MJ, Fait G, Many A, et al. Low molecularweight heparin for the prevention of obstetric complica-tions in women with thrombophilia. Hypertension inPregnancy. 2001;20:3544.

Kupferminc MJ. Thrombophilia and pregnancy. ReprodBiol Endocrinol. 2003;1:111166.

Magee LA, Cham C, Waterman EJ, Ohlsson A, VonDadelszen P. Hydralazine for treatment of severe hyper-tension in pregnancy: meta-analysis. BMJ. 2003;327:110.

Magee LA, Ornstein MP, Von Dadelszen P. Fortnightlyreview: management of hypertension in pregnancy. BMJ.1999;318:13321336.

Magpie Trial Group. Do women with preeclampsia, andtheir babies, benefit from magnesium sulfate? TheMagpie Trial: a randomised, placebo-controlled trial.

Lancet. 2002;359:18771890.

Report of the National High Blood Pressure EducationProgram. Working group report on high blood pressure inpregnancy. Am J Obstet Gynecol. 2000;183:S122.

Sibai BM. Chronic hypertension in pregnancy. ObstetGynecol. 2002;100:369377.

Sibai BM. Diagnosis and management of gestationalhypertension and preeclampsia. Obstet Gynecol.2003;102:181192.

Sibai BM, Lindheimer MD, Hauth J, et al. Risk factors forpreeclampsia, abruptio placentae, and adverse neonataloutcomes among women with chronic hypertension.National Institute of Child Health and HumanDevelopment Network of Maternal-Fetal Medicine Units.N Engl J Med. 1998;229:667671.

Sibai BM. Magnesium sulfate prophylaxis in preeclamp-

sia. Lessons learned from recent trials. Am J ObstetGynecol. 2004;190:15201526.

Vigil-DeGracia P, Montufar-Rueda C, Ruiz J. Expectantmanagement of severe preeclampsia and preeclampsiasuperimposed on chronic hypertension between 24 and34 weeks gestation. Eur J Obstet Gynecol Reprod Biol.2003;107:2427.

The author reports no financial relationships relevant to thisarticle.


Start ACE inhibitorsmmediately

postpartumn women with

vascular diabetesor diabeticnephropathy



Documents

1703OBGM_Article2