SUMMARY:

Recommendations for prenatal assessment and perinatal management, including delivery, are included in the ACOG preeclampsia and gestational hypertension guidelines.

Inpatient vs Outpatient Management

• Ambulatory management (outpatient) appropriate for the following
  • Gestational hypertension without severe features or
  • Preeclampsia without severe features
• Inpatient management appropriate for the following
  • Severe preeclampsia or
  • Poor adherence to monitoring recommendations

How to Measure BP

• Recommended technique for BP monitoring
  • Appropriate cuff size: 1.5 times upper arm circumference
  • Avoid tobacco or caffeine: Use in the 30 minutes preceding the measurement may lead to temporary rise in blood pressure
  • Patient should be upright after a 10-minute rest period
  • Inpatient setting: Measurement may be taken either
    • Sitting up or
    • Left lateral recumbent with arm at the level of the heart

Fetal and Maternal Assessment (Outpatient – No Severe Features)

Fetal Assessment

• Fetal growth assessment every 3-4 weeks
• Amniotic fluid assessment weekly
• Antenatal testing 1-2 times per week

Maternal Assessment

• Labs weekly (more frequently if concern that patient status is deteriorating)
  • Serum creatinine | Liver enzymes | Platelet count
  • Gestational hypertension: Include proteinuria
  • Note: If proteinuria is present, additional proteinuria measurements are not necessary
• Clinical evaluation: At least one visit per week in-clinic
  • Obtain BP and evaluate for severe features (see ‘Related ObG Topics’ below)
    • Combination ambulatory and in-clinic assessment
  • BP and symptom assessment are recommended “serially”, using a combination of in-clinic and ambulatory approaches, with at least one visit per week in-clinic
• sFlt-1/PlGF ratio to predict progression to preeclampsia with severe features
  • FDA approved | Studied in population of hospitalized patients between 23 and 35 weeks
  • ACOG states

There are insufficient data to recommend management strategies after a positive or negative test result

The sFlt-1:PlGF ratio alone should not replace current clinical criteria for diagnosing or excluding a diagnosis of preeclampsia with severe features

KEY POINTS:

Delivery vs Expectant Management

• Decision regarding management based on gestational age and results from the following evaluation
  • Maternal: CBC | Creatinine | LDH, AST, ALT | Proteinuria | Uric acid if superimposed preeclampsia suspected
  • Fetal: EFW | Amniotic fluid volume | Antenatal testing (BPP, NST)
• Candidate for expectant management
  • Gestational hypertension or preeclampsia without severe features <37w0d
  • Reassuring antenatal testing
  • Intact membranes
  • No vaginal bleeding
  • No evidence of active preterm labor
  • Note: Delivery at 37w0d | HYPITAT trial showed no benefit to expectant management beyond 37 weeks
• Candidate for delivery (expectant management not advised)
  • Severe range hypertension unresponsive to antihypertensive agent(s)
  • Persistent headache or persistent RUQ/epigastric pain unresponsive to treatment
  • Visual disturbance or altered sensorium or motor deficit
  • Stroke or MI
  • HELLP syndrome
  • Worsening renal function (Cr above 1.1 or double the baseline)
  • Pulmonary edema
  • Eclampsia
  • Placental abruption or bleeding in the absence of placenta previa
  • Abnormal antenatal testing
  • Fetal demise
  • Fetal lethal anomaly or extreme prematurity
  • UA Doppler REDF
  • Note: Fetal growth restriction, if other fetal assessment parameters are within normal range, is not an indication for delivery

Expectant Management for Severe Preeclampsia

• Shared decision making: Consider risk/benefit
  • Expectant management for severe preeclampsia provides benefit to fetus/newborn but potential risk to mother
• Risks of expectant management in the presence of severe features
  • Pulmonary edema | MI | Stroke | ARDS | Coagulopathy | Renal failure | Retinal injury
• ≥34w0d: Delivery is recommended
  • Do not delay delivery to administer steroids in late preterm
• <34w0d: Expectant management for women who are clinically stable 
  • Associated with higher GA (on average 1-2 weeks) at delivery | Improved neonatal outcomes
  • “Low maternal risk” in studies
  • Requires close maternal and fetal monitoring with serial laboratory testing
    • Deliver if maternal or fetal status deteriorates
  • Corticosteroid administration is recommended
    • “May not always be advisable” to delay delivery when indicated to provide full steroid course

Learn More – Primary Sources:

ACOG Practice Bulletin 222: Gestational Hypertension and Preeclampsia

Pre-eclampsia: pathophysiology and clinical implications

FIGO: A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-eclampsia

ACOG Clinical Practice Update: Biomarker Prediction of Preeclampsia With Severe Features

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

Related ObG Topics:

ASPRE Trial: A Combined Risk Algorithm and Use of Aspirin to Prevent Preterm Preeclampsia

Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines

Aspirin Treatment for Women at Risk for Preeclampsia – ACOG, SMFM and USPSTF Recommendations

Results from the SPREE Trial: How Does First Trimester Preeclampsia Screening Compare to Current Guidelines?

ISUOG Recommendations for Preeclampsia Prevention: Combined Screening and the Role of Ultrasound

ISUOG Recommendations: Fetal Ultrasound Follow-Up for Women with Established Preeclampsia

HYPITAT-II: Immediate Delivery or Expectant Management for Non-Severe Hypertension at 34 – 37 weeks?

ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy