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CMECNE

ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Decide whether a patient with preeclampsia can be managed expectantly or requires immediate delivery
2. Discuss appropriate outpatient monitoring of women with preeclampsia or gestational hypertension without severe features

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Jan 9 2019 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

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

Note: No RCT data are available to determine optimal maternal or fetal monitoring protocols

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

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

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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

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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