ACOG Recommendations: When to Deliver Medically Complicated Pregnancies

SUMMARY:

ACOG has developed important guidance on the timing of medically indicated late-preterm and early-term deliveries in collaboration with SMFM. The recommendations are based on placental, fetal and maternal complications.

KEY POINTS:

  • Antenatal Corticosteroids 
    • Anticipated late-preterm delivery: Administer single course of antenatal corticosteroids within 7 days of delivery if patient has not received a previous course 
    • Medically indicated late-preterm delivery should not be delayed for administration of corticosteroids 
  • Lung maturity testing 
    • Amniocentesis for determination of fetal lung maturity should not be used to guide timing of delivery (even in poorly dated pregnancies) 
  • Data are lacking for some conditions, such as dehiscence or chronic abruption 
    • In these cases, individualize timing of delivery

Placental Indications  

  • Previa (otherwise uncomplicated): 36w0d – 37w6d  
  • Accreta, increta, percreta (otherwise uncomplicated) : 34w0d – 35w6d  
  • Vasa previa: 34w0d – 37w0d 
  • Prior classical cesarean: 36w0d – 37w0d  
  • Previous uterine rupture: 36w0d – 37w0d  
  • Prior myomectomy requiring cesarean: 37w0d – 38w6d  
    • May require delivery similar to classical section (see above) if surgery was more extensive and complicated
    • With less extensive surgery, delivery may be considered as late as 38w6d
    • ACOG states

Timing of delivery should be individualized based on prior surgical details (if available) and the clinical situation

Fetal Conditions 

  • Oligohydramnios (DVP <2cm) isolated and uncomplicated : 36w0d – 37w6d (or at time of diagnosis if later) 
  • Polyhydramnios (otherwise uncomplicated): 39w0d – 39w6d  
  • Fetal growth restriction (FGR) – singleton
    • Uncomplicated and EFW between 3rd and 10th percentile: 38w0d – 39w0d
    • Uncomplicated and EFW <3rd percentile: 37w0d (or at time of diagnosis if later) 
    • UA Doppler decreased end diastolic flow without absent end diastolic flow: 37w0d (or at time of diagnosis if later) 
    • UA Doppler absent end diastolic flow: 33w0d – 34w0d (or at time of diagnosis if later) 
    • UA Doppler reversed end-diastolic flow: 30w0d – 32w0d (or at time of diagnosis if later) 
    • Note: Concurrent condition (e.g., oligohydramnios, preeclampsia, hypertension): 34w0d – 37w6d 
  • Multiple gestation – uncomplicated  
    • Di-di twins: 38w0d – 38w6d   
    • Mono-di twins: 34w0d – 37w6d   
    • Mono-mono twins: 32w0d – 34w0d   
    • Note: Triplets and higher: Individualize 
  • Alloimmunization 
    • At-risk and not requiring intrauterine transfusion: 37w0d – 38w6d  
    • Note: Requiring intrauterine transfusion: Individualize 

Maternal Conditions 

Chronic hypertension  

  • Uncomplicated, no meds: 38w0d – 39w6d  
  • Uncomplicated, controlled on meds: 37w0d – 39w6d  
  • Difficult to control: 36w0d – 37w6d  

Gestational hypertension 

  • Without severe BP: 37w0d (or at time of diagnosis if later) 
  • With severe BP: 34w0d (or at time of diagnosis if later) 

Preeclampsia 

  • Without severe features: 37w0d (or at time of diagnosis if later) 
  • With severe features 
    • Stable maternal-fetal status: 34w0d (or at time of diagnosis if later)  
    • Unstable or complicated by HELLP: Soon after maternal stabilization (guided by maternal/fetal status and gestational age)
    • Before viability: Soon after maternal stabilization (guided by maternal/fetal status and gestational age) 

Diabetes 

  • Pregestational diabetes 
    • Well-controlled: 39w0d – 39w6d   
    • With vascular complications, poor control, or prior stillbirth: 36w0d – 38w6d   
  • Gestational diabetes 
    • Well-controlled on diet: 39w0d – 40w6d   
    • Well-controlled on meds: 39w0 – 39w6d  
    • Note: Poorly-controlled: Individualize 

HIV 

  • Intact membranes & viral load > 1,000 copies/mL: 38w0d   
  • Viral load <1,000 copies/mL and antiretroviral therapy: ≥39w0d  

Intrahepatic cholestasis of Pregnancy 

  • Bile acids ≥100 micromol/L: 36w0d
  • Bile acids <100 micromol/L: 36w0d to 39w0d | Delivery <36 weeks may be required depending on clinical findings and lab values 

PROM and Stillbirth

  • Ruptured membranes  
    • Preterm PROM (PPROM): 34w0d to 36w6d
    • PROM (≥37w0d): Generally, deliver at time of diagnosis 
  • Previous stillbirth: Individualize
    • Early term birth not routinely recommended
    • “…maternal anxiety with a history of stillbirth should be considered and may warrant an early term delivery (37 0/7 weeks to 38 6/7 weeks) in women who are educated regarding, and accept, the associated neonatal risks”

Learn More – Primary Sources:

ACOG Committee Opinion 831: Medically Indicated Late-Preterm and Early-Term Deliveries