ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery

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

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