Expectant Management of Severe Preeclampsia Remote from Term: Patient Selection, Treatment, and Delivery Indications

Severe preeclampsia that develops at <34 weeks of gestation is associated with high perinatal mortality and morbidity rates. Management with immediate delivery leads to high neonatal mortality and morbidity rates and prolonged hospitalization in the neonatal intensive care unit because of prematurity. Conversely, attempts to prolong pregnancy with expectant management may result in fetal death or asphyxial damage in utero and increased maternal morbidity. Since 1990, 2 randomized trials and several observational studies have evaluated the benefits vs risks of expectant management of severe preeclampsia at <34 weeks of gestation. These studies included 1677 women with gestational age between 24 and 34 weeks and 115 women with gestational age of <25 weeks (overlap in some studies). The results of these studies suggest that expectant treatment in a select group of women with severe preeclampsia between 24 0/7 and 32 6/7 weeks of gestation in a suitable hospital is safe and improves neonatal outcome. For gestational age of <24 0/7 weeks, expectant treatment was associated with high maternal morbidity with limited perinatal benefit. Based on the review of these studies and our own experience, recommendations are made for the selection of the appropriate candidates for expectant treatment, criteria for maternal-fetal monitoring, and targets for delivery. Finally, we provide information regarding maternal counseling based on maternal condition and fetal gestational age at time of diagnosis.