Evaluation and management of severe preeclampsia before 34 weeks' gestation

OBJECTIVE: We sought to review the risks and benefits of expectant management of severe preeclampsia remote from term, and to provide recommendations for expectant management, maternal and fetal evaluation, treatment, and indications for delivery. METHODS: Studies were identified through a search of the MEDLINE database for relevant peer-reviewed articles published in the English language from January 1980 through December 2010. Additionally, the Cochrane Library, guidelines by organizations, and studies identified through review of the above documents and review articles were utilized to identify relevant articles. Where reliable data were not available, opinions of respected authorities were used. RESULTS AND RECOMMENDATIONS: Published randomized trials and observational studies regarding management of severe preeclampsia occurring < 34 weeks of gestation suggest that expectant management of selected patients can improve neonatal outcomes but that delivery is often required for worsening maternal or fetal condition. Patients who are not candidates for expectant management include women with eclampsia, pulmonary edema, disseminated intravascular coagulation, renal insufficiency, abruptio placentae, abnormal fetal testing, HELLP syndrome, or persistent symptoms of severe preeclampsia. For women with severe preeclampsia before the limit of viability, expectant management has been associated with frequent maternal morbidity with minimal or no benefits to the newborn. Expectant management of a select group of women with severe preeclampsia occurring < 34 weeks' gestation may improve newborn outcomes but requires careful in-hospital maternal and fetal surveillance.