OBSTETRICS

Expectant management of mild preeclampsiaversus superimposed preeclampsia up to37 weeksAmy M. Valent, DO; Emily A. DeFranco, DO, MS; Allessa Allison, MD; Ahmed Salem, MD;Lori Klarquist, DO; Kyle Gonzales, DO; Mounira Habli, MD; C. David Adair, MD;Casey Armistead, RN; Yuping Wang, MD, PhD; David Lewis, MD, MBA; Baha Sibai, MD

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Research Obstetrics ajog.orgmanagement. The ACOG PracticeBulletin, addressing chronic hyperten-sion in pregnancy, recommends deliveryat 34 weeks of gestation for patients withsuperimposed preeclampsia.9 Manage-ment and delivery timing in this patientpopulation is based on indirect con-clusions from severe preeclampsiastudies.10-12 Patient surveillance andexpectant management of severe pre-eclampsia and chronic hypertensionwith superimposed preeclampsia attertiary care institutions are similarlyassociated with prolonged pregnancy,decreased neonatal intensive care unitstays, and respiratory distress syndrome(RDS) without signicant maternalcompromise

ajog.org Obstetrics Researchsystolic blood pressure 140 mm Hg ordiastolic blood pressure 90 mm Hg on2 different occasions >4-6 hours apartor persistent, elevated pressures re-quiring antihypertensive therapy.Chronic hypertension was dened as theuse of antihypertensive medicationsprior to conception, diagnosis of hyper-tension 12 weekspostpartum in a previous pregnancy.Superimposed preeclampsia was denedas women with chronic hypertensionwho subsequently developed preec-lampsia with an acute exacerbation ofpreexisting hypertension in additionto either new-onset proteinuria denedby 0.3 g of total urinary proteinexcretion over a 24-hour period or asubstantial increase in baseline protein-uria if present early in pregnancy. Mildpreeclampsia was dened as hyper-tension >20 weeks gestation with thepresence of proteinuria.

Upon admission, the patient wasevaluated to ensure she did not meetcriteria for severe preeclampsia. Fetalviability was conrmed, baseline labo-ratory values (including but not limitedto liver enzyme tests, renal panel, uri-nalysis for protein evaluation, andcomplete blood cell count) and a 24-hour urine collection for total proteinexcretion were subsequently completedin the hospital. Serial ultrasound biom-etry every 3-4 weeks was performed toassess fetal growth. Antenatal surveil-lance with nonstress test, biophysicalprole, Doppler studies, fetal kickcounts, or a combination of these mo-dalities was used to determine fetal well-being. Laboratory assessments andcareful maternal clinical evaluations ofvital signs, urine output, symptoms, orsigns of disease progression wereroutinely performed. Patients admittedat 5g/d without the presence of other severesigns or symptoms were not indicationsfor delivery at the study institutions. Theprogression of severe disease 34 weeksof gestation was an indication fordelivery for all patients. Fetal reasons fordelivery included nonreassuring fetalheart tracing or abnormal fetal testing,which involved fetal growth restrictionwith persistent oligohydramnios, um-bilical artery Doppler velocimetry withreversed end-diastolic ow, or non-reassuring biophysical prole score.Maternal indications for deliveryincluded the development of renalinsufciency, eclampsia, placental ab-ruption, pulmonary edema, persistentgastrointestinal or neurologic symp-toms, uncontrollable hypertension withintravenous and/or orally titrated anti-hypertensive therapy, or laboratoryvalues suggesting thrombocytopenia(4-6 hours apartafter administration of intravenousantihypertensive therapy, oliguria (

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Research Obstetrics ajog.orgwomen diagnosed with mild pre-eclampsia, primary cesarean deliveryrates were not signicantly differentbetween the 2 groups.

The Figure demonstrates the most

TABLE 1Maternal characteristics

CharacteristicSuperimpreeclam

Age, y 30 6Race and ethnicity

Caucasian 83 (49)

Black 85 (50)

Other 3 (2)

Primigravida 64 (32)

Mode of delivery

Vaginal 35 (21)

Repeat cesarean 51 (30)

Primary cesarean 85 (50)

Oral antenatal antihypertensivemedications

128 (75)

Regimen with 1 medication 43 (25)Continuous variable are presented as mean SD. DichotomValent. Expectant management of preeclampsia. Am J Obcommon indications for delivery amongthis cohort. Women with superimposedpreeclampsia were more likely to bedelivered for uncontrollable, elevatedblood pressures (57% vs 39%; P< .001),and pregnancies complicated by mildpreeclampsia were delivered more com-monly for the development of persistentneurologic or gastrointestinal symptoms(20% vs 6%; P < .001).

Although patients with mild pre-eclampsia had signicantly shorter hos-pitalization stays compared to womenwith superimposed preeclampsia, nodifference in the latency periods betweendiagnosis and delivery among the 2groups were appreciated, even afterstratication at

conservative inpatient supervision,aggressive blood pressure management,

microvascular disease can complicate theclinical picture, diagnosis, and manage-

FIGUREIndications for delivery

Bar graph representing common indications for delivery in pregnancies complicated by super-

imposed preeclampsia (blue) and preeclampsia (green) expectantly managed in hospital setting. The

frequencies do not add up to 100% due to missing or other indications for delivery.

LFT, liver function testing; HELLP, hemolysis, elevated liver enzymes, and low platelet count; NR-ANFS, nonreassuring antenatal fetalsurveillance.

*Persistent neurological or gastrointestinal symptoms.

Valent. Expectant management of preeclampsia. Am J Obstet Gynecol 2015.

ajog.org Obstetrics Researchand longer hospitalizations. Hyperten-sive exacerbations and undiagnosed

TABLE 2

Maternal outcomes

Outcome variableSuperimposedpreeclampsia, n

EGA at diagnosis, wk 314/7 33/7Latency, d 10 13

5 [2e11]

Days in hospital 13 129 [6e16]

Severe preeclampsia 149 (87)

Pulmonary edema 7 (4)

Placental abruption 11 (6)

Thrombocytopenia 8 (5)

Elevated liver enzymes 24 (14)

Oliguria 7 (4)

HELLP 2 (1)

Eclampsia 1 (1)

Maternal compositea 25 (15)

Continuous variable are presented as mean SD or median [innumber (percent).

EGA, estimated gestational age; HELLP, hemolysis, elevated live

a Morbidity defined as 1 of the following: pulmonary edema, pValent. Expectant management of preeclampsia. Am J Obstment strategies. However, our studyshows that with careful inpatient[ 171Preeclampsia,n[ 186 P value

324/7 31/7 .0048 85 [3e10]

.12

10 78 [6e11]

< .001

157 (84) .56

0 (0) .01

5 (3) .18

12 (6) .62

29 (16) .79

5 (3) .66

7 (4) .22

1 (1) 1.0

9 (5) .003

terquartile range]. Dichotomous variables are presented as

r enzymes, and low platelet count.

lacental abruption, eclampsia, oliguria.

et Gynecol 2015.

APRIL 2015 Amerimanagement, women with super-imposed preeclampsia can continuepregnancy >34 weeks of gestation withtitrating doses of antihypertensives aslong as the blood pressure responds tothese increases.

Women in both groups were foundto have high rates of neonatal mor-tality and respiratory morbidities,especially deliveries 5%, we conclude that no signif-icant difference in neonatal outcomesoccurs following births to superimposedpreeclampsia and mild preeclampsiapregnancies managed expectantly in thelate preterm period. Similarly, the like-lihood of an adverse neonatal outcomefor births

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TABLE 3Maternal outcomes stratified by pre

Outcome variable

34 weeks of

515.e6 American Journal of Obstetrics& Gynecolgestation did not increase the risk of

erm gestational age groups

ation 34-366/7

92Preeclampsia,n[ 80 P value

Superimppreeclam

301/7 25/7 .08 336/7 26.2 4.1 .06 11.7 19.6 3.7 .02 14.6 1

67 (77) .70 69 (87)

0 (0) .02 1 (1)

4 (5) .93 5 (6)

6 (7) 1.0 2(3)

10 (12) 1.0 12 (15)

2 (2) .82 3 (4)

5 (6) .15 1 (1)

1 (1) 1.0 0 (0)

6 (8) .08 9 (11)

s variables are presented as number (percent).

r enzymes, and low platelet count.

lacental abruption, eclampsia, oliguria.

et Gynecol 2015.serious maternal complications such asHELLP, eclampsia, or pulmonaryedema.

Higher rates of pulmonary edemawere observed among women withsuperimposed preeclampsia but all ofthe events occurred

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ajog.org Obstetrics ResearchTABLE 4Neonatal outcomes

Outcome variable

at later gestational ages maternal ad-verse outcomes are increased predomi-nantly in women with superimposedpreeclampsia, overall adverse neonatal

5. Kuklina EV, Ayala C, Callaghan WM. Hyper-tensive disorders and severe obstetric morbidityin the United States. Obstet Gynecol 2009;113:1299-306.6. Sibai BM. Management of late preterm and

after hospitalization for cardiovascular disease.Am J Cardiol 2012;109:135-9.17. Cnossen JS, Morris RK, ter Riet G, et al.Use of uterine artery Doppler ultrasonographyto predict pre-eclampsia and intrauterine growth

Research Obstetrics ajog.orgmorbidity is much lower without an in-crease in serious maternal morbidities.This study further supports both cohortsand especially superimposed pre-eclampsia should be managed at centerswhere appropriate maternal and ne-onatal resources are available. Ascurrently practiced among women withmild preeclampsia, it is reasonable andsafe to manage superimposed preec-lampsia similarly with close inpatientobservation and delivery at 37 weeks ofgestation, unless an earlier indicationarises based on worsening disease, todecrease neonatal morbidity. This retro-spective study creates the basic platformto study both populations prospectivelywith larger cohorts to clearly determine ifthese are 2 different disease processes andtruly require different delivery manage-ment and timing. -

ACKNOWLEDGMENT

The authors thank Suneet Chauhan, MD, for hiscontribution to the study design and support forthe development of this study.

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Expectant management of mild preeclampsia versus superimposed preeclampsia up to 37 weeksMaterials and MethodsResultsCommentAcknowledgmentReferences