To enhance fetal lung maturation, glucocorticoids have been administered to women with severe hypertension who are remote from term. Treatment does not seem to worsen maternal hypertension, and a lower incidence of respiratory distress and improved fetal survival rates have been cited. hat said, only one randomized trial has evaluated corticosteroids given to hypertensive women for fetal lung maturation. his trial included 218 women with severe preeclampsia between 26 and 34 weeks' gestation who were randomly assigned to betamethasone or placebo administration (Amorim, 1999). Rates of neonatal complications that included respiratory distress, intraventricular hemorrhage, and death were reduced significantly when betamethasone was given compared with placebo. On the heaviy weighted negative side, there were two maternal deaths and 18 stillbirths. We add these indings to buttress our unenthusiastic acceptance of attempts to prolong gestation in many of these women (Alexander, 2015; Bloom, 2003).
Taken in toto, these studies do not show overwhelming beneits compared with maternal risks for expectant management of severe preeclampsia in women with gestations from 24 to 32 weeks. Despite these caveats, the Society for MaternalFetal Medicine (201r1) has determined that such m�nagement is a reasonable alternative in selected women with severe preeclampsia before 34 weeks (Fig. 40-14). The Task Force (2013) supports this recommendation. As shown in Table 40-10, such management calls for in-hospital maternal and fetal surveillance with delivery prompted by evidence for worsening severe preeclampsia or maternal or fetal compromise. Although attempts are made for vaginal delivery in most cases, the likelihood of cesarean delivery rises with decreasing gestational age.
Our view is more conservative. Undoubtedly, the overriding reason to terminate pregnancies with severe preeclampsia is maternal safety. Indeed, it seems obvious that a delay to prolong gestation in women with severe preeclampsia may have serious maternal consequences (see Table 40-9). These observations are even more pertinent when considered with the absence of convincing evidence that perinatal outcomes are markedly improved by the average prolongation of pregnancy by approximately 1 week. If undertaken, the caveats that mandate delivery shown in Table 40-10 should be strictly heeded.
• Corticosteroids to Ameliorate HELLP Syndrome
At least three randomized trials have evaluated the beneits of glucocorticoids given to improve the laboratory abnormalities
TABLE 40-1 0. Indications for Delivery in Women
Delivery ater Maternal Stabilization:
Delay Delivery 48 hr If Possible:
Thrombocytopenia < 1 OO,OOO/�L
Hepatic transaminase levels twice upper limit of normal alnitial dose only, do not delay delivery.
From the Society for Maternal-Fetal Medicine, 2011, and the Task Force of the American College of Obstetricians and Gynecologists, 201n3.