aim of improving neonatal outcome without compromising maternal safety. Aspects of such management always include careful daily-and usually more frequent-inpatient monitoring of the mother and her fetus.
Expectant Management of Preterm Severe Preeclampsia
Theoretically, antihypertensive therapy has potential application when severe preeclampsia develops before intact neonatal survival is likely. Such management is controversial, and it may be dangerous. In one of the irst studies, Sibai and the Memphis group (1985) attempted to prolong pregnancy because of fetal immaturity in 60 women with severe preeclampsia between 18 and 27 weeks. The results were disastrous. The perinatal mortaliy rate was 87 percent. Although no mothers die, 13 su.ired placental abruption, 10 had eclampsia, three developed renal ailure, two had hypertensive encephalopathy, one had an intracerebral hemorrhage, and another had a ruptured hepatic hematoma.
Because of their early study, the Memphis group redeined criteria and performed a randomized trial of aggressive versus expectant management for 95 women who had severe preeclampsia but with more advanced gestations of 28 to 32 weeks (Sibai, 1994). Women with HELLP syndrome were excluded rom this tria. Aggressive management included glucocorticoid administration for fetal lung maturation followed by delivery in 48 hours. Expectantly managed women were observed at bed rest and given either labetalol or nifedipine orally for severe hypertension. In this study, pregnancy was prolonged for a mean of 15.4 days in the expectant management group. An overall improvement in neonatal outcomes was also reported.
Following these experiences, expectant management became more commonly practiced, but with the caveat that women with HELLP syndrome or growth-restricted fetuses were usually excluded. But in a subsequent follow-up observational study, the Memphis group compared outcomes in 133 preeclamptic women with and 136 without HELLP syndrome who presented between 24 and 36 weeks (Abramovici, 1999). Women were subdivided into three study groups. The first group included those with complete HELLP syndrome. The second group included women with partial HELLP syndromedeined as either one or two but not all three of the deining laboratory values. The third group included women who had severe preeclampsia without HELLP syndrome. Perinatal outyrcomes were similar in each group, and importantly, outcomes were not improved with procrastination. Despite this, the investigators concluded that women with partial HELLP syndrome and those with severe preeclampsia alone could be managed expectantly. Those with fetal-growth restriction generally have shorter interval-to-delivery durations (McKinney, 2016).
Sibai and Barton (2007b) reviewed expectant management of severe preeclampsia from 24 to 34 weeks. More than 1200 women were included, and although the average time gained ranged from 5 to 10 days, the maternal morbidity rates were formidable. Serious complications in some of these and in later studies included placental abruption, HELLP syndrome, pulmonary edema, renal failure, and eclampsia (Table 40-9). Moreover, perinatal mortality rates averaged 90 per 1000 births. Fetal-growth restriction was common, and in the studies from The Netherlands, it was an astounding 94 percent (Ganzevoort, 2005a,b). Perinatal mortality rates are disproportionately high in these growth-restricted neonates, but maternal outcomes are not appreciably diferent (Haddad, 2007; Shear, 2005). The MEXPRE Latin Study was a multicenter trial that randomly assigned 267 women with severe preeclampsia at 28 to 32 weeks to prompt delivery or to expectant management (VigilDe Gracia, 2013). The perinatal mortality rate approximated