Title: Evaluation and management of severe preeclampsia before 34 weeks' gestation
Abstract: ObjectiveWe 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.MethodsStudies 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 RecommendationsPublished 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. 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. 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. 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. IntroductionPreeclampsia is a multisystem disorder that can manifest clinically with hypertension and proteinuria with or without accompanying symptoms, abnormal maternal laboratory test results, intrauterine growth restriction, or reduced amniotic fluid volume.1Sibai B. Dekker G. Kupfermic M. Preeclampsia.Lancet. 2005; 365 (Level III): 785-799Abstract Full Text Full Text PDF PubMed Scopus (2070) Google Scholar The incidence of severe preeclampsia ranges from 0.6-1.2% of pregnancies in Western countries.2Kuklina E.V. Aya C. Callaghan W.M. Hypertensive disorders and severe obstetric morbidity in the United States.Obstet Gynecol. 2009; 113 (Level II-3): 1299-1306PubMed Google Scholar, 3Catov J.M. Ness R.B. Kip K.E. Olsen J. Risk of early or severe preeclampsia related to preexisting conditions.Int J Epidemiol. 2007; 36 (Level II-3): 412-419Crossref PubMed Scopus (128) Google Scholar, 4Zhang J. Meikle S. Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States.Hypertens Pregnancy. 2003; 22 (Level II-3): 203-212Crossref PubMed Scopus (237) Google Scholar, 5Haddad B. Deis S. Goffinet F. Daniel B.J. Cabrol D. Sibai B.M. Maternal and perinatal outcomes during expectant management of 239 severe preeclamptic women between 24 and 33 weeks' gestation.Am J Obstet Gynecol. 2004; 190 (Level II-2): 1590-1595Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Preeclampsia <37 weeks' and severe preeclampsia <34 weeks' gestation complicates 0.6-1.5% and 0.3% of pregnancies, respectively.3Catov J.M. Ness R.B. Kip K.E. Olsen J. Risk of early or severe preeclampsia related to preexisting conditions.Int J Epidemiol. 2007; 36 (Level II-3): 412-419Crossref PubMed Scopus (128) Google Scholar, 6Gupta L.M. Gaston L. Chauhan S.P. Detection of fetal growth restriction with preterm severe preeclampsia: experience at two tertiary centers.Am J Perinatol. 2008; 25 (Level II-3): 247-249Crossref PubMed Scopus (12) Google Scholar The likelihood of severe and preterm preeclampsia is substantially increased in women with a history of preeclampsia, and in those with diabetes mellitus, chronic hypertension, or a multifetal gestation.1Sibai B. Dekker G. Kupfermic M. Preeclampsia.Lancet. 2005; 365 (Level III): 785-799Abstract Full Text Full Text PDF PubMed Scopus (2070) Google Scholar, 3Catov J.M. Ness R.B. Kip K.E. Olsen J. Risk of early or severe preeclampsia related to preexisting conditions.Int J Epidemiol. 2007; 36 (Level II-3): 412-419Crossref PubMed Scopus (128) Google Scholar, 7Sibai B.M. Akl S. Fairlie F. Moretti M. A protocol for managing severe preeclampsia in the second trimester.Am J Obstet Gynecol. 1990; 163 (Level II-2): 733-738Abstract Full Text PDF PubMed Scopus (96) Google Scholar, 8Visser W. Wallenburg H.C.S. Maternal and perinatal outcome of temporizing management in 254 consecutive patients with severe preeclampsia remote from term.Eur J Obstet Gynecol Reprod Biol. 1995; 63 (Level II-2): 147-154Abstract Full Text PDF PubMed Scopus (88) Google Scholar, 9Vigil-DeGarcia P. Montufar-Rueda C. Ruiz J. Expectant management of severe preeclampsia between 24 and 34 weeks' gestation.Eur J Obstet Gynecol Reprod Biol. 2003; 107 (Level II-2): 24-27Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 10Sibai B.M. Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.Am J Obstet Gynecol. 2007; 196 (514e1-9. Level II-2)Abstract Full Text Full Text PDF Scopus (186) Google Scholar Published reports use differing criteria for the diagnoses of preeclampsia, severe and superimposed preeclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. Commonly used definitions are presented in the Table.11Report of the National High Blood Pressure Education Program Working group report on high blood pressure in pregnancy.Am J Obstet Gynecol. 2000; 183 (Level III): S1-S22PubMed Google Scholar, 12American College of Obstetricians and GynecologistsDiagnosis and management of preeclampsia and eclampsia: ACOG practice bulletin no. 33.Obstet Gynecol. 2002; 99 (Level III): 159-167Crossref PubMed Google Scholar, 13Sibai B.M. Ramadan M.K. Usta I. Salama M. Mercer B.M. Friedman S.A. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome).Am J Obstet Gynecol. 1993; 169 (Level III): 1000-1006Abstract Full Text PDF PubMed Scopus (890) Google Scholar, 14Martin Jr, J.N. Blake P.G. Perry K.G. McCaul J.F. Hess L.W. Martin R.W. The natural history of HELLP syndrome: patterns of disease progression and regression.Am J Obstet Gynecol. 1991; 164 (Level III): 1500-1509Abstract Full Text PDF PubMed Scopus (281) Google Scholar For women with preexisting hypertension or proteinuria, the diagnosis of severe preeclampsia can be more difficult, but new-onset severe hypertension or proteinuria, or development of other clinical or laboratory findings of severe preeclampsia are suggestive of preeclampsia in this setting.Quality of evidenceThe quality of evidence for each included article was evaluated according to the categories outlined by the US Preventative Services Task Force:IProperly powered and conducted randomized controlled trial; well-conducted systematic review or metaanalysis of homogeneous randomized controlled trials.II-1Well-designed controlled trial without randomization.II-2Well-designed cohort or case-control analytic study.II-3Multiple time series with or without the intervention; dramatic results from uncontrolled experiments.IIIOpinions of respected authorities, based on clinical experience; descriptive studies or case reports; reports of expert committees.Recommendations are graded in the following categories:Level AThe recommendation is based on good and consistent scientific evidence.Level BThe recommendation is based on limited or inconsistent scientific evidence.Level CThe recommendation is based on expert opinion or consensus.The practice of medicine continues to evolve, and individual circumstances will vary. This opinion reflects information available at the time of its submission for publication and is neither designed nor intended to establish an exclusive standard of perinatal care. This publication is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine.TABLEDiagnostic criteria for preeclampsia, severe preeclampsia, and HELLP syndrome11Report of the National High Blood Pressure Education Program Working group report on high blood pressure in pregnancy.Am J Obstet Gynecol. 2000; 183 (Level III): S1-S22PubMed Google Scholar, 12American College of Obstetricians and GynecologistsDiagnosis and management of preeclampsia and eclampsia: ACOG practice bulletin no. 33.Obstet Gynecol. 2002; 99 (Level III): 159-167Crossref PubMed Google Scholar, 13Sibai B.M. Ramadan M.K. Usta I. Salama M. Mercer B.M. Friedman S.A. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome).Am J Obstet Gynecol. 1993; 169 (Level III): 1000-1006Abstract Full Text PDF PubMed Scopus (890) Google Scholar, 14Martin Jr, J.N. Blake P.G. Perry K.G. McCaul J.F. Hess L.W. Martin R.W. The natural history of HELLP syndrome: patterns of disease progression and regression.Am J Obstet Gynecol. 1991; 164 (Level III): 1500-1509Abstract Full Text PDF PubMed Scopus (281) Google Scholar➢Preeclampsia○Blood pressure ≥140 mm Hg or ≥90 mm Hg diastolic that occurs >20 wk' gestation in woman with previously normal blood pressure plus proteinuria defined as urinary excretion ≥0.3 g protein in 24-h urine specimen➢Severe preeclampsia (≥1 of following criteria is required)○Blood pressure ≥160 mm Hg systolic or ≥110 mm Hg diastolic on 2 occasions at least 6 h apart while patient is on bed rest○Proteinuria ≥5 g in 24-h urine specimen ≥3+ on 2 random urine samples collected at least 4 h apart○Oliguria <500 mL in 24 h○Cerebral or visual symptoms○Pulmonary edema or cyanosis○Epigastric or right upper quadrant pain○Impaired liver function○Thrombocytopenia○Fetal growth restriction➢Superimposed preeclampsia (≥1 of following criteria is required)○New-onset proteinuria ≥0.3 g protein in woman with hypertension <20 wk' gestation○If hypertension and proteinuria present <20 wk' gestation■Sudden increase in proteinuria if both hypertension and proteinuria are present <20 wk' gestation■Sudden increase in hypertension in woman whose hypertension has previously been well controlled■Thrombocytopenia (platelet count <100,000 cells/mm3)■Increase in alanine aminotransferase or aspartate aminotransferase to abnormal levelsWomen with chronic hypertension who develop persistent headache, scotoma, or epigastric pain also may have superimposed preeclampsia➢HELLP syndrome (differing diagnostic criteria have been reported, 2 commonly used criteria follow)○Sibai et al13Sibai B.M. Ramadan M.K. Usta I. Salama M. Mercer B.M. Friedman S.A. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome).Am J Obstet Gynecol. 1993; 169 (Level III): 1000-1006Abstract Full Text PDF PubMed Scopus (890) Google Scholar (each of following required)(1)Hemolysis on peripheral smear, lactate dehydrogenase >600 U/L, or total bilirubin >1.2 mg/dL(2)Aspartate aminotransferase >70 U/L(3)Platelet count <100,000 cells/mm3○Martin et al14Martin Jr, J.N. Blake P.G. Perry K.G. McCaul J.F. Hess L.W. Martin R.W. The natural history of HELLP syndrome: patterns of disease progression and regression.Am J Obstet Gynecol. 1991; 164 (Level III): 1500-1509Abstract Full Text PDF PubMed Scopus (281) Google Scholar (each of following required)(1)Lactate dehydrogenase >600 U/L(2)Aspartate aminotransferase or alanine aminotransferase >40 IU/L(3)Platelet count <150,000 cells/mm3SMFM. Severe preeclampsia. Am J Obstet Gynecol 2011. Open table in a new tab Severe preeclampsia occurring preterm can result in both acute1Sibai B. Dekker G. Kupfermic M. Preeclampsia.Lancet. 2005; 365 (Level III): 785-799Abstract Full Text Full Text PDF PubMed Scopus (2070) Google Scholar, 2Kuklina E.V. Aya C. Callaghan W.M. Hypertensive disorders and severe obstetric morbidity in the United States.Obstet Gynecol. 2009; 113 (Level II-3): 1299-1306PubMed Google Scholar, 4Zhang J. Meikle S. Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States.Hypertens Pregnancy. 2003; 22 (Level II-3): 203-212Crossref PubMed Scopus (237) Google Scholar, 7Sibai B.M. Akl S. Fairlie F. Moretti M. A protocol for managing severe preeclampsia in the second trimester.Am J Obstet Gynecol. 1990; 163 (Level II-2): 733-738Abstract Full Text PDF PubMed Scopus (96) Google Scholar, 8Visser W. Wallenburg H.C.S. Maternal and perinatal outcome of temporizing management in 254 consecutive patients with severe preeclampsia remote from term.Eur J Obstet Gynecol Reprod Biol. 1995; 63 (Level II-2): 147-154Abstract Full Text PDF PubMed Scopus (88) Google Scholar, 9Vigil-DeGarcia P. Montufar-Rueda C. Ruiz J. Expectant management of severe preeclampsia between 24 and 34 weeks' gestation.Eur J Obstet Gynecol Reprod Biol. 2003; 107 (Level II-2): 24-27Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 10Sibai B.M. Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.Am J Obstet Gynecol. 2007; 196 (514e1-9. Level II-2)Abstract Full Text Full Text PDF Scopus (186) Google Scholar and long-term complications for both the mother and her newborn.15Magnussen E.B. Vatlen L.J. Lund-Nilsen T.I. et al.Pregnancy cardiovascular risk factors as predictors of preeclampsia: population based cohort study.BMJ. 2007; 335 (Level II-2): 978-981Crossref PubMed Scopus (275) Google Scholar, 16Lykke A. Langoff-Ross J. Sibai B.M. et al.Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother.Hypertension. 2009; 53 (Level II-2): 944-951Crossref PubMed Scopus (463) Google Scholar Maternal complications of severe preeclampsia (Table) (as well as myocardial infarction, stroke, acute respiratory distress syndrome, coagulopathy, severe renal failure, retinal injury) occur more commonly in the presence of preexistent medical disorders, and with acute maternal organ dysfunction related to preeclampsia.10Sibai B.M. Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.Am J Obstet Gynecol. 2007; 196 (514e1-9. Level II-2)Abstract Full Text Full Text PDF Scopus (186) Google Scholar, 17Schiff E. Friedman S.A. Sibai B.M. Conservative management of severe preeclampsia remote from term.Obstet Gynecol. 1994; 84 (Level III): 626-630PubMed Google Scholar Maternal morbidities rarely persist after severe preeclampsia, although cardiovascular disease later in life is more common regardless of clinical presentation.15Magnussen E.B. Vatlen L.J. Lund-Nilsen T.I. et al.Pregnancy cardiovascular risk factors as predictors of preeclampsia: population based cohort study.BMJ. 2007; 335 (Level II-2): 978-981Crossref PubMed Scopus (275) Google Scholar, 16Lykke A. Langoff-Ross J. Sibai B.M. et al.Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother.Hypertension. 2009; 53 (Level II-2): 944-951Crossref PubMed Scopus (463) Google Scholar Fetal and newborn complications of severe preeclampsia result from exposure to uteroplacental insufficiency and/or from preterm birth.1Sibai B. Dekker G. Kupfermic M. Preeclampsia.Lancet. 2005; 365 (Level III): 785-799Abstract Full Text Full Text PDF PubMed Scopus (2070) Google Scholar, 10Sibai B.M. Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.Am J Obstet Gynecol. 2007; 196 (514e1-9. Level II-2)Abstract Full Text Full Text PDF Scopus (186) Google ScholarHistorically, women with severe preeclampsia have had delivery initiated upon diagnosis in order to limit maternal complications from worsening disease.1Sibai B. Dekker G. Kupfermic M. Preeclampsia.Lancet. 2005; 365 (Level III): 785-799Abstract Full Text Full Text PDF PubMed Scopus (2070) Google Scholar, 12American College of Obstetricians and GynecologistsDiagnosis and management of preeclampsia and eclampsia: ACOG practice bulletin no. 33.Obstet Gynecol. 2002; 99 (Level III): 159-167Crossref PubMed Google Scholar The clinical course of severe preeclampsia is often characterized by progressive deterioration if delivery is not pursued.10Sibai B.M. Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.Am J Obstet Gynecol. 2007; 196 (514e1-9. Level II-2)Abstract Full Text Full Text PDF Scopus (186) Google Scholar, 17Schiff E. Friedman S.A. Sibai B.M. Conservative management of severe preeclampsia remote from term.Obstet Gynecol. 1994; 84 (Level III): 626-630PubMed Google Scholar However, some have challenged the view that all patients with severe preeclampsia must be delivered expeditiously.7Sibai B.M. Akl S. Fairlie F. Moretti M. A protocol for managing severe preeclampsia in the second trimester.Am J Obstet Gynecol. 1990; 163 (Level II-2): 733-738Abstract Full Text PDF PubMed Scopus (96) Google Scholar The first attempts at expectant management were aimed at providing brief pregnancy prolongation to allow for antenatal corticosteroid administration, but the potential for longer expectant management was entertained because some patients remained stable or improved during initial observation. Further study has shown that median latency with expectant management ranges from 7–14 days.18Magee L.A. Yong P.J. Espinosa V. Côté A.M. Chen I. von Dadelszen P. Expectant management of severe preeclampsia remote from term: a structured systematic review.Hypertens Pregnancy. 2009; 28 (Level I): 312-347Crossref PubMed Scopus (79) Google ScholarIn this report, the risks and benefits of expectant management of severe preeclampsia remote from term are reviewed, and recommendations regarding expectant management, maternal and fetal evaluation, and indications for delivery are offered. For the purpose of this document, expectant management is defined as any attempt to delay delivery for antenatal corticosteroid administration or longer.What are the benefits and risks of expectant management of severe preeclampsia <34 weeks' gestation?Randomized trialsOnly 2 randomized trials of delivery vs expectant management of preterm severe preeclampsia have been published.19Odendaal H.J. Pattinson R.C. Bam R. Grove D. Kotze T.J. Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial.Obstet Gynecol. 1990; 76 (Level I): 1070-1075PubMed Google Scholar, 20Sibai B.M. Mercer B.M. Schiff E. Friedman S.A. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial.Am J Obstet Gynecol. 1994; 171 (Level I): 818-822Abstract Full Text PDF PubMed Google ScholarOdendaal et al19Odendaal H.J. Pattinson R.C. Bam R. Grove D. Kotze T.J. Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial.Obstet Gynecol. 1990; 76 (Level I): 1070-1075PubMed Google Scholar studied 38 women with severe preeclampsia between 28-34 weeks' gestation age and whose fetal weight was estimated to be between 650-1500 g. Eighteen women received antenatal corticosteroids for fetal maturation and were then treated expectantly, with delivery only for specific maternal or fetal indications. Another 20 patients were assigned to receive antenatal corticosteroids with planned delivery after 48 hours. Latency to delivery (7.1 vs 1.3 days; P < .05) and gestational age at delivery (223 vs 221 days; P < .05) were both greater with expectant management while total neonatal complications were reduced (33% vs 75%; P < .05) compared with planned delivery.Sibai et al20Sibai B.M. Mercer B.M. Schiff E. Friedman S.A. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial.Am J Obstet Gynecol. 1994; 171 (Level I): 818-822Abstract Full Text PDF PubMed Google Scholar studied 95 women with severe preeclampsia and no concurrent medical (eg, renal disease, insulin-dependent diabetes, connective tissue disease) or obstetric (eg, vaginal bleeding, premature rupture of membranes, multifetal gestation, preterm labor) complications at 28-32 weeks' gestation. Those randomized to expectant management delivered at a more advanced gestational age (32.9 vs 30.8 weeks; P < .01), and had newborns with higher birthweights (1622 vs 1233 g; P < .01) who required less frequent neonatal intensive care unit admission (76% vs 100%; P < .01). Newborns from the expectantly managed group had less frequent respiratory distress syndrome (22.4% vs 50%; P = .002) and necrotizing enterocolitis (0% vs 10.9%; P = .02), but were more frequently small for gestational age at birth (30.1 vs 10.9; P = .04). There were no cases of maternal eclampsia or pulmonary edema in either trial. Abruptio placentae was similar in frequency between the randomized groups in both studies, but was more common in both the expectantly and nonexpectantly managed groups from the Odendaal et al19Odendaal H.J. Pattinson R.C. Bam R. Grove D. Kotze T.J. Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial.Obstet Gynecol. 1990; 76 (Level I): 1070-1075PubMed Google Scholar trial (22% vs 15%) than in the Sibai et al20Sibai B.M. Mercer B.M. Schiff E. Friedman S.A. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial.Am J Obstet Gynecol. 1994; 171 (Level I): 818-822Abstract Full Text PDF PubMed Google Scholar study (4.1% vs 4.3%). HELLP syndrome complicated only 2 expectantly managed cases and 1 aggressively managed case in the latter study (4.1% vs 2.1%).Two additional randomized trials evaluated therapeutic interventions during expectant management. Fenakel et al21Fenakel K. Kenakel G. Appleman Z. et al.Nifedipine in treatment of severe preeclampsia.Obstet Gynecol. 1991; 77 (Level I): 331-337PubMed Google Scholar described 49 women with severe preeclampsia at 26-36 weeks who were randomly assigned to receive either sublingual and oral nifedipine or intravenous and oral hydralazine treatments for severe hypertension during expectant management. Those assigned to nifedipine therapy delivered more frequently at ≥36 weeks, were less frequently diagnosed with acute fetal distress, and their infants had a shorter mean duration of neonatal intensive care unit stay than those assigned to hydralazine therapy (P < .01 for each). However, mean gestational age at delivery (34.6 vs 33.6 weeks; P < .20) and pregnancy prolongation (15.5 vs 9.5 days; P < .07) were not improved, and no differences in the frequencies of “major” or “minor” newborn complications were seen between groups. In multicenter comparison of antihypertensive therapy alone vs antihypertensive therapy plus plasma volume expansion, Ganzevoort et al22Ganzevoort W. Rep A. Bousel G.J. et al.A randomized controlled trial comparing two temporizing management strategies, one with and one without plasma volume expansion, for severe preeclampsia.BJOG. 2005; 112 (Level I): 1358-1368Crossref PubMed Scopus (105) Google Scholar found that volume expansion gave no additional benefit among women expectantly managed with severe preeclampsia at 24-33 weeks 6 days.Observational studiesObservational studies regarding expectant management of severe preeclampsia have varied in their inclusion criteria and indications for delivery.5Haddad B. Deis S. Goffinet F. Daniel B.J. Cabrol D. Sibai B.M. Maternal and perinatal outcomes during expectant management of 239 severe preeclamptic women between 24 and 33 weeks' gestation.Am J Obstet Gynecol. 2004; 190 (Level II-2): 1590-1595Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 7Sibai B.M. Akl S. Fairlie F. Moretti M. A protocol for managing severe preeclampsia in the second trimester.Am J Obstet Gynecol. 1990; 163 (Level II-2): 733-738Abstract Full Text PDF PubMed Scopus (96) Google Scholar, 10Sibai B.M. Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.Am J Obstet Gynecol. 2007; 196 (514e1-9. Level II-2)Abstract Full Text Full Text PDF Scopus (186) Google Scholar, 18Magee L.A. Yong P.J. Espinosa V. Côté A.M. Chen I. von Dadelszen P. Expectant management of severe preeclampsia remote from term: a structured systematic review.Hypertens Pregnancy. 2009; 28 (Level I): 312-347Crossref PubMed Scopus (79) Google Scholar, 23Chua S. Redman C.W. Prognosis for pre-eclampsia complicated by 5 g or more of proteinuria in 24 hours.Eur J Obstet Gynecol Reprod Biol. 1992; 43 (Level II-3): 9-12Abstract Full Text PDF PubMed Scopus (79) Google Scholar, 24Olah K.S. Redman W.G. Gee H. Management of severe, early pre-eclampsia: is conservative management justified?.Eur J Obstet Gynecol Reprod Biol. 1993; 51 (Level II-2): 175-180Abstract Full Text PDF PubMed Scopus (65) Google Scholar, 25van Pampus M.G. Wolf H. Westenberg S.M. der Post V. Bonsel G.J. Treffers P.E. Maternal and perinatal outcome after expectant management of HELLP syndrome compared with preeclampsia without HELLP syndrome.Eur J Obstet Gynecol Reprod Biol. 1998; 76 (Level II-2): 31-36Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 26Chammas M.F. Nguyen T.M. Li M.A. Nuwayhid B.S. Castro L.C. Expectant management of severe preterm preeclampsia: is intrauterine growth restriction an indication for immediate delivery?.Am J Obstet Gynecol. 2000; 183 (Level II-3): 853-858Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 27Hall D.R. Odendaal H.J. Steyn D.W. Grove D. Expectant management of early onset, severe preeclampsia; maternal outcome.Br J Obstet Gynaecol. 2000; 107 (Level II-3): 1252-1257Crossref Scopus (93) Google Scholar, 28Hall D.R. Odendaal H.J. Kristen G.F. Smith J. Grove D. Expectant management of early onset, severe preeclampsia: perinatal outcome.Br J Obstet Gynaecol. 2000; 107 (Level II-3): 1258-1264Crossref Scopus (93) Google Scholar, 29Shear R.M. Rinfret D. Leduc L. Should we offer expectant management in cases of severe preterm preeclampsia with fetal growth restriction?.Am J Obstet Gynecol. 2005; 192 (Level II-3): 1119-1125Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 30Oettle C. Hall D. Roux A. Grove D. Early onset severe preeclampsia: expectant management at a secondary hospital in close association with a tertiary institution.BJOG. 2005; 112 (Level II-3): 84-88Crossref PubMed Scopus (30) Google Scholar, 31Bombrys A.E. Barton J.R. Nowacki E. Habli M. Sibai B.M. Expectant management of severe preeclampsia at <27 weeks' gestation: maternal and perinatal outcomes according to gestational age by weeks at onset of expectant management.Am J Obstet Gynecol. 2008; 199 (Level II-2): 247.e1-247.e6Abstract Full Text Full Text PDF Scopus (75) Google Scholar, 32Bombrys A.E. Barton J.R. Habli M. Sibai B.M. Expectant management of severe preeclampsia at 270/7-336/7 weeks' gestation: maternal and perinatal outcomes according to gestational age by weeks at onset of expectant management.Am J Perinatol. 2009; 26 (Level II-3): 441-446Crossref PubMed Scopus (46) Google Scholar, 33Hall D.R. Grove D. Carstens E. Early-preeclampsia: what proportion of women qualify for expectant management and if not, why not?.Eur J Obstet Gynecol Reprod Biol. 2006; 128 (Level II-3): 169-174Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 34Sarsam D.S. Shamden M. Al Wazan R. Expectant versus aggressive management in severe preeclampsia remote from term.Singapore Med J. 2008; 49 (Level II-1): 698-703PubMed Google Scholar, 35Abdel-Hady el.-S. Fawzy M. El-Negeri M. Nezar M. Ragab A. Helal A.S. Is expectant management of early-onset severe preeclampsia worthwhile in low-resource settings?.Arch Gynecol Obstet. 2010; 282 (Level II-2): 23-27Crossref PubMed Scopus (17) Google Scholar Some included only those women who remained stable after 24-48 hours of observation,