Timing and indications for delivery

1. Timing of delivery is based upon the maternal and fetal condition and gestational age.

2. Women who develop severe preeclampsia at or beyond 32 to 34 weeks of gestation should be delivered.

3. Women with mild disease remote from term can be managed expectantly to enable fetal growth and maturation.

4. Women with mild disease and a favorable cervix or who are noncompliant may benefit from induction as early as 37 weeks; otherwise, delivery by 40 weeks of gestation should be considered.

5. Women with stable, severe disease under 32 to 34 weeks may be managed expectantly with daily maternal and fetal monitoring. Delivery can be delayed until either a course of glucocorticoids to accelerate fetal lung maturation can be completed or there is evidence of fetal pulmonary maturity or 34 weeks of gestation are completed.

6. Delivery should be undertaken if there are signs of worsening disease (eg, severe hypertension not controlled with antihypertensive therapy, cerebral/visual symptoms, platelet count <100,000 cells/microL, deterioration in liver or renal function, abdominal pain, severe fetal growth restriction, abruption, nonreassuring fetal testing).

7. Eclampsia is also an indication for delivery.

D. Route of delivery. Delivery is usually by the vaginal route, with cesarean delivery reserved for the usual obstetrical indications. Severe preeclampsia does not mandate immediate cesarean birth.

IV. Anticonvulsant therapy is generally initiated during labor or while administering corticosteroids or prostaglandins prior to planned delivery and continued until 24 to 48 hours postpartum, when the risk of seizures is low. Magnesium sulfate is the drug of choice for seizure prevention.

A. Magnesium sulfate is given as a loading dose of 6 g intravenously, followed by 2 g per hour as a continuous infusion. Magnesium sulfate should be considered for prevention of eclampsia in all women with preeclampsia.

B. Magnesium toxicity is related to serum concentration: loss of deep tendon reflexes occurs at 8 to 10 mEq/L, respiratory paralysis at 10 to 15 mEq/L, and cardiac arrest at 20 to 25 mEq/L. Calcium gluconate (1 g intravenously over at 5 to 10 minutes) is administered to counteract magnesium toxicity.

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