Timing and mode of delivery for women with a hypertensive disorder of pregnancy
The phrase, ‘planned childbirth on the best day in the best way', alludes to the fact that there are a myriad of considerations regarding timing (and mode of) childbirth in women with a HDP, particularly pre-eclampsia (100).
Complicating this decision-making can be inaccurate determination of gestational age, and difficulty identifying those women who are at particular risk of an adverse outcome if pregnancy is prolonged. The literature on timing of childbirth has been complicated by the fact that ‘severe' pre-eclampsia has been variably defined by international organizations and yet, all list ‘severe' pre-eclampsia as an indication for interventionist management, that is, delivery.Regardless, the last decade has seen the publication of a significant body of work that informs our decisions about timing of delivery in women with a HDP, particularly pre-eclampsia. Delivery is recommended for women with pre-e clampsia or gestational hypertension at term for maternal benefit (101), although expectant care is recommended for women with any HDP at late preterm gestational ages to reduce neonatal respiratory morbidity (associated with labour induction and caesarean delivery) (102). Small trials suggest that expectant care of women with pre-eclampsia from fetal viability to 33+6 weeks reduces neonatal morbidity, but the magnitude of maternal risk has not been fully quantified (103). There are no trials to inform management of women with chronic hypertension.
Management should be based on the understanding that giving birth is the manner in which to initiate the cure for pre-eclampsia, and women with gestational hypertension or pre-existing hypertension may develop pre-eclampsia antepartum or postpartum (11, 14, 15). General guidance for delivery decisions is summarized in Table 21.7.
Place of delivery
All women with a HDP of any type require, and deserve access to, delivery in a centre that can provide emergency obstetric care, while women with a HDP and serious maternal complications require delivery in a centre capable of providing comprehensive obstetric care.
Timing of delivery
Women with pre-eclampsia
Consultation with an obstetrician is advised in women with preeclampsia. (If an obstetrician is not available in under-resourced
Table 21.7 Timing and mode of delivery in women with a HDP
| Gestational age at diagnosis (weeks) | |||||
| 20*0-viability | I Viability-29*6 | 130*0-33*6 | 34*0-36*6 | I ≥37*0 | |
| Perinatal prognosis | Survival: 18-50% | Survival: 60-95% | Survival: 98% | Survival: >99% | |
| Intact survival: 2-45% | Intact survival: 15-90% | Intact survival: 88-96% | Intact survival: >96% | ||
| Maternal risks (relative to normotensive pregnancy) | Significantly increased | Significantly increased | Significantly increased | Moderately increased | Minimally increased |
| In utero transfer to tertiary | NO as a routine, but centre | YES if stable for transfer | Ideally, but perinatal | NO, but centre should be | NO |
| centre | should be competent with second trimester termination and/or expectant management | outcomes unchanged if postpartum transfer | competent with expectant management | ||
| Expectant management | NO as a routine, but at 22-23 weeks some may attempt to attain perinatal survival | YES rate of adverse maternal outcomes same with expedited delivery; significant perinatal gains | YES acute morbidity and school-age issues are associated with late preterm birth | NO post-HYPITAT | |
| Betamethasone for fetal | NO | YES | YES | YES if non-laboured | NO |
| lungs | caesarean | ||||
| Assessment and surveillance | Minimum standard: on admission, day after admission, every Monday and Thursday until delivery, and on day of delivery; additional testing as indicated by changes in clinical state | ||||
| NOTE: this approach has been associated with >80% reduction in adverse maternal outcomes | |||||
| Maternal | Blood: CBC, INR, APTT, fibrinogen, creatinine, electrolytes, uric acid, AST, LDH, bilirubin, albumin, glucose (to R/O AFLP) | ||||
| Urine: dipstick, protein:creatinine ratio; pulse oximetry | |||||
| Fetal | Ultrasound: AFI, umbilical artery Doppler, ductus venosus Doppler; NST | ||||
| Deciding when to deliver | Women with 'severe pre-eclampsia, as defined in this textbook, should be delivered | Delivery, post-HYPITAT | |||
| Route of delivery | Vaginal (misoprostol IOL) | Probable caesarean, unless IUFD | Vaginal; fetal or uterine status may preclude vaginal delivery | ||
AFI, amniotic fluid index; AFLP1 acute fatty liver of pregnancy; APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; CBC, complete blood count; INR, international normalized ratio; IOL, induction of labour; IUFD, intrauterine fetal death; LDH, lactate dehydrogenase; NST, non-stress test; PTB, preterm birth; R/O, role of. Source data from The FIGO Textbook of Pregnancy Hypertension (2016) p 170,
settings, consultation with at least a medical practitioner is recommended.)
When using the severity criteria endorsed here, all women with ‘severe’ pre-eclampsia or eclampsia should be delivered within 24 hours, regardless of gestational age.
For women with non-severe pre-eclampsia at less than 24+0 weeks’ gestation, counselling should include information about delivery within days as an option. In contrast, for women with non-severe pre-eclampsia at 24+0-33+6 weeks’ gestation, expectant management should be considered, but only in centres capable of caring for very preterm infants. For women with non-severe pre-eclampsia at 34+0-36+6 weeks’ gestation, expectant management is advised, while for those with pre-eclampsia at 37+0 weeks’ gestation or greater, initiating delivery within 24 hours is recommended (101, 102).For women with non-severe pre-eclampsia complicated by HELLP syndrome at 24+0-34+6 weeks’ gestation, consider delaying delivery long enough to administer antenatal corticosteroids for acceleration of fetal pulmonary maturity as long as there is temporary improvement in maternal laboratory testing (14, 15). All women with HELLP syndrome at 35+0 weeks or more of gestation should be considered for delivery within 24 hours.