Preeclampsia 2010

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Preeclampsia 2010

  1. 1. Preeclampsia / Gestational Hypertension Diagnosis & Management 2010
  2. 2. For Patients at Risk for Developing Preeclampsia Obtain Baseline Labs <ul><li>Multifetal gestation </li></ul><ul><li>History of preeclampsia < 34 weeks </li></ul><ul><li>History of chronic hypertension </li></ul><ul><li>1 st trimester systolic ≥ 130, diastolic ≥ 80 </li></ul><ul><li>BMI > 40 </li></ul><ul><li>APA Syndrome </li></ul><ul><li>Thrombophilia </li></ul><ul><li>Collagen vascular disease </li></ul><ul><li>Renal disease </li></ul><ul><li>Pregestational diabetes </li></ul><ul><li>BMJ 2005:330:565 </li></ul>
  3. 3. Chronic Hypertension Patients Increased Risk of Developing Superimposed Pre-Eclampsia <ul><li>Chronic hypertension of 4 years duration or more (31% get Preeclampsia) </li></ul><ul><li>Superimposed pre-eclampsia in previous pregnancy (32% Recur) </li></ul><ul><li>Sabai </li></ul><ul><li>NEJM 1998:339:667 </li></ul>
  4. 4. Baseline Labs for Patients at Risk <ul><li>CBC with platelets </li></ul><ul><li>SGOT/SGPT/total bilirubin </li></ul><ul><li>BUN/CR </li></ul><ul><li>Evaluation for proteinuria </li></ul>
  5. 5. Consider ASA in High Risk Patients Prevention of Pre-Eclampsia <ul><li>Meta-Analysis of over 12,000 women </li></ul><ul><li>ASA 81 mg once daily (at bedtime) </li></ul><ul><ul><li>OR perinatal death (.79) </li></ul></ul><ul><ul><li>OR pre-eclampsia (.86) </li></ul></ul><ul><ul><li>An increase in birth weight  215 G </li></ul></ul><ul><ul><li>No increase of abruption </li></ul></ul><ul><li>ASA causes no harm 96,000 women </li></ul><ul><ul><li>Abruption </li></ul></ul><ul><ul><li>Neonatal bleeding </li></ul></ul><ul><ul><li>Maternal bleeding </li></ul></ul><ul><ul><li>Coomarasamy Meta-Analysis </li></ul></ul><ul><ul><li>Obstet Gynecol 2003:101:1319 </li></ul></ul><ul><ul><li>Knight </li></ul></ul><ul><ul><li>Cochrane Data Base 2000:2:CD000492 </li></ul></ul>
  6. 6. Consider Ca for All Patients Decrease Severity of Preeclampsia <ul><li>Calcium 1500 mg daily </li></ul><ul><ul><li>Reduction in severity of pre-eclampsia and incidence of eclampsia </li></ul></ul><ul><ul><li>WHO Randomized Trial over 8000 women </li></ul></ul><ul><ul><li>AJOG 2006:194:639 </li></ul></ul>
  7. 7. Diagnosis Gestational Hypertension <ul><li>Hypertension after 20 th week of gestation (with no history of CHTN + normal BP < 20 wk) </li></ul><ul><li>Systolic 140 mm Hg and/or diastolic of 90 mm Hg on 2 occasions at least 6 hours apart and not more than 7 days apart </li></ul><ul><li>AND </li></ul><ul><li>No proteinuria </li></ul><ul><li>50% progress to preeclampsia if diagnosed before 32 weeks </li></ul><ul><li>Obstet Gynecol 2003:102:181 </li></ul><ul><li>Am J Obstet Gynecol 2001:184:979 </li></ul>
  8. 8. Diagnosis Preeclampsia <ul><li>Hypertension after 20 th week of gestation (with no history of CHTN + normal BP < 20 wk) </li></ul><ul><li>Systolic 140 mm Hg and/or diastolic of 90 mm Hg on 2 occasions at least 6 hours apart and not more than 7 days apart </li></ul><ul><li>AND </li></ul><ul><li>Proteinuria - Dipstick 1+ or 30mg/dl >4 hrs apart </li></ul><ul><li>- 300 mg/24 hr </li></ul>ObstetGynecol 2003:102:181
  9. 9. Diagnosis of Superimposed Pre-Eclampsia <ul><li>Development of new onset proteinuria ≥300mg/24 hours </li></ul><ul><li>If history of proteinuria before 20 weeks EGA  sudden increase in proteinuria </li></ul><ul><li>Sudden increase in blood pressure in a woman whose hypertension has previously been well controlled </li></ul><ul><li>Lab changes </li></ul><ul><ul><li>Platelet count  100K </li></ul></ul><ul><ul><li>Increase in SGOT/SGPT/LDH </li></ul></ul><ul><ul><li>Increased uric acid </li></ul></ul><ul><li>Develop symptoms </li></ul><ul><li>Am J Obstet Gynecol 2000:183:S1 </li></ul>
  10. 10. “Impending Preeclampsia” <ul><li>“ If blood pressure is rising (30mm Hg ↑ systolic/15mm Hg ↑diastolic) or 130 s /80 s close observation is warranted” </li></ul><ul><li>Blood pressure should be re-evaluated in 24 – 72 hours or monitored at home </li></ul><ul><li>Important to discuss signs/symptoms </li></ul><ul><li>Lab evaluation for at least Uric acid ( ≥ 5.5) and Urine dipstick (1+) </li></ul><ul><li>AmJ Obstet Gynecol 2000:183:S1 </li></ul><ul><li>Obstet Gynecol 2006:108:826 </li></ul>
  11. 11. Edema and Rapid Weight Gain <ul><li>Facial and upper extremity edema </li></ul><ul><li>Rapid weight gain 5 lbs/one week “May indicate the fluid and sodium retention of preeclampsia, they are neither universally present or uniquely characteristic of preeclampsia. These signs are at most an indication for close monitoring of blood pressure and urinary protein.” </li></ul><ul><li>Am J Obstet Gynecol 2000:183:S1 </li></ul>
  12. 12. Assessment of Severity Laboratory Evaluation Sibai. Am J Obstet Gynecol 2009 <ul><li>Creatinine 1.2 </li></ul><ul><li>Proteinuria 1+ or 30 mg/dl or 300 mg/24 hr </li></ul><ul><li>-CBC Hemo concentrated 40% </li></ul><ul><li>- PT/PTT/Fibrinogen check especially if liver test are abnormal OR PLATELETS < 100k </li></ul>LP ● Platelets  100k EL ● SGOT/SGPT  2x upper limit ( 70 ) H ● LDH  600 Iu and/or total bilirubin ≥1.2mg/dl
  13. 13. Diagnosis HELLP Syndrome <ul><li>H emolysis PBS + 1 criteria </li></ul><ul><ul><ul><li>Elevated LDH > 600 Iu/l </li></ul></ul></ul><ul><ul><ul><li>Elevated total bilirubin > 1.2 mg/dl </li></ul></ul></ul><ul><ul><ul><li>Low serum haptoglobin < 25 mg/dl </li></ul></ul></ul><ul><ul><ul><li>Blood smear with schistocytes </li></ul></ul></ul><ul><ul><li>EL </li></ul></ul><ul><ul><ul><li>Elevated liver function test </li></ul></ul></ul><ul><ul><ul><li>Above upper limit of normal or 2 SD above the mean AST > 70 u/l </li></ul></ul></ul><ul><ul><li>LP </li></ul></ul><ul><ul><ul><li>Low platelets < 100K </li></ul></ul></ul>Obstet Gynecol 2004:103:981 Sibai. Am J Obstet Gynecol 2009
  14. 14. “ Partial HELLP” ≈ 20% of Severe Disease Am J Obstet Gynecol 1996:175:460 Sao Paulo Med J 2002:120:180 Sibai. Am J Obstet Gynecol 2009 20 LP LP 24 or H 7 30 EL LP 6 12 H Combined % Isolated %
  15. 15. Lab Abnormalities Uric Acid <ul><li>Increase uric acid in the blood is not predictive of the severity of preeclampsia </li></ul><ul><li>It is helpful in confirming the diagnosis. ( 5.5) </li></ul><ul><li>Uric acid may be most useful in diagnosing superimposed preeclampsia 54%S/78%SP </li></ul><ul><li>Meta Analysis </li></ul><ul><li>BJOG 2006:113:369 </li></ul><ul><li>Am J Obstet Gynecol 1998:17:1067 </li></ul>
  16. 16. Assessment of Severity Remember the Baby <ul><li>Fetal movement </li></ul><ul><li>IUGR </li></ul><ul><ul><li>Fundal height </li></ul></ul><ul><ul><li>Sono evaluation for EFW/AFI </li></ul></ul><ul><ul><li><10% vs <5% </li></ul></ul><ul><li>AFI </li></ul><ul><li>NST </li></ul>
  17. 17. Epigastric pain Right upper quadrant pain Retrosternal chest pain Nausea and vomiting Shortness of breath/Congestive Heart Failure Headaches (not responsive to analgesics) Visual changes Altered mental status Bleeding from mucosal membranes Jaundice Signs and Symptoms Severe preeclampsia Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009
  18. 18. Prodromal Symptoms in Patients with Eclampsia BMJ 1994:309:1395 Am J Obstet Gynecol 2000:182:1389 Am J Obstet Gynecol 2002:186:1174 75% At least one of the above symptoms 10 – 20% Epigastric pain 20 – 30% Visual Change Blurred vision Photophobia 50 – 75% Headache
  19. 19. Criteria for Severe Preeclampsia* <ul><li>Systolic blood pressure ≥ 160 mm Hg or diastolic ≥ 110 mm Hg on two occasional at least six hours apart while on bedrest </li></ul><ul><li>Symptoms of central nervous system dysfunction </li></ul><ul><ul><li>Blurred vision, scotomata, altered mental status, severe headache </li></ul></ul><ul><li>Symptoms of liver capsule distention </li></ul><ul><ul><li>Right upper quadrant or epigastric pain </li></ul></ul><ul><ul><li>Nausea, vomiting </li></ul></ul><ul><li>Impaired liver function </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Proteinuria </li></ul><ul><ul><li>Over 5 grams in 24 hours or 3+ or more on two random samples four hours apart </li></ul></ul><ul><li>Oliguria 500 ml in 24 hours </li></ul><ul><li>Intrauterine fetal growth restriction </li></ul><ul><li>Pulmonary edema or cyanosis </li></ul><ul><li>Cerebrovascular accident </li></ul><ul><li>* One criteria required </li></ul>SIBAI 2006 ACOG 33:2002
  20. 20. Criteria for Severe Gestational Hypertension* <ul><li>Systolic blood pressure ≥ 160 mm Hg or diastolic ≥ 110 mm Hg on two occasional at least six hours apart while on bedrest </li></ul><ul><li>Symptoms of central nervous system dysfunction </li></ul><ul><ul><li>Blurred vision, scotomata, altered mental status, severe headache </li></ul></ul><ul><li>Symptoms of liver capsule distention </li></ul><ul><ul><li>Right upper quadrant or epigastric pain </li></ul></ul><ul><ul><li>Nausea, vomiting </li></ul></ul><ul><li>Impaired liver function </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Oliguria 500 ml in 24 hours </li></ul><ul><li>Intrauterine fetal growth restriction </li></ul><ul><li>Pulmonary edema or cyanosis </li></ul><ul><li>Cerebrovascular accident </li></ul><ul><li>*One criteria required </li></ul><ul><li>Am J Obstet Gynecol 2002:186:66 </li></ul>
  21. 21. Complications of Preeclampsia Obstet Gynecol 2000:95:24 Am J Obster Gynecol 2004:190:1520 2 / 100 1 / 200 Eclampsia ≈No Mg < 2 1 < 2 Perinatal death 43 27 13 NICU 19 10 4 IUGR 19 2 3 Delivery < 34 4 < 1 < 1 Abruption 13 5 < 1 Kidney disease 20 3 < 1 Liver disease Severe (%) Mild (%) Control Complication
  22. 22. Complications Severe Gestational HTN & Severe Preeclampsia <ul><li>Abruption 7 % </li></ul><ul><li>Pulmonary edema 5 % </li></ul><ul><li>DIC 10 % </li></ul><ul><li>Acute Renal Failure 3 % </li></ul><ul><li>IUGR 20 % </li></ul><ul><li>HELLP 15 % </li></ul><ul><li>Eclampsia (On Mg 0.5%) vs ( No Mg 2%) </li></ul><ul><ul><li>AM J Obstet Gynecol 2002:186:66 </li></ul></ul><ul><ul><li>Lancet 2005:365:785 </li></ul></ul>Obstet Gynecol 2000:95:24
  23. 23. Complications HELLP Syndrome <ul><li>Abruption 10 % </li></ul><ul><li>Pulmonary edema 10 % </li></ul><ul><li>DIC 15 % </li></ul><ul><li>Acute renal failure 3 % </li></ul><ul><li>PTD ≤28 15% </li></ul><ul><li>ARDS / CVA / Sepsis <1% </li></ul><ul><li>Death 1% </li></ul>Obstet Gynecol 2004:103:981
  24. 24. ATYPICAL DISEASE <ul><li>Late Eclampsia > 48 hours after delivery </li></ul><ul><li>Early Preeclampsia prior to 20 weeks </li></ul><ul><li>Gestational proteinuria </li></ul><ul><li>+ 1 or more Sx/Sx or lab criteria </li></ul><ul><li>Gestational HTN </li></ul><ul><li>+ 1 or more Sx/Sx or lab criteria </li></ul>Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.
  25. 25. ATYPICAL DISEASE Overlapping role of hypertension, capillary leak, maternal symptoms, and fibrinolysis/hemolysis in the spectrum of atypical preeclampsia Blood Pressure may be normal Fibrinolysis/Hemolysis 1 or none Low plts/DIC/ LFT’s elevated HELLP or Renal Failure Capillary Leak Symptoms Proteinuria, Facial edema, Pleural effusions, Pulmonary edema , Ascites Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009.
  26. 26. Atypical Disease <ul><li>Not always a progression of mild  severe  eclampsia </li></ul><ul><li>15% of HELLP no proteinuria AND no hypertension </li></ul><ul><li>15% of eclampsia no hypertension </li></ul><ul><li>15% of eclampsia no proteinuria </li></ul><ul><li>30% of eclampsia mild hypertension or no hypertension and no proteinuria </li></ul>Am J Obstet Gynecol 2000:182:307 & Sibai 2009; 200:481.e1-481.e7. BMJ 1994:309:1395 Obstet Gynecol 2004:103:981
  27. 27. ATYPICAL DISEASE <ul><li>< 20 week onset r/o Molar pregnancy and -Lupus nephritis, APA , HUS , TTP </li></ul><ul><li>Seizure >48hrs and< 4 weeks PP ~ 15% </li></ul><ul><li>- Start Magnesium ( 6 & 2 ) and R/O other causes </li></ul>Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.
  28. 28. Initial Evaluation for Gestational Hypertension & Preeclampsia <ul><li>Consider initial hospitalization for bedrest and serial evaluation of blood pressure/ labs </li></ul><ul><li>Rule out other disorders </li></ul><ul><li>Assess the severity of disease </li></ul><ul><ul><li>Sx/Sx </li></ul></ul><ul><ul><li>HELLP Labs </li></ul></ul><ul><ul><li>Total bilirubin/LDH/PBS </li></ul></ul><ul><ul><li>Serum creatinine </li></ul></ul><ul><ul><li>24 hr urine for total protein </li></ul></ul><ul><li>Assess the baby </li></ul><ul><ul><li>NST </li></ul></ul><ul><ul><li>Sono/AFI </li></ul></ul>
  29. 29. Management Mild Preeclampsia & Gestational Hypertension <ul><li>“ Initial inpatient monitoring” is reassuring </li></ul><ul><ul><li>Sono for : EFW / AFI / BPP </li></ul></ul><ul><ul><li>Labs </li></ul></ul><ul><ul><li>Signs/symptoms </li></ul></ul><ul><ul><li>Blood pressure “stable” </li></ul></ul><ul><ul><li>Serial NST/BPP </li></ul></ul><ul><li>Home management </li></ul><ul><ul><li>Restricted activity, not bedrest </li></ul></ul><ul><ul><li>No salt restriction </li></ul></ul><ul><ul><li>Antihypertensives do not alter the course of disease or alter perinatal morbidity </li></ul></ul><ul><ul><li>Labs once/week </li></ul></ul><ul><ul><li>NST 2x week and daily fetal movement </li></ul></ul><ul><ul><li>Sono every 2-3 weeks </li></ul></ul><ul><ul><li>BP and urine dipstick daily </li></ul></ul><ul><ul><li>Obstet Gynecol 2003:102:181 </li></ul></ul>
  30. 30. Mild Preeclampsia Home Management Progression of Disease Consider Admission to Hospital <ul><li>Systolic > 150 </li></ul><ul><li>Diastolic > 100 </li></ul><ul><li>Signs/symptoms of severe disease </li></ul><ul><li>Lab abnormalities (HELLP) </li></ul><ul><li>Sudden increase to 2+ or more proteinuria </li></ul><ul><li>Urinary protein > 1000mg/24 hr </li></ul><ul><li>Non reassuring/Equivocal fetal testing </li></ul>Obstet Gynecol 2003:102:181
  31. 31. Indications for Delivery in Preeclampsia <ul><li>Maternal indications </li></ul><ul><ul><li>Gestational age greater than or equal to 37 weeks of gestation </li></ul></ul><ul><ul><li>Persistent or labile severe hypertension </li></ul></ul><ul><ul><li>Platelet count less 100,000 cells per cubic millimeter </li></ul></ul><ul><ul><li>Deteriorating liver function </li></ul></ul><ul><ul><li>Progressive deterioration in renal function </li></ul></ul><ul><ul><li>Abruptio placentae </li></ul></ul><ul><ul><li>Persistent severe headaches or visual changes </li></ul></ul><ul><ul><li>Persistent severe epigastric pain, nausea, or vomiting </li></ul></ul><ul><li>Fetal indications </li></ul><ul><ul><li>Fetal growth restriction </li></ul></ul><ul><ul><li>Nonreassuring results from fetal testing </li></ul></ul><ul><ul><li>Oligohydramnios </li></ul></ul>Am J Obstet Gynecol 2000:183:S1 Obstet Gynecol 2003:102:181
  32. 32. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial Lancet 2009; 374: 979–88 Induction (n=377) Expectant (n=379) Vaginal Delivery 323 (85%) 307 (84%) NS Cesarean section 54 (14%) 72 (19%) NS Poor Maternal Outcome 117 (31%) 166 (44%) p<0·0001 Composite Adverse neonatal outcome 24 (6%) 32 (8%) NS
  33. 33. Indications for Delivery in Preeclampsia <ul><li>Maternal indications </li></ul><ul><ul><li>Gestational age greater than or equal to 37 weeks of gestation </li></ul></ul><ul><ul><li>Persistent or labile severe hypertension </li></ul></ul><ul><ul><li>Platelet count less 100,000 cells per cubic millimeter </li></ul></ul><ul><ul><li>Deteriorating liver function </li></ul></ul><ul><ul><li>Progressive deterioration in renal function </li></ul></ul><ul><ul><li>Abruptio placentae </li></ul></ul><ul><ul><li>Persistent severe headaches or visual changes </li></ul></ul><ul><ul><li>Persistent severe epigastric pain, nausea, or vomiting </li></ul></ul><ul><li>Fetal indications </li></ul><ul><ul><li>Fetal growth restriction </li></ul></ul><ul><ul><li>Nonreassuring results from fetal testing </li></ul></ul><ul><ul><li>Oligohydramnios </li></ul></ul>Am J Obstet Gynecol 2000:183:S1 Obstet Gynecol 2003:102:181
  34. 34. Indications for Delivery Preeclampsia <ul><li>34 weeks AND </li></ul><ul><ul><li>Severe preeclampsia </li></ul></ul><ul><ul><li>IUGR </li></ul></ul><ul><ul><li>Oligohydramnios </li></ul></ul><ul><ul><li>Non reassuring fetal testing </li></ul></ul><ul><ul><li>Labor or SROM </li></ul></ul>
  35. 35. Expectant Management Severe Disease <ul><li>Severe disease @ 33 weeks </li></ul><ul><ul><li>BMS + deliver </li></ul></ul><ul><li>Severe disease < 23 weeks </li></ul><ul><ul><li>Deliver </li></ul></ul><ul><li>Severe disease 23 – 32 weeks </li></ul><ul><ul><li>Level III Regional Hospital </li></ul></ul><ul><ul><li>Expert care </li></ul></ul><ul><ul><li>Clinical Obstet Gynecol 2005:48 (2):430 </li></ul></ul>
  36. 36. Postpartum Antihypertensive Treatment <ul><li>Treatment for labile or persistent hypertension ≥ 155 or ≥ 105 </li></ul><ul><ul><li>Nifedipine 10 mg q 6 hr </li></ul></ul><ul><ul><li>Procardia 30 XL once or twice / day </li></ul></ul><ul><ul><li>Labetalol 200 mg q 8 hr </li></ul></ul><ul><li>“ Continue antihypertensive medications until 3-4 weeks postpartum and observe BP at 1-2 week intervals for one month, then at 3-6 month intervals for one year.” Alternative is to decrease meds if normotensive > 48 hours </li></ul><ul><li>Blood pressure returns to normal after delivery </li></ul><ul><ul><li>~1 week for Gestational Hypertension </li></ul></ul><ul><ul><li>~2-3 weeks for Mild PreEclampsia </li></ul></ul><ul><ul><li>~4-6 weeks for Severe PreEclampsia </li></ul></ul><ul><li>Am J Obstet Gynecol 1994:171:506 </li></ul><ul><li>Am J Obstet Gynecol 2000: 183:S1 </li></ul><ul><li>Obstet Gynecol 2003:102:181 </li></ul>
  37. 37. Multiple RCT Conclusively Demonstrate Clinical Obstet Gynecol 2005:48:478 <ul><li>In patients with SEVERE preeclampsia Mg So 4 significantly decreases the risk of eclampsia 4 RCT </li></ul>128 / 6330 (2.0%) 49 / 6343 (0.6%) Seizures No Mg So 4 Mg So 4
  38. 38. Magnesium Sulfate Mild Preeclampsia 2 Small Randomized Trials Am J Obstet Gynecol 1997:176:623 Obstet Gynecol 2003:101:217 Risk of eclampsia with no Mg So 4 1 / 200 13.8% 12.5% Progression to severe disease 0 / 181 0 / 176 Eclampsia Placebo Mg So 4
  39. 39. Mg SO 4 not Currently Recommended for Seizure Prophylaxis with Mild Preeclampsia <ul><li>Imminent eclampsia defined as ≥ 2 of : Severe headache, epigastric pain, or hyper-reflexia </li></ul>SIBAI Am J Obstet Gynecol 2004:190:1520 Obstet Gynecol 2005:105:402 Lancet 2002:359:1877 To prevent one – “imminent” – 4% PPV 1 / 36 To prevent one seizure – severe 1 / 71 To prevent one seizure – mild 1 / 400 Patients with mild PrE who seize 1 / 200
  40. 40. Continued Assessment of Maternal Status for patients who have initial Mild PreEclampsia is Necessary in Labor <ul><li>An induction may last 24 – 48 hours At least 10% of patients may progress to severe disease (BP,Sx/Sx/Labs) during this time frame </li></ul><ul><li>Beware of “Imminent Eclampsia” in a patient previously classified as “Mild” </li></ul><ul><li>Be observant for findings suggestive of HELLP. Bleeding mucosal membranes, petechia at site of BP cuff, epigastric pain </li></ul>
  41. 41. Preeclampsia Summary <ul><li>Outpatient management  Hospitalize For: </li></ul><ul><ul><li>Labile BP >150 S />100 S </li></ul></ul><ul><ul><li>Increase proteinuria >1000mg </li></ul></ul><ul><ul><li>Sx/Sx </li></ul></ul><ul><ul><li>Lab abnormalities </li></ul></ul><ul><ul><li>Non reassuring fetal testing/Repeat equivocal testing </li></ul></ul><ul><li>≥ 34 weeks EGA deliver For: </li></ul><ul><ul><li>Severe preeclampsia or Atypical disease </li></ul></ul><ul><ul><li>IUGR </li></ul></ul><ul><ul><li>Oligohydramnios </li></ul></ul><ul><ul><li>Non reassuring fetal testing / Repeat Equivocal Testing </li></ul></ul><ul><li>≥ 37 weeks EGA deliver For: </li></ul><ul><ul><li>Only the rare patient should not be delivered </li></ul></ul><ul><ul><li>Twin gestations </li></ul></ul><ul><li>≥ 38 weeks EGA deliver </li></ul><ul><li>All delivered </li></ul>Lancet 2005:365:785 Obstet Gynecol 2003:102:181 Lancet 2009; 374: 979–88

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