I think gentle induction at 36 or 37 weeks is the way to go with severe preeclampsia, but no cesareans.   Usually they induce easily.   But in order to get a meaningful answer, you will have to give more details about the case.

Dear colliuge

We did so for some pts who were preterm and with some concidrations like: no retractable bp, no trombocytopenia no oliguria...

But anyhow, it is dangerous and l don't recommend it exept for some especial cases.

I had an obese woman who i met.  When I took her  blood pressure laying down after half an hour of calm talk it was 250/140,    She had had eclampsia, full seizures on previous birth, ending in emergency cesarean.     I met her at 7 months pregnancy and I took that blood pressure.   She refused all medical treatment, so I told her the only thing I could offer her was that garlic lowers blood pressure according to a study- see below.   So she ate a full head of garlic every day, and sometimes 1 1/2 or 2 heads (not cloves- the full head)   I took her blood pressure 4 weeks later and it was  180/100.   She delivered herself at home with no complications.  

Crit Rev Food Sci Nutr. 2013;53(7):670-81. 

Garlic in clinical practice: an evidence-based overview.

RESULTS:

Available evidence showed that garlic can reduce blood pressure (BP) in hypertensive patients and patients with elevated systolic BP (SBP), but not in normotensive subjects. 

We limit expectant management until 34wKS 

Dear Nelson... Are you sure? Expectant management of SEVERE PREECLAMPSIA?  MEXPRE LATIN STUDY--> http://www.ncbi.nlm.nih.gov/pubmed/23954534

This study does not demonstrate neonatal benefit with expectant management of severe preeclampsia from 28 to 34 weeks. Additionally, a conservative approach may increase the risk of abruption and small for gestational age.

Full and summary version attached. Enjoy. 

"The clinical course of severe preeclampsia is often characterized by progressive deterioration of maternal and fetal conditions if delivery is not pursued (21–23). Therefore, in the interest of the woman and her fetus, delivery is recommended when gestational age is at or beyond 34 0/7 weeks. "

Severe preeclamsia is a life threatening condition for both parturient and fetus. “Severe” means, that pathophysiological changes are constantly progressing and delivering of the fetus is the only ethiologic treatment. Expectant strategy may have sad maternal and perinatal consequences. If gestation age is less than 34 – stabilization of woman condition and fetal lung maturation is acceptable for 24 - max. 48 hours in tertiary care center under close fetal and maternal monitoring. More prolongation of pregnancy has negative risk/ benefit ratio.  If gestation is more than 34 weeks labor induction or C.S. is indicated.   

Dear Kestutis. 

Im agree with your vision. The benefical effect of expectant management comes from small clinical trials. 

Kindly check.It gives results of RCTs and observational studies regarding treatment and expectant management.Thank You.

It depends on the gestational age. If pre term, can do expectant management for steroids to act.

There are several issues to consider:

First and foremost,the health of the mother is paramount. If the severe feature are an indication of maternal CNS  dysfunction( Unremitting Headache, Visual disturbance) then temporization is unwise and potentially catastrophic.

IT is reasonable to stabilize with IV magnesium and IV anti-hypertensive agents and then reassess. IF after controlling the BP and seizure prophylaxis with Magnesium, the severe symptoms resolve, then  temporization may be considered BUT the risk to mom and fetus from an abrupt acceleration in condition is high and I would not consider it in a setting where emergent delivery  and experienced nursing are not available.

I have found that some patients with severe features are paradoxically volume overloaded( BNP is markedly elevated) and with careful use of Lasix and labetolol the elevated LFTs and low platelets have improved and normalized.  

So if treatment and optimization of the maternal condition is successful, temporization to get a full course of Betamethasone is warranted and likely to be beneficial.

Beyond 48 hrs, temporization is not going to benefit the fetus unless you are either at the limits of viability(22-25 weeks) OR unless you can get at least a week additional maturation in utero.

Remember the ONLY group that did worse in Liggins initial work on steroid for lung maturation was in the hypertensive, proteinuric, growth restricted fetus.

I agree with the other contributor that temporization in the face of severe features after 34 weeks is unwise and unlikely to benefit the baby, in fact, I usually deliver once a full course of steroids is on board after 32 weeks since the survival is over 95% at that GA.

Attachement by Dr. Afandyieva is excelellent. Bottom line - very small percentage of patients may benefit from expectant management. If you select your patient incorrectly you are risking severe maternal morbidity without benefit for the fetus.

Dear Ramiro

Do you consider your situation resource-poor, or economically advanced. as the consensus seems to be that delivery should occur after steroids between 32- 34 weeks, I suspect that you are asking about a gestational age below 30 weeks or so.

We looked at this issue in a small study in the early "90's. In our setting at the time those cases less than 36 weeks gestation were clearly non-starters. 26 to 29 weeks might depend on maternal past history. Our management of preterm neonates has probably improved more than our understanding of the disease.. If you have good INNCU facilities it might be better to deliver early than place the mother at risk. 

Article: Expectant management of early onset severe pre-eclampsia in Durban

J Moodley · S A Koranteng · C Rout

ABSTRACT: Fifty patients with severe pre-eclampsia who presented before 32 weeks' gestation were managed conservatively (sedation, bed rest, antihypertensive therapy and intensive fetal and maternal monitoring) until intervention was indicated. Twelve patients presented before 26 weeks of pregnancy and there were no fetal survivors in this group; 23 presented between 26 and 29 weeks and 8(34,8%) of the babies in this group survived. The rate of perinatal loss in those presenting between 30 and 32 weeks was 26,6% (N = 4). Patients who had a history of a hypertensive disorder in their previous pregnancy(ies) had a higher perinatal mortality rate; 23 such mothers experienced 16 perinatal losses compared with 27 mothers who had no such history and who had only 8 perinatal losses. There was 1 maternal death, there were 2 cases of eclampsia, 3 of pulmonary oedema, 4 of abruptio placentae and 1 case of renal failure; 2 patients had disseminated intravascular coagulation. The local indigent and underprivileged black population have a more aggressive form of early onset of severe pre-eclampsia than that reported for other population groups. The high maternal complication rate of 30,8% and the low fetal survival rate before 26 weeks indicate that there is no place in our setting for expectant management of severe pre-eclampsia in patients presenting before 26 weeks. This applies particularly to those with a previous history of hypertension in pregnancy.

Full-text · Article · Sep 1993 · South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde

Thank You,Cristopher! It is quite interesting, although the sample size is small.I support Ivan that expectant management only for buying time;for steroids to work.Otherwise, it can lead to the  fatal consequences.

Dear Ramiro,

I agree with colleagues, expectant management is only to buy time:

- Transfer to an appropiate center

- Allow steroids to act

- Prepare for an induction . . .

Progression of PE specially can lead to irreversible renal injury, in our setting (3rd level & 10,000 births a year) about 40% of renal impairment in reproductive age women is linked to PE. This burden is huge both for families & health care.

Dr Rout's information clearly highlights the very real potential consequences of expectant management in the face of preeclampsia with severe features with maternal death and severe maternal morbidity. A similar findings was reported by Sabai.

While I believe that the survival information in today's NICU setting are better in the 23-26 week group, expectant management beyond the 48 hrs needed for maternal stabilization and betamethasone effect should not be attempted outside of a center with specialized expertise and even then it should not be " standard of care" unless there is informed consent of the potential adverse maternal ( and Fetal ) consequences.