Most medicolegal claims involving these patients concern issues such as patient selection for outpatient management, documentation of instructions and patient options, and a failure to appreciate the clinical significance of patient complaints during telephone calls.
Outpatient or home management should be considered only for patients who are highly reliable. (Reliable patients keep their appointments and have immediate transportation, phone access, and family members readily available.) Patients should be counseled to rest at home and to avoid operating a car, as well as to immediately report symptoms such as headache, blurred vision, epigastric or abdominal pain, nausea or vomiting, contractions, and vaginal bleeding.
One way to avoid communication problems is to instruct the patient to mention that she was diagnosed with gestational hypertension when talking with office or hospital nursing or clerical staff, another doctor in the same practice who may not be familiar with her case, or personnel at the answering service.5 A policy should be implemented whereby such calls are communicated to the physician as soon as possible. The presence of the aforementioned symptoms—particularly if they are persistent—is an indication for immediate evaluation at the office or hospital.
Severe gestational hypertension. Women with severe gestational hypertension are at increased risk for adverse maternal and perinatal outcomes.7 These women should be managed similarly to those who have severe preeclampsia. Therefore, a diagnosis of severe gestational hypertension requires immediate hospitalization.
Antihypertensive medications should not be used to control BP on an outpatient basis in these women. Following hospitalization, women with severe gestational hypertension should undergo evaluation of maternal and fetal status, including a platelet count, liver enzymes, and 24-hour urine protein. Fetal evaluation should include ultrasound examination of fetal weight and fluid and nonstress testing or a biophysical profile, as indicated. As discussed, subsequent management depends on the factors listed in TABLE 4.
Mild preeclampsia. Pregnancies complicated by mild preeclampsia, particularly those at less than 36 weeks’ gestation, are associated with increased rates of fetal growth retardation (10% to 15%), preterm delivery (50%), abruptio placentae (1% to 2%), and eclampsia (1%).6 The first step in managing these patients is prompt evaluation of maternal and fetal conditions. A decision can then be made regarding the need for delivery, expectant management, or hospitalization.
Maternal evaluation should include serial measurements of blood pressure, urine dipstick evaluation for proteinuria, 24-hour urine protein measurements, a platelet count, liver enzymes, and documentation of any symptoms. Fetal evaluation should include ultrasound assessment of the amniotic fluid and estimated fetal weight, as well as a nonstress test.
Indications for delivery include persistent headaches or visual symptoms, epigastric or RUQ pain, and thrombocytopenia (TABLE 5). Some women may be eligible for outpatient management with rest at home if they satisfy the criteria listed in TABLE 6. Subsequent management is outlined in TABLE 7.
If a woman is managed as an outpatient, prompt hospitalization is indicated if there is any evidence of disease progression (e.g., significant changes in BP or proteinuria, excessive weight gain, new symptoms) or abnormal fetal growth. Antihypertensive medications should be avoided during outpatient management. Women should be counseled to report the same symptoms and changes in fetal movement described for patients with gestational hypertension. When calls are made to office or hospital personnel and the on-call physician, patients should explain that they have been diagnosed with preeclampsia. Finally, women should be given specific phone numbers to call and be advised when to report immediately to the hospital.
Severe preeclampsia. Pregnancies complicated by severe preeclampsia usually are marked by a significant reduction in uteroplacental and fetoplacental blood flow. This reduction is particularly pronounced in women who develop severe preeclampsia at less than 32 weeks’ gestation. Thus, these pregnancies are associated with high rates of perinatal mortality and morbidity, mainly because of severe fetal growth retardation and preterm delivery.7 They also may be associated with increased rates of maternal morbidity, such as HELLP syndrome, disseminated intravascular coagulopathy (DIC) (from severe abruptio placentae), pulmonary edema, eclampsia, or acute renal failure. Consequently, the onset of severe preeclampsia requires immediate hospitalization and intensive monitoring of maternal and fetal conditions.8
The first steps in management are administering magnesium sulfate to prevent convulsions9 and antihypertensive drugs to control extreme levels of hypertension, as well as evaluation of the patient for the presence of symptoms and/or hemolysis, elevated liver enzymes, elevated serum creatinine, and thrombocytopenia.8
In general, delivery is considered appropriate for the mother regardless of gestational age. Unfortunately, it may not be appropriate for the fetus, particularly when the gestational age is less than 33 weeks. Consequently, expectant management—in an attempt to prolong pregnancy in the interest of fetal viability—may be appropriate for gestations between 24 and 32 weeks. However, it is appropriate only in a select group of patients and should be practiced only in a tertiary-care center with adequate maternal and neonatal facilities. Patients should be informed of the risks and benefits of such management, which requires close daily monitoring of maternal-fetal conditions. It is recommended that such patients be managed in consultation with a perinatologist. Antepartum fetal testing and maternal liver enzymes and platelet counts should be performed daily. Indications for delivery during expectant management are listed in TABLE 8.