Managing High Risk Pregnancies

Documents to Request

• MFM consultation notes
• Serial blood pressure logs
• Laboratory trend data (minimum: CBC, CMP, LDH, uric acid, protein/creatinine ratio or 24-hour urine)
• Ultrasound reports (growth, Doppler, cervical length, amniotic fluid)
• Antenatal testing results (NST, BPP)
• Medication administration records
• Prior obstetric records (history of preeclampsia, preterm birth, FGR)

Step 1: Classify Hypertensive Disorders of Pregnancy

Per ACOG Practice Bulletin No. 222:

Step 2: Manage Preeclampsia by Severity

Without Severe Features

• Weekly BP monitoring and symptom assessment
• Weekly labs: CBC, CMP, LDH (begin at diagnosis)
• Twice-weekly NST or modified BPP starting at diagnosis
• Growth ultrasound every 3–4 weeks
• Delivery at 37 + 0 weeks (ACOG recommendation)

With Severe Features

• < 34 weeks: Consider expectant management at a tertiary center IF maternal/fetal status stable
  • Betamethasone for fetal lung maturity (12 mg IM × 2 doses, 24 hours apart)
  • Magnesium sulfate for seizure prophylaxis and neuroprotection
  • Continuous FHR monitoring
  • Labs q 6–12 hours
  • Deliver if worsening despite management
• 34 + 0 to 36 + 6 weeks: Deliver after betamethasone administration (if not previously given)
• ≥ 37 weeks: Deliver — do not delay
• Eclampsia or HELLP at any GA: Stabilize and deliver regardless of gestational age

Antihypertensive Therapy (Acute Severe HTN: BP ≥ 160/110)

Treat within 30–60 minutes per ACOG Committee Opinion No. 767:

Step 3: Manage Fetal Growth Restriction (FGR)

Per SMFM guidance, classify FGR and determine surveillance:

Delivery timing:

• Isolated FGR: 37–38 weeks
• FGR with abnormal Doppler: 34–37 weeks (based on severity)
• Absent/reversed end-diastolic flow: 32–34 weeks (with steroids)

Step 4: Manage Preterm Labor and Short Cervix

Short cervix (< 25 mm on transvaginal US before 24 weeks):

• Vaginal progesterone 200 mg nightly (singleton with no prior PTB)
• Cerclage consideration (singleton with prior PTB and progressive shortening)
• Serial cervical length measurements q 2 weeks from 16–24 weeks in high-risk patients

Active preterm labor (23 + 0 to 33 + 6 weeks):

• Betamethasone 12 mg IM × 2 doses, 24 hours apart
• Tocolysis for 48 hours to complete steroid course (nifedipine or indomethacin < 32 weeks)
• Magnesium sulfate for neuroprotection if < 32 weeks (4 g bolus + 1 g/hr)
• GBS prophylaxis if status positive or unknown
• Transfer to facility with appropriate NICU level

Step 5: Apply ACOG Delivery Timing Table

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the high-risk condition correctly classified per ACOG diagnostic criteria?
2. Does the surveillance plan match the condition and gestational age?
3. Are laboratory trends documented with interpretation (improving, stable, worsening)?
4. Is delivery timing specified and consistent with ACOG recommendations?
5. Are all medications documented with indication, dose, route, and timing?

Quality Audit

• Each high-risk condition is named with ACOG-consistent diagnostic criteria
• Blood pressure classification follows ACOG thresholds (≥ 140/90 and ≥ 160/110)
• Preeclampsia severity is classified and documented with supporting lab values
• Acute severe hypertension treatment documented with agent, dose, and time
• Magnesium sulfate indication, loading dose, and maintenance documented
• Betamethasone administration documented with dates and times of both doses
• Antenatal testing schedule documented (NST/BPP frequency)
• Growth ultrasound interval documented and appropriate for condition
• Umbilical artery Doppler results documented for FGR cases
• Delivery timing plan stated with GA and supporting rationale
• MFM consultation documented with recommendations
• Tocolytic therapy documented with drug, dose, duration, and contraindications checked
• Neonatal team notification documented for anticipated preterm delivery

Guidelines

1. Apply ACOG diagnostic thresholds precisely — do not round blood pressures or paraphrase laboratory criteria.
2. Trend, do not snapshot — a single lab value is less important than the trajectory across serial measurements.
3. Document the reasoning for delivery timing — state the condition, the ACOG-recommended window, and why the chosen GA was selected.
4. Escalate proactively — if any severe feature is present, document the decision pathway even if expectant management is pursued.
5. Distinguish chronic from gestational — the onset before or after 20 weeks is the defining criterion and must be documented.
6. Track steroid and magnesium exposure — document both doses of betamethasone with times, and magnesium start/stop times.
7. Use standardized Doppler terminology — normal, elevated S/D ratio, absent end-diastolic flow (AEDF), reversed end-diastolic flow (REDF).