14. Maternal and neonatal outcome in vaginal delivery versus caesarean section in severe early onset preeclampsia prior to 28 weeks’ gestation, a systematic review

Abstract

Introduction preeclampsia with an onset prior to 28 weeks’ gestation poses a dilemma for the obstetrician with regard to mode of delivery for optimal maternal and neonatal outcome. Objective To analyze the succes rate of attempted vaginal delivery (VD) in preeclampsia prior to 28 weeks’ gestation and the maternal and neonatal outcome according to mode of delivery (VD versus CS). Methods A comprehensive search was performed in the bibliographic databases Pubmed, Embase.com and Wiley Cochrane Library from inception up to June 2017. Main outcome was succes rate of attempted vaginal delivery in women with preeclampsia prior to 28 weeks’ gestation. Secondary outcomes were maternal outcomes: maternal death, ICU admission, postpartum hemorrhage  > 1 liter, placental abruption and manual removal of placenta after VD or CS. Neonatal outcomes were: neonatal death, neonatal morbidity (composite outcome) and live discharge from NICU after VD versus CS. Results Eight studies, either retrospective or prospective cohort studies, describing a total of 162 women, were included for this review. No RCT’s were found. Succes rates of vaginal delivery varied from 1.8 to 80% and rates for CS after attempted vaginal delivery after induction of labor varied from 13 to 51%. Two studies (n  =  53) described no statistical significant difference in maternal outcomes according to delivery mode. Two other studies (n = 107) described no statistical significant difference in neonatal outcomes according mode of delivery. Conclusions There are no RCT’s on mode of delivery in women with severe early-onset preeclampsia prior to 28 weeks’ gestation. Studies that do report the primary outcome are small, therefore no firm conclusions can be made. However, giving the available evidence in the reported studies, a trial of labor can be considered in preeclamptic patients prior to 28 weeks’ gestation.