225. Delivery or expectant management for the prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: An individual patient data meta-analysis

Abstract

Introduction Hypertensive disorders affect about 10% of pregnancies. Delivery is the definitive treatment. Delay carries maternal risks, but early delivery increases fetal risk so appropriate timing is difficult. Objective To compare immediate delivery and expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disease of pregnancy. Study Design A systematic review and meta-analysis of individual patient data of randomized controlled trials including pregnant women from 34 gestational weeks with hypertensive disease allocated to immediate delivery or expectant management. Main outcomes were respiratory distress syndrome (RDS) and a composite of HELLP syndrome and eclampsia. Five datasets (GRIT, HYPITAT I and II, DIGITAT, and “Deliver or Deliberate”) were merged and analyzed using a 2-stage meta-analysis approach. We calculated relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% confidence intervals (CI). Results Main outcomes were available for 1,724 eligible women. Immediate delivery reduced overall HELLP syndrome and eclampsia risk (0.8% vs. 2.8%; RR 0.33, CI [0.15–0.73]; I[b] = 0%; NNT 51, CI [31.1–139.3]) as well as in the subgroup with preeclampsia (1.1% vs. 3.5%; RR 0.39, CI [0.15-0.98]; I[b] = 0%). The risk of RDS increased after immediate delivery (3.4% vs. 1.6%; RR 1.9, CI [1.05–3.6]; I[b] = 24%; NNH 58, CI [31.1-363.1]), but this effect was dependent on gestational age. Increased risk was present in the 35th week (5.1% vs. 0.6%; RR 5.5, CI [1.0–29.6]; I[b] = 0%), but this risk was lower in the 36th week, and did not reach statistical significance. (1.5% vs. 0.4%; RR 3.4, 95% CI [0.4–30.3]; I[b] = 0%). We found no evidence of difference in NICU admissions, 5-min Apgar score Conclusion In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, while the effect on the baby is dependent on gestational age.