296: Expectant management versus immediate delivery in women with preeclampsia with severe features

Abstract

ACOG recommends expectant management (EM) of preeclampsia with severe features (SPE) for neonatal benefit in select women; but this may come with maternal harm. We compared maternal and neonatal outcomes in women with SPE managed with immediate delivery (ID) versus EM. Retrospective cohort study of women with SPE delivering viable singletons at 23-34 wks from 2013–2018 at a single tertiary care center (24hr MFM/Neonatology access) where EM was widely adopted in 2016 (ID standard pre-2016). We defined EM by time from SPE diagnosis to decision for delivery (ID≤2 days, EM >2 days). An alternate analysis evaluated EM by intent - defining women initiated/titrated on oral anti-hypertensives as EM. Patients ineligible for EM (i.e. abnormal labs, eclampsia, pulmonary edema) were excluded from both groups. Primary outcomes were composites of maternal and neonatal morbidity (Table). Groups were compared using appropriate tests, odds ratios (OR) were calculated (ID as reference) and adjusted for confounders. Neonatal outcomes were compared across delivery gestational age (GA) ranges. Of 664 women with SPE, 418 women met study criteria; 122 had EM and 296 ID. With the exception of GA at SPE diagnosis (29wks EM vs 31wks ID p< 0.001), baseline characteristics were similar between groups. Maternal hospitalization was extended by 5 days in the EM group (ID median 6 days (IQR 5-8) vs EM 11 (8-19), p< 0.001). There was no difference in composite maternal morbidity (or components) between EM versus ID (Table). While nonsignificant, there was reduced composite neonatal morbidity (and components) after adjusting for earlier GA at SPE diagnosis in the EM group (Table). With EM defined by antihypertensive use (n=203 EM, n=215 ID), maternal outcomes were still not compromised and neonatal outcomes significantly benefited (Table). There was no difference in neonatal outcomes when stratified by GA range at delivery (p=NS, Figure) EM of SPE is associated with neonatal benefit without increased maternal harm. Larger studies should evaluate if these results are limited to certain GAs.View Large Image Figure ViewerDownload Hi-res image Download (PPT)