Expectant Management vs. Induction of Labor in Women With Severe Proteinuria in Preeclampsia [20K

Abstract

INTRODUCTION: A 2013 report from the American College of Obstetricians and Gynecologists (the College) task force removed greater than 5g proteinuria in a 24-hour urine collection from the severe symptoms list for preeclampsia. We sought to determine the perinatal outcomes following implementation of this guideline. METHODS: A decision analytic model was created using TreeAge software. Our study compared induction of labor (IOL) at 34 weeks gestation with expectant management from 34-37 weeks gestation. For each week of expectant management, we calculated the rate of spontaneous delivery and risk of developing severe symptoms. Utilities were included with a discounted life expectancy rate of 3% to produce quality adjusted life years (QALYs). Our theoretical population included 100,000 pregnant women with mild gestational hypertension, greater than 5 g protein in a 24-hour urine collection and no other severe symptoms. We analyzed both neonatal and maternal outcomes. RESULTS: Expectant management based on the new guidelines resulted in 23,068 cases of progression to or complications of severe disease, 3 additional maternal deaths, and 10 more stillbirths. Conversely, IOL at 34 weeks resulted in 440 more neonatal deaths and 355 more cases of cerebral palsy. CONCLUSION: Our model and analysis support the updated College guideline for expectant management of women with mild hypertension, greater than 5 g proteinuria and no other severe symptoms. Although expectant management leads to higher rates of maternal death, stillbirths, and adverse maternal events, the significant rates of cerebral palsy and neonatal death in preterm delivery at 34 weeks support expectant management over IOL at 34 weeks.