Expectant Management Of Severe Preeclampsia Research Articles

Pregnancy latency and fetal growth restriction in expectant management of severe pre-eclampsia

Pregnancy latency and fetal growth restriction in expectant management of severe pre-eclampsia

Maternal morbidity and pregnancy latency in expectant management of severe pre-eclampsia

Maternal morbidity and pregnancy latency in expectant management of severe pre-eclampsia

Amount of Proteinuria and Duration of Expectant Management in Severe Preeclampsia.

The aim of the study is to evaluate the association between the amount of proteinuria at the time of diagnosis of preeclampsia with severe features (severe preeclampsia [SPE]) and duration of expectant management (EM) and other perinatal outcomes. This is a retrospective cohort study of patients with SPE delivering live, non-anomalous singletons at 230/7 to 342/7 weeks' estimated gestational age (EGA) at a single tertiary center 2016 to 2018. Patients with proteinuria assessment (24-hour total urine protein or urine protein-to-creatinine ratio extrapolation) within 3 days of SPE diagnosis were included. Patients delivered for an indication other than SPE were excluded. Patients were categorized by amount of proteinuria (mg): none (≤300), mild (301-1,000), moderate (1,001-3,000), and massive (≥3,001). The primary outcome was the proportion of potential EM time achieved (%EM), i.e., days of EM divided by days from SPE diagnosis to 34 weeks. Secondary outcomes included delivery EGA, days of EM, and perinatal outcomes. Bivariable and multivariable analyses compared outcomes across groups. Of 295 patients included, 21% had no proteinuria, 33% mild, 19% moderate, and 27% massive. Groups differed by EGA at diagnosis, age, parity, chronic hypertension, and renal disease. %EM was not significantly different between groups (adjusted β coefficient 4.1 [95% CI -5.3, 13.5] for mild proteinuria vs. none, -4.1 [95% CI -14.9, 6.6] for moderate proteinuria vs. none, and -5.6 [95% CI -16.0, 4.7] for massive proteinuria vs. none). Increasing proteinuria was associated with earlier delivery EGA but only days of EM in the mild versus no proteinuria groups. There was no significant association between proteinuria and maternal composite morbidity, but patients with mild and massive proteinuria had higher odds of neonatal composite morbidities compared with no proteinuria. Among patients with SPE, proteinuria level was not consistently associated with duration of EM. However, patients with the greatest amounts of proteinuria may have worse neonatal and selected maternal outcomes. · Amount of proteinuria was not associated with the duration of expectant management.. · Greater proteinuria was associated with earlier delivery in severe preeclampsia.. · Massive proteinuria in preeclampsia was associated with select adverse maternal and neonatal outcomes..

Factors associated with longer latency in expectant management of severe pre-eclampsia

Expectant management of pre-eclampsia with severe features (SPREX) is often considered if diagnosed < 34 weeks. We sought to identify antepartum factors associated with latency of ≥7 days (long latency) and latency ≥14 days (very-long latency) among patients undergoing expectant management of SPREX.

Diagnosis to Delivery Outcomes of Early Severe Preeclampsia

Expectant management of severe preeclampsia (sPEC) diagnosed at < 34 weeks remains individualized, with limited data available to counsel patients. Existing literature includes women with prior chronic hypertension (cHTN), who may have different underlying physiology. Our objective was to evaluate outcomes of women with early sPEC at our institution, comparing those diagnosed at earlier vs. later gestational age (GA).

Outcomes following medical termination versus prolonged pregnancy in women with severe preeclampsia before 26 weeks.

ObjectiveTo compare maternal complications and describe neonatal outcomes in women with severe preeclampsia at ≤ 26+0 weeks in two countries with different management policies: expectant management (Brazil) versus termination of pregnancy (France).MethodsWe conducted a retrospective comparative study by reviewing the medical records of women with severe preeclampsia at ≤ 26+0 weeks, from January 2010 to June 2018, in two centers: Hospital das Clínicas da Faculdade de Medicina, in Sao Paulo, Brazil (where medical abortion is forbidden in this indication) and Hôpital Antoine-Béclère, Clamart, France (where medical termination is accepted). We collected information on maternal characteristics, laboratory tests, maternal complications and fetal and newborn characteristics. We used Student’s t-test and the Mann-Whitney U nonparametric test to compare quantitative variables, and Chi-square test or Fisher's exact test to evaluate the associations between the qualitative variables.ResultsThere was no between-group difference in maternal complications during hospitalization (p = 0.846). In Brazil, the rate of cesarean section was 66.7%, and 20% of patients had vertical incision. The rate of spontaneous fetal death was 35.6% and among the live-born infants 26.6% were discharged from hospital. In France, one patient had a cesarean section with vertical incision.ConclusionWhen comparing termination of pregnancy to expectant management in severe preeclampsia before 26 weeks, maternal complications were equivalent but maternal reproductive future might have been compromised in 20% of cases due to a higher risk of uterine rupture in subsequent pregnancies for patients having classic cesarean (vertical incision). 26.6% of children survived the neonatal period when pregnancy was pursued, however we lack information on their long-term follow-up.

Outcomes before and after Adopting Guidelines for Expectant Management of Severe Preeclampsia.

This study aimed to compare maternal and neonatal outcomes in women with severe preeclampsia before and after implementation of the American College of Obstetricians and Gynecologists (ACOG) taskforce hypertensive guidelines. Single-center retrospective cohort study of women with severe preeclampsia delivering live nonanomalous singletons 23 to 342/7 weeks from 2013 to 2017. In 2015, the ACOG guidelines for expectant management of severe preeclampsia were implemented at our institution. Based on this, patients were categorized as preguideline (January 2013-December 2015) or postguideline adoption (January 2016-December 2017). Primary outcomes included composite maternal morbidity and composite neonatal morbidity; secondary outcomes included composite components, length of stay, birth weight, and delivery gestational age. Groups were compared with Student's t-test, Chi-square, and Wilcoxon's rank-sum tests; adjusted odds ratios (aOR; 95% confidence intervals [CIs]) were calculated. Yearly composite outcomes were compared using the Cochran-Armitage trend test. We estimated a sample size of 250 per group would provide 80% power at α = 0.05 to detect a 50% reduction in neonatal morbidity from a baseline rate of 21.5%. From 2013 to 2017, a total of 543 women with severe preeclampsia were identified: 278 (51%) preguideline and 265 (49%) postguideline. Baseline characteristics were overall similar between groups. There were no significant differences in maternal (aOR = 0.96, 95% CI: 0.6-1.41) or neonatal (aOR = 0.88, 95% CI: 0.61-1.28) composite morbidity between groups. Furthermore, there were no differences in composite maternal or neonatal morbidity over time. Perinatal outcomes were similar before and after implementation of severe preeclampsia management guidelines at our institution. Studies to evaluate if benefits are limited to subsets of this population, such as earlier gestational ages, are needed. · Expectant management of severe preeclampsia has yet to be fully evaluated outside of trial conditions.. · We did not see a significant improvement in neonatal composite morbidity/mortality.. · We also did not see a worsened composite maternal morbidity/mortality..

Expectant management of early-onset severe preeclampsia: a principal component analysis.

Preeclampsia is a multisystem disorder that is characterized by hypertension with either proteinuria or end-organ dysfunction in both previously normotensive women and chronically hypertensive women. To identify the important influencing factors for early-onset severe preeclampsia, this study undertook to explore the associations between preeclampsia characteristics, along with the decreased latency and poor neonatal outcomes during expectant management of severe preeclampsia before 34 weeks of gestation. A total of 213 patients were retrospectively studied. Pregnancy outcomes in terms of maternal complications and neonatal outcomes were determined. Statistical analysis was performed by principal component analysis, Student's t-test, and Pearson correlation analysis. Neonatal mortality was influenced by gestational age at delivery and birth weight. The main factors that influenced pregnancy outcome were gestational age at diagnosis, the 24-h urine protein level, the plasma albumin level, and hydrothorax plus ascites. When the gestational age at diagnosis was 25 weeks, and 4/7 days, the probability that the pregnancy would be classified into group 2 with 79.3% neonatal survival was almost 50%. Only the plasma albumin level and hydrothorax plus ascites affected prolongation. Plasma albumin level and hydrothorax plus ascites should be considered seriously, as they may be a reason to terminate the expectant management of early-onset severe preeclampsia. Given its unsatisfactory pregnancy outcomes, expectant management should be reconsidered before 25 weeks and 4/7 days.

Efficacy of expectant management of severe preeclampsia and preeclampsia superimposed on chronic hypertension before 34 weeks gestation.

To investigate the effect of chronic hypertension on expectant management for preeclampsia (PE). Pregnant women who were diagnosed with severe PE before 34 weeks of gestation between 2005 and 2016 and managed at a tertiary center were the subjects of the study. Mothers were classified into two groups: a severe superimposed PE (SSP) group and a severe PE (SP) group. We compared the groups in terms of perinatal outcomes. Pregnancy prolongation from the diagnosis of severe PE to delivery. The SSP group included 30 women whereas the SP group included 79 women. Expectant management could be performed in 24 subjects (80.0%) in the SSP group and 49 (62.0%) in the SP group (P = 0.110). Gestational age at diagnosis of PE (P = 0.016) and gestational age at delivery (P = 0.031) were significantly lower in the SSP group than in the SP group. There were no significant differences between the groups in terms of pregnancy prolongation (SSP, 8.5 days versus SP, 6.0 days; P = 0.25) or maternal and neonatal complications. Compared to severe PE, severe PE superimposed on chronic hypertension does not increase the prevalence of maternal complications, and an equivalent pregnancy prolongation was obtained. Expectant management was possible in severe superimposed PE on chronic hypertension, as it was in severe PE.

53. Expectant management of severe preeclampsia in a developing country: Maternal outcomes and perinatal survival

Background Management of severe preeclampsia which develops prior to 34 still debatable. Immediate delivery leads to high neonatal mortality and morbidity due to prematurity, conversely expectant management may potentially increase maternal morbidity and mortality. Objective of this study was to determine maternal outcomes and perinatal survival achieved with expectant management in patients presenting with preeclampsia Study Design A retrospective cohort analysis of outcome in patients with severe preeclampsia in a tertiary hospital in Indonesia during 3 years: 165 patients (178 fetuses) managed expectantly were studied. Neonatal outcomes (birth weight, APGAR score, fetal growth restriction (FGR), intrauterine fetal death (IUFD), early neonatal death, and maternal complications (HELLP syndrome, pulmonary edema, eclampsia, renal insufficiency, and placental abruption) were registered. Results 25 patients had a preeclampsia disease onset Conclusion Neonatal outcome in preterm severe preeclampsia depends mainly on GA at onset of preeclampsia and GA at delivery. Expectant management of preeclampsia presenting at less

Expectant Management of Severe Preeclampsia in Pregnant Women Remote from Term: A Randomised Controlled Study

Expectant Management of Severe Preeclampsia in Pregnant Women Remote from Term: A Randomised Controlled Study

789: Expectant management in severe preeclampsia diagnosed at less than 28 weeks: is it really safe and are we improving outcomes?

789: Expectant management in severe preeclampsia diagnosed at less than 28 weeks: is it really safe and are we improving outcomes?

What to Expect From Expectant Management in Severe Preeclampsia at &lt;34 Weeks’ Gestation

What to Expect From Expectant Management in Severe Preeclampsia at &lt;34 Weeks’ Gestation

Management of preeclampsia.

Most patients with a pregnancy-induced hypertensive disorder have no clinical symptoms. So it can only be reliably detected by repetitive searches (screening) for the early signs and symptoms in the 2nd half of pregnancy. Adequate and proper prenatal care is the most important part of management of preeclampsia. Maternal antenatal monitoring includes identifying women at increased risk, early detection of preeclampsia by recognizing clinical signs and symptoms, and to observe progression of the condition to the severe state. As the etiology of preeclampsia remains in question, the only effective treatment is to deliver the infant and placenta; ancillary therapy is predominantly symptomatic and not directed at underlying causes. Once the diagnosis of preeclampsia is made, subsequent therapy will depend on the results of initial maternal and fetal evaluation. The primary objective of management of preeclampsia must always be safety of the mother. Although delivery is always appropriate for the mother, it may not be optimal for the fetus that is extremely premature. The decision between delivery and expectant management depends on fetal gestational age, maternal and fetal status at time of initial evaluation, presence of labor or rupture of fetal membranes, and level of available neonatal and maternal services. It is important to emphasize that hypertension is merely one manifestation of this disease, albeit directly related to one of the most serious consequences for the mother, i.e cerebral involvement, which may manifest itself as convulsions, focal neurological events such as cortical blindness, and even cerebral hemorrhage. The benefits of acute pharmacologic control of severe hypertension prior to delivery are generally accepted. The more contentious issues are the role of pharmacologic therapy in allowing prolongation of pregnancy and the ability of such therapy to modify the course of the underlying systemic disorder and affect fetal and maternal outcome. Ali hypertensive drugs affect both the mother and the fetus; some may produce side effects in the mother and others may produce adverse effects on the fetus or the newborn. The indirect effects of antihypertensive drugs on the fetus may be by impairing uteroplacental perfusion or directly by influencing the fetal cardiovascular circulation. In general, women with mild disease developing at 37weeks' gestation or longer have a pregnancy outcome similar to that found in normotensive pregnancy. Thus, those patients should undergo induction of labor for delivery. Induction of labor and/or delivery is also recommended for those at or beyond 34 weeks' gestation in the presence of severe preeclampsia, labor or rupture of membranes, or non-reassuring tests of fetal well-being because the mother is at slightly increased risk for development of placental abruption and progression to eclampsia. In women who remain undelivered, close maternal and fetal evaluation is essential. The type of test and frequency of evaluation will depend on fetal gestational age as well as severity of maternal condition, and presence or absence of IUGR. These tests should be repeated promptly in case of worsening maternal condition (progression to severe disease) or fetal condition (reduced fetal movement or suspected IUGR). Expectant management of severe preeclampsia:The clinical course of severe preeclampsia may be characterized by progressive deterioration in both maternal and fetal conditions. Because these pregnancies have been associated with increased rates of maternal morbidity and mortality and with significant risks for the fetus, there is universal agreement that such patients be delivered if the disease develops after 34weeks' gestational, 243. Delivery is also clearly indicated when there is imminent eclampsia (persistent severe symptoms), multiorgan dysfunction, severe IUGR, suspected placental abruption, or non-reassuring fetal testing before 34 weeks' gestation. There is disagreement however, about treatment of patients with severe preeclampsia before 34 weeks' gestation where maternal condition is stable and fetal condition is reassuring. The Cochrane review on interventionist versus expectant care states that it is not possible to draw firm conclusions, as there are only two small trials (133 women) that have compared a policy of early elective delivery, with a policy of delayed delivery, and the confidence intervals for all outcomes are wide. However, the evidence is promising that short-term morbidity for the baby may be reduced by a policy of expectant care. Sibai and Barton recently reviewed the literature on maternal and perinatal of expected management of severe preeclampsia remote from term and reviewed the major studies in the literature. Based on this review, they concluded that the results of these studies suggest that expectant treatment in a select group of women with severe preeclampsia between 24 0/7 and 32 6/7weeks of gestation in a suitable hospital is safe and improves neonatal outcome. Most studies on expectant management report 7-10days of prolongation. For gestational age of 24 0/7weeks, expectant treatment was associated with high maternal morbidity with limited perinatal benefit.

Expectant Management of Severe Preeclampsia Remote From Term

Preeclampsia occurs in ∼2% to 12% of all pregnancies, and early severe preeclampsia accounts for ∼25% of all cases. The only known treatment for preeclampsia is delivery, yet an early preterm delivery increases the risk for adverse neonatal outcomes. This randomized, multicenter, parallel, open-label clinical trial was undertaken to determine whether expectant management of severe preeclampsia at less than 34 weeks’ gestation results in better perinatal outcomes compared with prompt delivery (PD) after steroid administration. Pregnant women with severe hypertensive disorders at 28 to 33 weeks’ gestation were randomly allocated to the PD or expectant management (EXM) group. Prompt delivery patients received glucocorticoid therapy followed by delivery in 24 to 72 hours. Patients in the EXM group were treated with glucocorticoid therapy followed by delivery only for specific maternal/fetal indications or reaching 34 weeks’ gestation. The primary outcome was perinatal mortality (fetal and neonatal death). Secondary outcomes were composite neonatal morbidities, neonatal birth data, and maternal morbidities and death. Of 267 women, the final cohort included 131 patients (138 births) in the EXM group and 133 (137 births) in the PD group. The 2 groups did not differ significantly in baseline characteristics. Reasons for delivery in the EXM group were uncontrollable blood pressure (40.4%), fetal compromise (29%), persistent symptoms (28.2%), reaching 34 weeks’ gestation (26.0%), and maternal complications (21.3%). Perinatal mortality rates were 9.4% in the PD group and 8.7% in the EXM group, not a significant difference. Composite neonatal morbidities were 56.4% in the PD group and 55.6% in the EXP group (relative risk, 1.01; 95% confidence interval, 0.81–1.26; P = 0.89). The PD group had lower birth weights at delivery (1543 ± 438 vs 1659 ± 509 g), but the EXM group had more small-for-gestational age infants (13 [9.4%] vs 30 [21.7%]; P = 0.005) and abruptio placentae (2 [1.5%] vs 10 [7.6%]; P = 0.01). Rates of total neonatal morbidity and mortality stratified by gestational age at randomization were 85% (63/75), 66.3% (65/98), and 36.2% (37/102), respectively, for 28 to 29 weeks, 30 to 31 weeks, and 32 to 33 weeks, with no significant differences between the PD and EXM groups. The average pregnancy prolongation in the EXM group was 10.3 ± 8 days compared with 2.2 ± 0.8 days in the PD group (P = 0.0001). No maternal deaths occurred. Oral antihypertensive medications to maintain blood pressure at less than 160/110 mm Hg were used in 61 women (46.5%) in the EXM group. No significant differences in perinatal mortality were noted between women with or without oral antihypertensive medications (7 [11.48%] vs 5 [7.14%]; P = 0.29). The incidence of severe hypertension was 41% and 38.6% in these 2 groups, respectively (P = 0.81). Five women in each oral antihypertensive group had abruptio placentae. Higher maternal morbidity (37.7% vs 14.3%; P = 0.02) was found in the EXM group receiving oral antihypertensive medications. The only curative treatment for severe preeclampsia is delivery of the fetus. At very early preterm, the consequences of neonatal prematurity must be weighed against potential maternal morbidity by prolonging gestation. The most important factors for improved neonatal outcome are gestational age on presentation, use of corticosteroids, and providing intensive neonatal care. Severe preeclampsia before 34 weeks should be managed with PD after corticoid administration.

Clinical trial of expectant management of severe preeclampsia that develops at

Objective: This study was to examine the clinical usefulness of expectant management of early-onset severe preeclampsia.Methods: We reviewed the obstetric records of all Japanese singleton deliveries at ≥22 weeks’ gestation managed at Japanese Red Cross Katsushika Maternity Hospital between 2007 and 2012. We compared the obstetric characteristics and perinatal outcomes between the cases of deliveries before (n = 19) and after completion of corticosteroids (n = 30) (immediate delivery versus expectant management).Results: Although the gestational age at delivery in the patients expectantly managed was higher than that in the patients required immediate deliveries (31.0 versus 29.3 weeks), the difference in the incidence of neonatal respiratory distress syndrome between the two groups did not reach the statistical significance (74 versus 47%, p = 0.06). The incidence of pulmonary edema in the patients expectantly managed was significantly higher than that in the patients required immediate deliveries within the first 48 h (20 versus 0%, p = 0.04).Conclusion: The current results could not support the clinical usefulness of expectant management of early-onset severe preeclampsia.

Expectant management of severe preeclampsia with severe fetal growth restriction in the second trimester

We investigated whether women with severe fetal growth restriction (FGR <5th percentile) associated with severe preeclampsia (PE) occurring in the second trimester are candidates for expectant management. This is a retrospective study involving 33 women who developed severe PE or superimposed PE in the second trimester and were expectantly managed at a tertiary center. They were divided into groups with and without severe FGR on admission (severe FGR (+) group: 17 women; severe FGR (-) group: 16 women) for comparison of the duration of pregnancy prolongation, major maternal complications, and perinatal outcomes. The data are presented as medians (range) or frequencies (percentage). The duration of pregnancy prolongation was 10days in both groups. Major maternal complications occurred in 5 of 17 women (29.4%) in the severe FGR (+) and 5 of 16 (31.3%) in the severe FGR (-) group, showing very similar incidence rates in the 2 groups. The perinatal survival rates were favorable at 82.4% (14/17) in the severe FGR (+) and 100% (16/16) in the severe FGR (-) group. Regarding expectant management of severe preeclampsia occurring in the second trimester, there was no difference in the duration of pregnancy prolongation between the groups with and without severe FGR on admission. Because favorable perinatal outcomes can be expected without compromising maternal safety by prolonging pregnancy as expectant management for severe FGR, it was suggested that women with severe FGR are suitable candidates for expectant management.

Expectant management of severe preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter clinical trial

The objective of the study was to determine whether expectant management of severe preeclampsia prior to 34 weeks of gestation results in improved neonatal outcome in countries with limited resources. This was a randomized clinical trial performed in 8 tertiary hospitals in Latin America. Criteria of randomization included gestational age between 28 and 33 weeks' gestation and the presence of severe hypertensive disorders. Patients were randomized to steroids with prompt delivery (PD group) after 48 hours vs steroids and expectant management (EXM group). The primary outcome was perinatal mortality. A total of 267 patients were randomized, 133 to the PD group and 134 to the EXM group. Pregnancy prolongation was 2.2 days for the PD group vs 10.3 days for the EXM group (P = .0001). The rate of perinatal mortality (9.4% vs 8.7%; P = .81; relative risk [RR], 0.91; 95% confidence interval [CI], 0.34-1.93) was not improved with expectant management, and neither was the composite of neonatal morbidities (56.4% vs 55.6%; P = .89; RR, 01.01; 95% CI, 0.81-1.26). There was no significant difference in maternal morbidity in the EXM group compared with the PD group (25.2% vs 20.3%; P = .34; RR, 1.24; 95% CI, 0.79-1.94). However, small gestational age (21.7% vs 9.4%; P = .005; RR, 2.27; 95% CI, 1.21-4.14) and abruption were more common with expectant management (RR, 5.07; 95% CI, 1.13-22.7; P = .01). There were no maternal deaths. This study does not demonstrate neonatal benefit with expectant management of severe preeclampsia from 28 to 34 weeks. Additionally, a conservative approach may increase the risk of abruption and small for gestational age.

Benefits and Risks of Expectant Management of Severe Preeclampsia at &lt; 26 Weeks Gestation

Benefits and Risks of Expectant Management of Severe Preeclampsia at &lt; 26 Weeks Gestation

Maternal and Perinatal Outcome During Expectant Management of Severe Pre-Eclampsia Between 24 and 34 Weeks of Gestation

To determine the maternal and perinatal outcome after expectant management of severe pre-eclampsia between 24 and 34weeks of gestation. The maternal and fetal status was monitored by an intensive, non-invasive method among 94 women with severe pre-eclampsia between 24 and 34weeks of gestation who were scheduled for expectant management in the OICU at a tertiary care center. Pregnancy prolongation and maternal and perinatal morbidity and mortality were analyzed by the Student 't' test and the Mann-Whitney U test. The days of pregnancy prolongation and perinatal mortality were significantly higher among those managed at <30weeks. Increasing gestational age correlated with a reduction of RDS. Maternal morbidities were significantly higher among those managed at <28weeks. But, there was no maternal mortality. Expectant management of severe pre-eclampsia at 30-34weeks in a tertiary care center of a developing country is associated with good perinatal outcome and risk reduction for the mother.