Management Of Severe Preeclampsia Research Articles

Practice variation in late-preterm deliveries: a physician survey.

ObjectiveLate preterm (LPT) neonates account for over 70% of all preterm births in the US. Approximately 60% of LPT births are the result of non-spontaneous deliveries.The optimal timing of delivery for many obstetric conditions at LPT gestations is unclear, likely resulting in obstetric practice variation. The purpose of this study is to identify variation in the obstetrical management of LPT pregnancies.Study designWe surveyed obstetrical providers in NC identified from NC Medical Board and NC Obstetrical and Gynecological Society membership lists. Participants answered demographic questions and 6 multiple-choice vignettes on management of LPT pregnancies.ResultWe obtained 215/859 (29%) completed surveys; 167 (78%) from Obstetrics/Gynecology, 27 (13%) from Maternal-Fetal Medicine, and 21 (10%) from Family Medicine physicians. Overall, we found more agreement on respondents’ management of chorioamnionitis (97% would proceed with delivery), mild preeclampsia (84% would delay delivery/expectantly manage), and fetal growth restriction (80% would delay delivery/expectantly manage). We found less agreement on the management of severe preeclampsia (71% would proceed with delivery), premature preterm rupture of membranes (69% would proceed with delivery), and placenta previa (67% would delay delivery/expectantly manage). Management of LPT pregnancies complicated by PPROM, FGR, and placenta previa vary by specialty.ConclusionObstetrical providers report practice variation in the management of LPT pregnancies. Variation might be influenced by provider specialty. The absence of widespread agreement on best practice might be a source of modifiable LPT birth.

Benefits and Risks of Expectant Management of Severe Preeclampsia at < 26 Weeks Gestation

Benefits and Risks of Expectant Management of Severe Preeclampsia at < 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.

Benefits and risks of expectant management of severe preeclampsia at less than 26weeks gestation: the impact of gestational age and severe fetal growth restriction

Benefits and risks of expectant management of severe preeclampsia at less than 26weeks gestation: the impact of gestational age and severe fetal growth restriction

Cerebral Oxygen Supply Monitored by Near Infrared Spectroscopy (NIRS) in the First Days of Life in Preterm Infants after Maternal Use of Labetolol

Background and aims: The aim of management of severe preeclampsia is to improve neonatal outcome and to prevent maternal complications. Antihypertensive treatment improves maternal outcome but has the potential to be deleterious. Maternal hypertension and preeclampsia can cause fetal IUGR and brainsparing. Although effects are to be expected from maternal use of beta blockers, scarce information on neonatal cerebral hemodynamics is available. Labetolol-induced changes in blood pressure (MABP) may influence regional cerebral saturation (rScO2). Methods: 18 infants with GA < 32 weeks, born after maternal use of labetolol (ML-group) were included and matched for GA, birth weight (BW) and gender (C-group). Arterial oxygen saturation, MABP, heart rate (HR) and rScO2 were monitored and an average was calculated on day 1 and 2. Results: GA, BW, respiratory support, use of inotropics and incidence of IVH did not differ between groups. Antenatal brainsparing was more prevalent in the ML-group (P< 0.05). HR was significantly lower in the ML-group in the first 48 hours but was always within normal limits (144 BPM ± 10.5 vs 152 BPM ± 10.7, p< 0.001). MABP was not different at all time points. rScO2 was significantly higher in the ML group (68 ± 10 vs 62 ± 9, p< 0.001). Conclusions: Despite lower HR in infants of preeclamptic mothers treated with labetolol cerebral oxygenation seems not to be compromised. Brainsparing seems to be associated with a higher oxygen delivery in the brain probably due to vasodilation and/or loss of autoregulatory ability of the cerebral vascular bed.

Treatment of retained placenta with acupuncture

[1] Hnat MD, Sibai BM, Caritis S, Hauth J, Lindheimer MD, MacPherson C, et al. Perinatal outcome in women with recurrent preeclampsia compared with women who develop preeclampsia as nulliparas. Am J Obstet Gynecol 2002;186(3):422–6. [2] Odendaal HJ, Pattinson RC, Bam R, Grove D, Kotze TJ. Aggressive or expectant management for patients with severe preeclampsia between 28–34 weeks' gestation: a randomized controlled trial. Obstet Gynecol 1990;76(6):1070–5. [3] Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial. Am J Obstet Gynecol 1994;171(3):818–22. [4] Thomas T, Jophy R,Mhaskar A, Misquith D. Are we increasing serious maternal morbidity by postponing termination of pregnancy in severe pre-eclampsia/eclampsia? J Obstet Gynecol 2005;25(4):347–51. [5] Bassaw B, Roopnarinesingh S, Sirjusingh A. An audit of perinatal mortality. West Indian Med J 2001;50(1):42–6.

Evaluation and management of severe preeclampsia before 34 weeks' gestation

We sought to review the risks and benefits of expectant management of severe preeclampsia remote from term, and to provide recommendations for expectant management, maternal and fetal evaluation, treatment, and indications for delivery. Studies were identified through a search of the MEDLINE database for relevant peer-reviewed articles published in the English language from January 1980 through December 2010. Additionally, the Cochrane Library, guidelines by organizations, and studies identified through review of the above documents and review articles were utilized to identify relevant articles. Where reliable data were not available, opinions of respected authorities were used. Published randomized trials and observational studies regarding management of severe preeclampsia occurring <34 weeks of gestation suggest that expectant management of selected patients can improve neonatal outcomes but that delivery is often required for worsening maternal or fetal condition. Patients who are not candidates for expectant management include women with eclampsia, pulmonary edema, disseminated intravascular coagulation, renal insufficiency, abruptio placentae, abnormal fetal testing, HELLP syndrome, or persistent symptoms of severe preeclampsia. For women with severe preeclampsia before the limit of viability, expectant management has been associated with frequent maternal morbidity with minimal or no benefits to the newborn. Expectant management of a select group of women with severe preeclampsia occurring <34 weeks' gestation may improve newborn outcomes but requires careful in-hospital maternal and fetal surveillance.

Benefits and risks of expectant management of severe preeclampsia at less than 26 weeks gestation: the impact of gestational age and severe fetal growth restriction

To determine maternal and perinatal outcome in women with severe preeclampsia at <26 weeks according to gestational age at the onset of expectant management and the presence of severe fetal growth restriction (<5th percentile). Fifty-one patients (53 fetuses; 2 twins) were retrospectively studied. Median prolongation was 7 days (2-55). Maternal morbidity rate was 43%. Perinatal survival rate was 42%. Severe fetal growth restriction complicated 17 fetuses (33%). There were no perinatal survivors in those managed at <24 weeks (n = 12). For those at 24-24(6/7) and 25-25(6/7) weeks, the perinatal survival rates were 50% and 57%, respectively, and in the presence of severe fetal growth restriction 0% and 30%, respectively. Perinatal outcome in severe preeclampsia in the midtrimester is dependent on gestational age and/or the presence of severe fetal growth restriction. Given the high maternal morbidity and the extremely low perinatal survival rates, we do not recommend expectant management before 24 weeks and/or in those with severe fetal growth restriction at any gestational age <26 weeks.

BOOK REVIEW

Alexander Heazell, Errol R. Norwitz, Louise C. Kenny, Philip N. Baker , editors . Hypertension in Pregnancy . 208 pages . Cambridge University Press , Cambridge , 2010 . ISBN: 978-0-521-73156-0 . Price: £35.00 USD 59.00 . Hypertensive disorders complicate 5–10% of all pregnancies. Knowledge about diagnostics and management is essential to all physicians and paramedical staff working with pregnant women. This book, which has a handy format and easily goes into the pocket of the white coat, covers the different types of hypertensive disorders in pregnancy. It starts with a well written chapter providing information of normal physiological changes in pregnancy. It gives a brief introduction to the pathophysiological changes contributing to hypertension in pregnancy and goes into management more or less like clinical guidelines. Special chapters are dedicated to long-term effects on cardiovascular health and insulin resistance as well as anesthesiological concerns. The mechanisms behind the onset of hypertension in pregnancy are not fully understood and, due to their complexity, may be hard to grasp. The book provides a comprehensive description of the connection between inflammation, oxidative stress and endothelial dysfunction in preeclampsia, but in our view this does not really facilitate the understanding of these complex interactions. Perhaps more illustrations would have made understanding easier. Preexisting chronic hypertension occurs in approximately 2% of pregnancies. In about 10%, there is an underlying cause; an often neglected fact among obstetricians. The chapter about secondary hypertension covers several of these underlying conditions, the most common being renovascular disease. Some of them are very rare, such as pheochromocytoma, but they are nevertheless important to keep in mind as pregnancy is extremely hazardous in these patients. The management of severe preeclampsia and HELLP (hemolysis, elevated liver enzymes, low platelets) is challenging. In small settings, cases may be rare and the need for good clinical guidelines is obvious. This book offers a high quality review of this, based on evidence. The algorithm is easy to follow and provides a helpful aid to clinicians. The long-term effect of hypertension in pregnancy is an emerging area of interest. The book ends with describing the link between preeclampsia and the risk of cardiovascular disease. This chapter could, however, have been further developed and an inclusion of suggestions for follow-up would have been of use to the reader. Intrapartal management of women with preeclampsia and HELLP is sometimes challenging and offers difficult decisions. An extension of the discussion regarding this problem would have made this book even more useful. Due to the multiple authors, some repetition is inevitable. However, the reiterations of the definition of preeclampsia, antihypertensive treatment and the defective trophoblast invasion in preeclampsia could have been considerably reduced by more careful editing. Apart from minor lapses, the book offers a good updated complement to more extensive literature, and can be recommended to gynecologists and obstetricians, anesthesiologists, general practitioners and other professionals dealing with this group of patients.

Maternal and perinatal outcome of severe pre-eclampsia in Enugu, Nigeria after introduction of Magnesium sulfate

Magnesium sulfate (MgSO4) is the most effective seizure prophylaxis in the management of severe pre-eclampsia, and its use is progressively spreading in our environment. It was introduced at the pioneer teaching hospital of southeastern Nigeria in 2007. A study on the outcome of its use is therefore necessary. The objective was to determine the effect of introducing MgSO4 on the maternal and perinatal outcomes of severe pre-eclampsia in Enugu, South eastern Nigeria. A retrospective study of all cases of severe pre-eclampsia managed at the University of Nigeria Teaching Hospital Enugu (UNTH), Nigeria, from 1 January 2005 to 31 December 2008 - 2 years before, and 2 years after the introduction of MgSO4 - was performed. The prevalence of severe preeclampsia within the study period was 3.3%. The mean age of study participants was 24.5 ± 2.9 years. Thirty women received MgSO4 while 47 women received diazepam. Eclampsia occurred only in a member of the diazepam group but there were no maternal deaths. Babies from the diazepam group were more likely to have low 1 minute Apgar scores but the association was not significant [OR = 3.08 (95% CI 0.78, 13.33)]. Longer hospital stay was significantly lower among women who received MgSO4 [OR = 0.32 (95% CI 0.11, 0.93)]. Perinatal mortality did not differ between the groups. MgSO4 is effective in the management of severe pre-eclamptics at the UNTH, Enugu. Therefore, its accessibility and wider use should be promoted.

758: Benefits and risks of expectant management of severe preeclampsia at less than 26 weeks gestation: the impact of gestational age and severe fetal growth restriction

758: Benefits and risks of expectant management of severe preeclampsia at less than 26 weeks gestation: the impact of gestational age and severe fetal growth restriction

P9 Maternal and perinatal outcomes of expectant management in severe preeclampsia between 24 and 33 weeks' gestation

Despite multiple doses of β2-agonists in the treatment of acute asthma exacerbation, significant residual airways obstruction often remains.To determine whether the addition of inhaled ipratropium bromide to salbutamol provides improvement in lung function and clinical asthma symptoms in young children with acute asthma exacerbation.This study was a prospective, double-blind randomized control trial of children aged 3 to 15 years who presented with an acute asthma exacerbation at the emergency department or outpatient clinic of Thammasat University Hospital, Pathumthani, Thailand, between September 2001 and February 2003. Subjects were randomized to receive 3 doses of nebulized salbutamol mixed with isotonic sodium chloride solution (control) or ipratropium bromide (treatment) every 20 minutes. Additional doses of salbutamol were given every 30 minutes as needed. Asthma outcome measures were evaluated 40, 70, 100, and 120 minutes after baseline. Primary outcomes were the differences in percent change in asthma clinical score and percent change in peak expiratory flow rate (PEFR) from baseline. Secondary outcomes included change in percent predicted PEFR.Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group.Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies.

P10 Maternal death in Brazil last ten years: late maternal mortality rises

Objective: This study was undertaken to determine maternal and perinatal outcomes after expectant management of severe preeclampsia between 24 and 33 weeks’ gestation. Study design: This was a retrospective analysis of outcome in patients with severe preeclampsia between January, 2005 and December, 2009. Thirtysix patients with severe preeclampsia geatational aged 24-33 weeks were studied. Corticosteroids were administered. Perinatal and maternal complications (a composite maternal morbidities including HELLP syndrome, pulmonary edema, eclampsia, and renal insufficiency) were analyzed. Results: Mean of gestational aged was 30.7 weeks. The days of pregnancy prolongation were 5 days (range 2-22). There were five perinatal deaths (13.88%), four cases in those managed at < 28 weeks and one case in those managed at 28-30 weeks. Cesarean section rate was 94.44%. Maternal morbidities developed in four cases, two pulmonary edema, one placental abruption and one HELLP syndrome. There was no maternal death. Conclusion: Expectant management of severe preeclampsia at 24 to 33 weeks is associated with good perinatal outcome with a minimal risk for the mother. However, it should be done in the tertiary care center with close maternal and fetal monitoring.

Diagnosis and management of pre-eclampsia: an update.

Pre-eclampsia is a significant, multifactorial, multiorgan disease affecting 5%–8% of all pregnancies in the US where it is the third leading cause of maternal mortality. Despite improvements in the diagnosis and management of pre-eclampsia, severe complications can occur in both the mother and the fetus, and there is no effective method of prevention. Early detection and identification of pregnant women most at risk of developing the disease have proven challenging, but recent efforts combining biochemical and biophysical markers are promising. Efforts at prevention of pre-eclampsia with aspirin and calcium have had limited success, but research on modifiable risk factors, such as obesity surgery, are encouraging. Obstetric management of severe pre-eclampsia focuses on medical management of blood pressure and prevention of seizures using magnesium sulfate, but the ultimate cure remains delivery of the fetus and placenta. Timing of delivery depends on several factors, including gestational age, fetal lung maturity, and most importantly, disease severity. Anesthetic management includes regional anesthesia with careful evaluation of the patient’s airway, volume status, and coagulation status to reduce morbidity and mortality. The potential complications of general anesthesia, including intracranial hemorrhage, in these patients make regional anesthesia the preferred choice in many cases. Nevertheless, it is important to be aware of the contraindications to neuraxial anesthesia and to prepare always for the possibility of encountering a difficult airway.

O94 Management of severe pre-eclampsia: the way forward

International Journal of Gynecology & ObstetricsVolume 107, Issue S2 p. S119-S119 Free communication (oral) presentations O94 Management of severe pre-eclampsia: the way forward S. Basak, S. BasakSearch for more papers by this authorS. Roy, S. RoySearch for more papers by this author S. Basak, S. BasakSearch for more papers by this authorS. Roy, S. RoySearch for more papers by this author First published: 20 November 2009 https://doi.org/10.1016/S0020-7292(09)60466-5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume107, IssueS2Abstracts of XIX FIGO World Congress of Gynecology and ObstetricsOctober 2009Pages S119-S119 RelatedInformation

Expectant Management of Severe Preeclampsia at 27 (0/7) to 33 (6/7) Weeks' Gestation: Maternal and Perinatal Outcomes According to Gestational Age by Weeks at Onset of Expectant Management

The aim of expectant management of severe preeclampsia between 27 (0/7) and 33 (6/7) weeks of gestation is to improve perinatal outcome without compromising maternal safety. Perinatal outcome is dependent in large part on the gestational age at the time of disease onset and maternal and fetal status at the time of presentation. This retrospective study evaluated maternal morbidity and perinatal outcome with expectant management of severe preeclampsia between 27 (0/7) and 33 (6/7) weeks' gestation, with data stratified by gestational age at the time of onset of expectant management. The investigators reviewed the medical records of 336 gravid women with severe primary or superimposed preeclampsia who delivered before 34 (0/7) weeks at an Ohio medical center, to identify a study population of 66 patients (71 fetuses) between 27 (0/7) and 33 (6/7) weeks. All patients were treated with corticosteroids for fetal lung maturity. Expectant management resulted in pregnancies being prolonged by a median of 5 days (range: 3-35). Nineteen (27%) newborns had a birth weight below the 10th percentile for gestational age, and 6 (8%) had a birth weight below the fifth percentile. Among patients in whom expectant management was instituted at 27-27 (6/7) weeks, there was 1 neonatal.

Expectant Management of Severe Preeclampsia at 270/7to 336/7Weeks' Gestation: Maternal and Perinatal Outcomes According to Gestational Age by Weeks at Onset of Expectant Management

We sought to determine perinatal outcome and maternal morbidities based on gestational age (GA) at onset of expectant management in severe preeclampsia (PE) between 27(0/7) and 33 (6/7) weeks. In this retrospective analysis of outcome in patients with severe preeclampsia, we studied 66 patients (71 fetuses) with severe PE at 27 (0)/ (7) to 33(6/ 7). All patients received corticosteroids. Perinatal and maternal complications were analyzed. Five patients had twin gestations. Median for days of prolongation was 5 days (range, 3 to 35). Birth weights of 19 (27%) were < 10% for gestational age, and 6 (8%) were < 5%. All fetuses survived except for one neonatal death at 27 weeks, and three infants had chronic lung disease-two at 27 and one at 28 weeks-but there were no cases of intraventricular hemorrhage (>or= grade ?). Rate of abruption was significantly higher at 27 to 28 weeks as compared with > 28 weeks (25% vs 6%, p = 0.05). There was no eclampsia, and two had transient renal insufficiency at 27 weeks. Four of 11 (36%) patients with expectant management at >or= 32 weeks had pulmonary edema or hemolytic anemia, elevated liver enzymes, and low platelet count. During expectant management, rate of respiratory distress syndrome and other serious neonatal complications decrease with increasing GA, supporting a role for such management in early severe preeclampsia. Because there is significant maternal morbidity at >or= 32 weeks with minimal neonatal benefit, consideration should be given for delivery of these pregnancies following corticosteroid administration.

Anaesthetic management of patients with pre-eclampsia/eclampsia and perinatal outcome

Objective. This study examined risk factors for perinatal mortality associated with anaesthesia for caesarean delivery in patients with pre-eclampsia/eclampsia. The study is apt because perinatal mortality rate is one of the indicators of health status of pregnant women, new mothers and their newborns. The information obtained may help to assess changes in public health policy and practise amongst women of child-bearing age.Aim. The role of anaesthesia in perinatal outcome in pre-eclamptics.Methods and materials. The hospital records (cases notes, labour ward and newborn special care unit and theatre records) of patients with pre-eclampsia/eclampsia, which had caesarean delivery and their babies at the University of Nigeria Teaching hospital (UNTH), Enugu, Nigeria from July 1998 to June 2006, were retrospectively reviewed. The term perinatal mortality refers to stillbirths and neonatal deaths within 7 days of birth.Results. There were a total of 6798 deliveries and 1579 women delivered through caesarean section. Of these, 196 were patients with pre-eclampsia/eclampsia. There were a total of 19 stillbirths (9%) and 19 (9%) early neonatal deaths in the pre-eclampsia/eclampsia group going a perinatal mortality of 180/1000 births. Amongst these women, 157 delivered under general anaesthesia, 34 under spinal anaesthesia and five under epidural block. Of the 38 perinatal deaths, 30 delivered by general anaesthesia and eight by regional anaesthesia.Conclusion. Pre-eclampsia/eclampsia continues to be a cause of foetal loss in the developing world even where essential obstetric services are available. Early onset management of severe pre-eclampsia with maintenance of adequate placental perfusion during anaesthesia may result in lower perinatal deaths.

742: Expectant management of severe preeclampsia between 24-32 weeks gestation: A ten year review

742: Expectant management of severe preeclampsia between 24-32 weeks gestation: A ten year review

Expectant management of severe preeclampsia at less than 27 weeks' gestation: maternal and perinatal outcomes according to gestational age by weeks at onset of expectant management

The objective of the study was to determine perinatal outcome and maternal morbidities based on gestational age (GA) at the onset of expectant management in severe preeclampsia at less than 27 weeks. This was a retrospective analysis of outcome in patients with severe preeclampsia. Forty-six patients (51 fetuses) with severe preeclampsia at less than 27 weeks were studied. Corticosteroids were administered beyond 23 weeks. Perinatal and maternal complications (a composite maternal morbidities including HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, pulmonary edema, eclampsia, and renal insufficiency were analyzed. Four patients had multifetal gestations (1 triplet, 3 twins). Median days of prolongation was 6 (range 2-46). Overall perinatal survival was 29 of 51 (57%). Birthweights of 27 (53%) were less than 10%, and 18 (35%) were less than 5%. There were no perinatal survivors in those with a GA less than 23 weeks, at 23 to 23 6/7 weeks, 2 of 10 (20%) survived, and both reached 26 weeks at delivery. For those at 24 to 24 6/7, 25 to 25 6/7, and 26 to 26 6/7 weeks, the perinatal survival rates were 5 of 7 (71%), 13 of 17 (76%), and 9 of 10 (90%), respectively; but rates of respiratory complications were high. There were no maternal deaths, but overall maternal morbidity was 21 of 46 (46%), but was 9 of 14 (64%) in those at less than 24 weeks. Perinatal outcome in severe preeclampsia in the midtrimester is dependent on GA at onset of expectant management and GA at delivery. Given the high maternal morbidity and extremely low perinatal survival in expectant management at less than 24 weeks, termination of pregnancies should be offered after extensive counseling.