Interventionist versus expectant care for severe pre‐eclampsia between 24 and 34 weeks' gestation
Abstract
Background
Severe pre‐eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs remote from term, between 24 and 34 weeks' gestation. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to ensure that the development of serious maternal complications, such as eclampsia (fits) and kidney failure are prevented. Others prefer a more expectant approach delaying delivery in an attempt to reduce the mortality and morbidity for the child associated with being born too early.
Objectives
The objective of the review was to compare the effects of a policy of interventionist care and early delivery with a policy of expectant care and delayed delivery for women with early onset severe pre‐eclampsia.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013).
Selection criteria
Randomised trials comparing the two intervention strategies for women with early onset severe pre‐eclampsia.
Data collection and analysis
Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy.
Main results
Four trials, with a total of 425 women are included in this review. Trials were at low risk of bias for methods of randomisation and allocation concealment; high risk for blinding; unclear risk for incomplete outcome data and other bias; and low risk for selective reporting. There are insufficient data for reliable conclusions about the comparative effects on most outcomes for the mother. For the baby, there is insufficient evidence for reliable conclusions about the effects on stillbirth or death after delivery (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.69 to 1.71; four studies; 425 women). Babies whose mothers had been allocated to the interventionist group had more intraventricular haemorrhage (RR 1.82, 95% CI 1.06 to 3.14; one study; 262 women), more hyaline membrane disease (RR 2.30, 95% CI 1.39 to 3.81; two studies; 133 women), require more ventilation (RR 1.50, 95% CI 1.11 to 2.02; two studies; 300 women) and were more likely to have a lower gestation at birth in days (average mean difference (MD) ‐9.91, 95% CI ‐16.37 to ‐3.45; four studies; 425 women), more likely to be admitted to neonatal intensive care (RR 1.35, 95% CI 1.16 to 1.58) and have a longer stay in the neonatal intensive care unit (average MD 11.14 days, 95% CI 1.57 to 20.72 days; two studies; 125 women) than those allocated an expectant policy. Nevertheless, babies allocated to the interventionist policy were less likely to be small‐for‐gestational age (RR 0.30, 95% CI 0.14 to 0.65; two studies; 125 women). Women who had been allocated to the interventionist group were more likely to have a caesarean section (RR 1.09, 95% CI 1.01 to 1.18; four studies; 425 women) than those allocated an expectant policy. There were no statistically significant differences between the two strategies for any other outcomes.
Authors' conclusions
This review suggests that an expectant approach to the management of women with severe early onset pre‐eclampsia may be associated with decreased morbidity for the baby. However, this evidence is based on data from only four trials. Further large trials are needed to confirm or refute these findings and establish if this approach is safe for the mother.
PICOs
Plain language summary
Interventionist versus expectant care for severe pre‐eclampsia before term
Women who develop pre‐eclampsia (high blood pressure and protein in the urine) before 34 weeks of pregnancy (early onset) are at risk of severe complications, and even death. These involve the woman's liver, kidneys, clotting system and cause neurological disturbances such as headache, visual disturbances, and exaggerated tendon reflexes. If the placenta is involved, this can cause growth restriction or reduced amniotic fluid, placing the baby at risk. The only known cure for pre‐eclampsia is delivery of the baby. Being born too early can in itself have problems for the baby, even with the administration of corticosteroids 24 to 48 hours beforehand to help mature the lungs. Some hospitals follow a policy of early delivery within 24 to 48 hours, interventionist management, whilst others prefer to delay delivery until it is no longer possible to safely stabilise the woman's condition, expectant management.
This review included four trials that randomly assigned women to a policy of interventionist management or expectant management when presenting with severe pre‐eclampsia before 34 weeks of pregnancy. A total of 425 women were included in these four trials. Babies born to women allocated to an interventionist approach were more likely to experience adverse effects such as intraventricular haemorrhage and neonatal respiratory distress syndrome. They were also more likely to require admission to the neonatal intensive care unit and ventilation, have a longer stay in the neonatal unit and weigh less at birth than those babies born to women allocated to an expectant management approach. Women in the interventionist group were also more likely to require caesarean section for delivery. Delaying delivery may therefore be more beneficial for the baby. There are insufficient data, however, for reliable conclusions about the comparative effects on most outcomes for the mother and hence the maternal safety of an expectant approach.
This evidence is based on data from only four small trials. Further large trials with long‐term follow‐up of the children are needed to confirm or refute whether expectant care is better than early delivery for women who suffer from severe pre‐eclampsia before 34 weeks of pregnancy.
