|Year : 2020 | Volume
| Issue : 1 | Page : 1-6
Pregnancy outcomes among women with early-onset severe preeclampsia managed conservatively
Johnbosco Ifunanya Nwafor, Darlington- Peter Chibuzor Ugoji, Blessing Idzuinya Onwe, Vitus Okwuchukwu Obi, Chuka Nobert Obi, Victor Jude Uchenna Onuchukwu, Chukwunenye Chukwu Ibo
Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, South-East Nigeria
|Date of Submission||23-Jun-2019|
|Date of Decision||01-Sep-2019|
|Date of Acceptance||18-Sep-2019|
|Date of Web Publication||18-Mar-2020|
Dr. Johnbosco Ifunanya Nwafor
Department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki
Background: Conservative management of early-onset severe preeclampsia is gaining widespread acceptance among obstetricians despite well-known maternal risks associated with it. There is limited data on the outcome of pregnancy of women managed with this modality of management in Nigerian setting. Objective: We determined the maternal and perinatal outcome of women managed conservatively for early-onset severe preeclampsia. Materials and Methods: This was a 7-year retrospective study of 118 women with early-onset severe preeclampsia that were managed conservatively at the Alex Ekwueme Federal University Teaching Hospital, Abakaliki. The data were entered and analyzed using the SPSS software version 22.0 (SPSS Inc., Chicago, IL, USA). Results: The median duration of expectant management was 12 days (range 3–20 days). The mean gestational age at delivery was 33.4 ± 2.5 weeks. The most common indication for delivery was uncontrolled hypertension (35.6%). Adverse maternal outcomes found in the study included abruptio placentae (11%), acute renal failure (2.5%), pulmonary edema (0.8%), eclampsia (11.9%), disseminated intravascular coagulation (2.5%), Haemolysis, elevated liver enzymes and low platelet (HELLP) syndrome (2.5%), and maternal death (2.5%). Perinatal mortality occurred in 68 (57.6%) cases in the study. Perinatal survival improved significantly with gestational age, with reductions in perinatal mortality of approximately 50% per week between 28 and 34 weeks' gestation on admission. Conclusion: Delayed delivery of women with early-onset severe preeclampsia improved perinatal outcome in this study, but it was associated with considerable maternal morbidity and mortality. Therefore, proper patient selection, adequate counseling of women on the risks and benefit of conservative management, close maternal monitoring, and the presence of advanced neonatal care are necessary to optimize pregnancy outcome when this management modality is adopted.
Keywords: Conservative management, early onset preeclampsia, outcome
|How to cite this article:|
Nwafor JI, Ugoji DP, Onwe BI, Obi VO, Obi CN, Uchenna Onuchukwu VJ, Ibo CC. Pregnancy outcomes among women with early-onset severe preeclampsia managed conservatively. Sahel Med J 2020;23:1-6
|How to cite this URL:|
Nwafor JI, Ugoji DP, Onwe BI, Obi VO, Obi CN, Uchenna Onuchukwu VJ, Ibo CC. Pregnancy outcomes among women with early-onset severe preeclampsia managed conservatively. Sahel Med J [serial online] 2020 [cited 2020 Mar 28];23:1-6. Available from: http://www.smjonline.org/text.asp?2020/23/1/1/280941
| Introduction|| |
Preeclampsia is a major cause of maternal and perinatal morbidity and mortality and it accounts for 21.1% of the maternal death and 30.2% of perinatal mortality in Abakaliki.
Preeclampsia affects 5%–7% of pregnancies, and early-onset preeclampsia developing remote from term (<34 weeks) accounts for 25% of pregnancies complicated with preeclampsia., Preeclampsia is defined as severe in the presence of one of the following: systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg, eclampsia, pulmonary edema, symptoms suggesting significant end-organ involvement (such as persistent headache, visual disturbances, epigastric or right upper quadrant pain), oliguria <500 ml/24 h, microangiopathic hemolysis, thromboctyopenia, severe intrauterine growth restriction, or oligohydramnious. The course of early-onset severe preeclampsia is associated with progressive deterioration of the maternal condition. Therefore, the definitive treatment for preeclampsia is the delivery of the placenta. Conventionally, women with severe preeclampsia, regardless of gestational age, are usually delivered without delay. Delivery at earlier gestational age, however, is associated with increased risk of adverse neonatal outcome.
In recent times, a new approach in the treatment of women with severe preeclampsia remote from term has been advocated by several investigators worldwide. With improvement in methods for fetomaternal surveillance, several authors advocate conservative management for early-onset severe preeclampsia <34 weeks gestation against the traditional idea that such women needed to be delivered immediately. Because of the improvement of neonatal outcome after corticosteroid prophylaxis, many obstetricians delayed delivery for 48 h to allow a complete course of corticosteroid treatment. The objective of expectant management is to improve the perinatal outcome in terms of neonatal survival, and with lower morbidity. However, prolongation of pregnancy may increase the risk of maternal morbidity, which includes placental abruption, renal failure, pulmonary edema, and eclampsia.
There is inadequate literature regarding the outcome of expectant management in developing countries with limited health resources, where the fetus is considered salvageable at a gestation of 28–30 weeks or even later. The aim of this study was to evaluate the maternal and perinatal outcomes of women who had expectant management of early-onset severe preeclampsia at the Alex Ekwueme Federal University Teaching Hospital, Abakaliki.
| Materials and Methods|| |
Alex Ekwueme Federal University Teaching Hospital (formerly known as Federal Teaching Hospital) Abakaliki is a tertiary hospital within Abakaliki, Ebonyi State, Nigeria. The hospital manages about 4500 deliveries annually and receives referral from all parts of the state and neighboring states of Benue, Enugu, Cross River, and Abia as well as any part of the country. Department of Obstetrics and Gynaecology is 1 of the 10 Clinical Departments in the hospital, it has ten teams with each comprising consultants, senior registrars, registrars, senior house officers, and house officers. The department runs gynecological clinics, preconception, antenatal, intrapartum, and postnatal services.
This is a 7-year retrospective study of women managed conservatively for early-onset severe preeclampsia from January 1, 2012 to December 31, 2018, at the Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria.
Inclusion and Exclusion criteria
Inclusion criteria were women with singleton pregnancies who were admitted with a diagnosis of severe preeclampsia between the 28 and 34 weeks' of gestation, according to the American College of Obstetrics and Gynecologists' 2013 criteria, identified from the medical records. The exclusion criteria were women who delivered within the first 24 h of admission and those with intrauterine fetal demise on admission.
The hospital numbers of the eligible women during the study period were retrieved from the admission register in the antenatal ward. The case notes were then retrieved from the medical records department of the hospital. A pro forma containing information on the maternal demographic details, gestational age at diagnosis, systolic and diastolic blood pressure recordings, and various laboratory parameters on admission was used to extract information from the case notes. Data regarding the duration of expectant management, gestational age at delivery, use of magnesium sulfate prophylaxis, antihypertensive medication, corticosteroid therapy, and mode of delivery were also retrieved. In addition, complications such as eclampsia, abruptio placentae, pulmonary edema, renal failure, HELLP syndrome, and maternal death were also noted. Neonatal data included birth weight, admission into neonatal intensive care unit, stillbirth, and early neonatal death.
The approval for the study was sought and obtained from the Research and Ethics Committee of the hospital on January 21, 2019, with protocol no: AEFUTHA/REC/Vol2/2019/038. The study adhered to guidelines of 2013 Helsinki's declaration. The study was carried out as per the guidelines given in the Declaration of Helsinki 2013.
The data were entered and analyzed using the SPSS version 22.0 (SPSS Inc., Chicago, IL, USA, 2013). Data are presented as mean (standard deviation) or as a percentage with range, as appropriate. Association of continuous variable, gestational age at diagnosis, with primary outcomes was compared using the Student's t-test. Multivariate logistic regression was performed to assess the independent association of gestational age at diagnosis with primary outcomes, after adjusting for other variables. A value of P < 0.05 was considered statistically significant.
| Results|| |
During the period of the study, 118 patients with severe preeclampsia before 34 weeks' gestation who met the inclusion criteria were delivered in our facility.
[Table 1] shows the sociodemographics and clinical characteristics of the study population. The mean age of the patients was 24.6 ± 2.8. Women between the ages of 21 and 25 years accounted for the majority (38.1%) of the patients. Nulliparous women accounted for well over half of the study cohorts. The median duration of expectant management was 12 days (range 3–20 days). Majority (47.5%) of the women carried their pregnancies between 8 and 12 days following admission. Only eleven (9.3%) of the study cohorts had their pregnancy duration extended between 16 and 20 days on conservative treatment. Cesarean section was performed in 71 (60.2%) women. Among women who had cesarean section, 50 (70.4%) had emergency cesarean section, whereas 21 (29.6%) were delivered by elective cesarean section.
|Table 1: Demographic and obstetrics characteristics of the study cohort (n=118)|
Click here to view
The indications for delivery are shown in [Table 2]. The most common indication for delivery among women with early-onset severe preeclampsia was uncontrolled hypertension (35.6%). Other indications for delivery include intrauterine fetal death (22%), eclampsia (11.9%), abruptio placentae (11), fetal distress (11.9%), and prolongation of pregnancy up to 34 weeks gestation (7.6%).
[Table 3] shows the various maternal and perinatal complications in the study cohort, based on the gestational age at the diagnosis of preeclampsia. Of the 118 women who met the inclusion criteria, 40 (33.9%) had one or more of the composite adverse maternal outcomes. Maternal mortality resulting from this treatment modality in this study was 2.5%. Of the 3 maternal deaths, 2 were due to disseminated intravascular coagulopathy, and one was from massive postpartum hemorrhage following abruptio placentae. The incidence of adverse maternal outcomes was higher in women who were diagnosed at 33–<34 weeks' gestation, compared with earlier gestational age at diagnosis. Six women developed abruptio placentae in the group who were diagnosed at 31–32 weeks, compared with 4 in gestational age 28–30 weeks and 3 in gestational age 33–<34 weeks. The incidence of eclampsia seems to decline with increasing gestational age. Eclampsia occurred in 6 women who were in the gestational age range of 28–30 weeks and its occurrence reduced by half in women at gestational age between 33 and <34 weeks. Logistic regression analysis showed that gestational age at diagnosis of preeclampsia was not associated with adverse maternal outcomes, after adjusting for other variables.
|Table 3: Maternal and perinatal complications based on gestational age at the diagnosis of preeclampsia|
Click here to view
Perinatal mortality occurred in 68 (57.6%) cases in the study. Perinatal mortality was significantly higher in those diagnosed at 28–30 weeks' gestation (37/40; 92.5%) compared to those at 31–32 weeks (25/65; 38.5%), and those at 33–<34 weeks (6/14; 46.2%) (P < 0.001). Perinatal survival improved significantly with gestational age, with reductions in perinatal mortality of approximately 50% per week between 28 and 34 weeks' gestation on admission.
| Discussion|| |
The determination of optimal timing of delivery for women with early-onset preeclampsia with severe features is a very difficult decision for obstetricians because immediate delivery will result in high perinatal mortality, whereas conservative management to optimize fetal outcome may increase the risk of considerable severe maternal morbidity and mortality.
The study found that it was possible to prolong pregnancy by a median duration of 12 days in women with early-onset severe preeclampsia. This finding was similar to that of studies done in Rotterdam (18 days), India (14 days), and Latin America (10.3 days). However, the duration of pregnancy prolongation in this study was higher than the findings of the study carried out in China (8 days), but lower than that of a study done in Sweden (24 days). Prolongation of pregnancy by more than 1 week may have contributed to improved perinatal survival found in this study.
The perinatal mortality found in this study was 57.6%, and it was the highest among women who were diagnosed with severe preeclampsia at 28–30 weeks' gestation. Perinatal survival improved significantly with gestational age, with reductions in perinatal mortality of approximately 50% per week between 28 and 34 weeks' gestation on admission. This finding is significantly higher than that of studies in Rotterdam (20.5%), India (36.8%), Latin America (9.4%), and Panama (7%). The lower limit of fetal salvage is considered to be 28 weeks in our locality, as in most developing nations. We observed that the perinatal mortality rate was higher when preeclampsia was diagnosed between 28 and 30 weeks. The gestational age at which the fetus is considered salvageable varies widely between developing and developed nations. The lower limit of neonatal survival is between 28 and 32 weeks' gestation in the former, whereas it is 24 weeks or even lower in most developed nations. Perinatal morbidity and mortality rates in developing countries may be higher than those at <24 weeks in developed countries, even when the fetus is delivered at 30–32 weeks' gestation, due to a lack of resources and the inaccessibility of advanced neonatal care facilities.
There were three maternal deaths in the study, which was higher than the results from other studies. Studies done in Rotterdam, India, and Latin America did not report maternal mortality following conservative management of severe preeclampsia. A study done in USA by Sibai and Barton found only one maternal death occurred during expectant management following the diagnosis of preeclampsia at 24 weeks' gestation. Furthermore, the incidence of other major maternal complications (abruptio placentae, acute renal failure, pulmonary edema, eclampsia, disseminated intravascular coagulation HELLP syndrome) in our study was 37%. These findings show that there is a need for frequent and aggressive monitoring in those women considered for expectant management. Being a tertiary referral center, a higher proportion of preeclamptic women with increased risk are referred from the peripheral health facilities than in the other studies, which might account for the higher rates in this study. Women with severe features of preeclampsia at admission were found to have higher rates of adverse maternal outcomes in the study.
Strengths and Limitations
The strength of this study is that we used statistical analysis to adjust for the possible factors contributing to the outcomes, using multivariate regression analysis. We also assessed the effect of the interaction of gestational age at diagnosis and the pregnancy outcomes. However, the study has some limitations. Due to the lack of follow-up after discharge, the data on neonatal morbidity and mortality as well as maternal outcome for the rest of the puerperium were not available for the analysis, and finally retrospective nature of the study limits its validity.
| Conclusion|| |
Delaying delivery of women with early-onset severe preeclampsia was associated with significant improvement in perinatal outcome in this study, but it was associated with considerable maternal morbidity and mortality. Therefore, proper patient selection, adequate counseling of women on the risks of conservative management, optimal maternal monitoring, and the presence of functional neonatal care are necessary to optimize pregnancy outcome when this management modality is adopted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nwafor JI. Pattern and determinants of mortality among eclamptic women that presented in the federal teaching hospital, Abakaliki, Southeast, Nigeria. Trop J Obstet Gynaecol 2019;36:67-72. [Full text]
Chen Q, Shen F, Gao YF, Zhao M. An analysis of expectant management in women with early-onset preeclampsia in China. J Hum Hypertens 2015;29:379-84.
Valent AM, DeFranco EA, Allison A, Salem A, Klarquist L, Gonzales K, et al.
Expectant management of mild preeclampsia versus superimposed preeclampsia up to 37 weeks. Am J Obstet Gynecol 2015;212:515.e1-8.
Rebecca AM, Pierce-Williams DO, Ehsanipoor RM. Expectant management of early-onset preeclampsia with severe features. Top Obstet Gynecol 2018;38:1-7.
Haddad B, Sibai BM. Expectant management of severe preeclampsia: Proper candidates and pregnancy outcome. Clin Obstet Gynecol 2005;48:430-40.
Chammas MF, Nguyen TM, Li MA, Nuwayhid BS, Castro LC. Expectant management of severe preterm preeclampsia: Is intrauterine growth restriction an indication for immediate delivery? Am J Obstet Gynecol 2000;183:853-8.
Magee LA, Yong PJ, Espinosa V, Côté AM, Chen I, von Dadelszen P. Expectant management of severe preeclampsia remote from term: A structured systematic review. Hypertens Pregnancy 2009;28:312-47.
Haddad B, Sibai BM. Expectant management in pregnancies with severe pre-eclampsia. Semin Perinatol 2009;33:143-51.
Gaugler-Senden IP, Huijssoon AG, Visser W, Steegers EA, de Groot CJ. Maternal and perinatal outcome of preeclampsia with an onset before 24 weeks' gestation. Audit in a tertiary referral center. Eur J Obstet Gynecol Reprod Biol 2006;128:216-21.
Many A, Kuperminc MJ, Pausner D, Lessing JB. Treatment of severe preeclampsia remote from term: A clinical dilemma. Obstet Gynecol Surv 1999;54:723-7.
Sarsam DS, Shamden M, Al Wazan R. Expectant versus aggressive management in severe preeclampsia remote from term. Singapore Med J 2008;49:698-703.
Sezik M, Ozkaya O, Sezik HT, Yapar EG. Expectant management of severe preeclampsia presenting before 25 weeks of gestation. Med Sci Monit 2007;13:CR523-7.
American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American college of obstetricians and gynecologists' task force on hypertension in pregnancy. Obstet Gynecol 2013;122:1122-31.
Witlin AG, Saade GR, Mattar F, Sibai BM. Predictors of neonatal outcome in women with severe preeclampsia or eclampsia between 24 and 33 weeks' gestation. Am J Obstet Gynecol 2000;182:607-11.
Abdel-Hady EL, Fawzy M, El-Negeri M, Nezar M, Ragab A, Helal AS. Is expectant management of early-onset severe preeclampsia worthwhile in low-resource settings? Arch Gynecol Obstet 2010;282:23-7.
Vigil-De Gracia P, Reyes Tejada O, Calle Miñaca A, Tellez G, Chon VY, Herrarte E, et al.
Expectant management of severe preeclampsia remote from term: The MEXPRE Latin study, a randomized, multicenter clinical trial. Am J Obstet Gynecol 2013;209:425.e1-8.
Jelin AC, Cheng YW, Shaffer BL, Kaimal AJ, Little SE, Caughey AB. Early-onset preeclampsia and neonatal outcomes. J Matern Fetal Neonatal Med 2010;23:389-92.
Bombrys AE, Barton JR, Habli M, Sibai BM. 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. Am J Perinatol 2009;26:441-6.
Vijayan N, Keepanasseril A, Plakkal N, Udupa V, Raghavan SS. Maternal and perinatal outcomes in women undergoing expectant management of early-onset pre-eclampsia: A retrospective cohort study. S Afr J Obstet Gynaecol 2018;24:23-8.
Vigil-De Gracia P, Montufar-Rueda C, Ruiz J. Expectant management of severe preeclampsia and preeclampsia superimposed on chronic hypertension between 24 and 34 weeks' gestation. Eur J Obstet Gynecol Reprod Biol 2003;107:24-7.
Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: Patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007;196:514.e1-9.
[Table 1], [Table 2], [Table 3]