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Sisti G, Rubin G, Schiattarella A. Immediate delivery versus expectant management in women with chronic hypertension: a meta-analysis of randomized controlled trials. Minerva Obstet Gynecol 2024; 76:174-180. [PMID: 37140588 DOI: 10.23736/s2724-606x.23.05194-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
INTRODUCTION The current guidelines regarding chronic hypertension during pregnancy recommend induction of labor at term. The only previous meta-analysis on this topic found two randomized controlled trials but failed to pool together their results. We aimed to find the best literature-based evidence regarding delivery timing in chronic hypertension during pregnancy. EVIDENCE ACQUISITION We searched the following electronic databases: MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, and the Cochrane Central Register of Controlled Trials, Google Scholar. We selected randomized controlled trials comparing expectant management versus immediate delivery. The search was performed by two authors and the conflicts resolved in meetings. Data collection and analysis: we collected maternal and neonatal outcomes in a metanalysis following the random-effects model. EVIDENCE SYNTHESIS Two studies were found. The summary effect measure was 1.1 (C.I. 0.51-2.1) regarding the maternal outcomes, 2.6 (C.I. 0.91-7.44) regarding the neonatal outcomes, and 1.5 (C.I. 0.8-2.79) combined. There was no statistically significant difference between maternal and neonatal outcomes (P=0.2). CONCLUSIONS The results of our meta-analysis pointed towards a non-difference between immediate delivery and expectant management, in women with chronic hypertension.
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Affiliation(s)
- Giovanni Sisti
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine - Tucson, The University of Arizona, Tucson, AZ, USA -
| | - Gal Rubin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine - Tucson, The University of Arizona, Tucson, AZ, USA
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
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Kirkham K, Tohill S, Hutcheon JA, Dorling J, Gkini E, Moakes CA, Stubbs C, Thornton J, von Dadelszen P, Magee LA. WILL (When to induce labour to limit risk in pregnancy hypertension): Protocol for a multicentre randomised trial. Pregnancy Hypertens 2023; 32:35-42. [PMID: 37019046 DOI: 10.1016/j.preghy.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/23/2023] [Accepted: 03/17/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVES To address optimal timing of birth for women with chronic or gestational hypertension who reach term and remain well. STUDY DESIGN Pragmatic, non-masked randomised trial. INCLUSION maternal age ≥16 years, chronic or gestational hypertension, singleton pregnancy, live fetus, 36+0-37+6 weeks' gestation, and able to give documented informed consent. EXCLUSION contraindication to either trial arm (e.g., pre-eclampsia or another indication for birth at term), blood pressure (BP) ≥ 160/110 mmHg until controlled, major fetal anomaly anticipated to require neonatal care unit admission, or participation in another timing of birth trial. Randomisation (1:1 ratio, minimised for key prognostic variables: site, hypertension type, and prior Caesarean) to 'planned early term birth at 38+0-3 weeks' or 'usual care at term' (revised from 'expectant care until at least 40+0 weeks', Aug 2022). OUTCOMES Maternal co-primary: composite of 'poor maternal outcome' (severe hypertension, maternal death, or maternal morbidity). Neonatal co-primary: neonatal care unit admission for ≥4 h. Each co-primary is measured until primary hospital discharge or 28 days post-birth (whichever is earlier). Key secondary: Caesarean birth. ANALYSIS Sample of 1080 participants (540/arm) will detect an 8% reduction in the maternal co-primary (90% power, superiority hypothesis), and give 94% power for a between-group non-inferiority margin of difference of 9% in the neonatal co-primary. Analysis will be by intention-to-treat. Ethics approval has been obtained (NHS Health Research Authority London Fulham Research Ethics Committee, 18/LO/2033). CONCLUSIONS The study will provide data for women to make informed choices about their care and allow health systems to plan services.
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Affiliation(s)
- Katie Kirkham
- Birmingham Clinical Trials Unit, University of Birmingham, UK
| | - Sue Tohill
- Maternity Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Canada
| | - Jon Dorling
- Department of Paediatrics, University of Southampton, UK
| | - Eleni Gkini
- Birmingham Clinical Trials Unit, University of Birmingham, UK
| | | | - Clive Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, UK
| | - Jim Thornton
- Department of Obstetrics and Gynaecology, University of Nottingham, UK
| | - Peter von Dadelszen
- Institute of Women and Children's Health, King's College London, UK; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Laura A Magee
- Institute of Women and Children's Health, King's College London, UK; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Sisti G, Fochesato C, Elkafrawi D, Marcus B, Schiattarella A. Is blood pressure 120-139/80-89 mmHg before 20 weeks a risk factor for hypertensive disorders of pregnancy? A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 284:66-75. [PMID: 36934679 DOI: 10.1016/j.ejogrb.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023]
Abstract
AIM Hypertensive disorders of pregnancy affect approximately 10% of pregnant women worldwide with serious fetal and maternal implications. Chronic hypertension is diagnosed prior to 20 weeks of gestation and affects 1.5% of pregnant women. The American College of Obstetricians and Gynecologists defines hypertension in pregnancy as a systolic blood pressure higher than 140 mmHg or a diastolic blood pressure higher than 90 mmHg. In real-world clinical practice, practitioners consider the cut-off of 140/90 mmHg as a marker of true hypertension in pregnancy and consider blood pressures lower than that as normal. METHODS To assess the association between a lower range of blood pressures and the development of hypertensive disorders of pregnancy, we performed a meta-analysis of current published studies comparing the occurrence of hypertensive disorders of pregnancy in patients with blood pressures of 120-139/80-89 mmHg before 20 weeks to those with blood pressures<120/80 mmHg. RESULTS We included 24 studies: 12362/106870 (11.6 %) patients with blood pressures of 120-139/80-89 mmHg, and 26044/463280 (5.6 %) with blood pressures lower than 120/80 mmHg, developed hypertensive disorders of pregnancy [risk ratio 2.85 (C.I. 2.47-3.3)] - test for overall effect: Z = 14.1 (p < 0.00001). CONCLUSIONS We showed evidence of poor pregnancy outcome in patients with blood pressure lower than the routinely accepted cut-off of 140/90 mmHg. Therefore, interventions to mitigate the risk of hypertensive disorders in pregnancy in women with blood pressures 120-139/80-89 mmHg should be planned in new clinical trials.
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Affiliation(s)
- Giovanni Sisti
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine -Tucson, The University of Arizona, 1501 N. Campbell Ave, Tucson, AZ, United States
| | - Cecilia Fochesato
- Department of Obstetrics and Gynecology, Multimedica Ospedale San Giuseppe, Milan, Italy
| | - Deena Elkafrawi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, SUNY Upstate Medical University, 750 Adams St, Syracuse, NY 13210, United States
| | - Brooke Marcus
- College of Medicine -Tucson, The University of Arizona, 1501 N. Campbell Ave, Tucson, AZ, United States
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy.
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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Magee LA, Khalil A, Kametas N, von Dadelszen P. Toward personalized management of chronic hypertension in pregnancy. Am J Obstet Gynecol 2022; 226:S1196-S1210. [PMID: 32687817 PMCID: PMC7367795 DOI: 10.1016/j.ajog.2020.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/27/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022]
Abstract
Chronic hypertension complicates 1% to 2% of pregnancies, and it is increasingly common. Women with chronic hypertension are an easily recognized group who are in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. We reviewed recent data on management to inform current care and future research. This study is a narrative review of published literature. Compared with normotensive women, women with chronic hypertension are at an increased risk of maternal and perinatal complications. Women with chronic hypertension who wish to be involved in their care can do by measuring blood pressure at home. Accurate devices for home blood pressure monitoring are now readily available. The diagnostic criteria for superimposed preeclampsia remain problematic because most guidelines continue to include deteriorating blood pressure control in the definition. It has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely available clinical data and laboratory results. Although chronic hypertension is a strong risk factor for preeclampsia, and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. It is unclear whether calcium has an independent effect in preeclampsia prevention in such women. Treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been observed; however, the lack of evidence for the latter is possibly owing to few events. In addition, treating chronic hypertension neither reduces nor increases fetal or newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. Antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. At present, blood pressure treatment targets used in clinics are the same as those used at home, although blood pressure values tend to be inconsistently lower at home among women with hypertension. Although starting all women on the same antihypertensive medication is usually effective in reducing blood pressure, it remains unclear whether there is an optimal agent for such an approach or how best to use combinations of antihypertensive medications. An alternative approach is to individualize care, using maternal characteristics and blood pressure features beyond blood pressure level (eg, variability) that are of prognostic value. Outcomes may be improved by timed birth between 38 0/7 and 39 6/7 weeks' gestation based on observational literature; of note, confirmatory trial evidence is pending. Postnatal care is facilitated by the acceptability of most antihypertensives (including angiotensin-converting enzymes inhibitors) for use in breastfeeding. The evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning with international guidelines. Addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy.
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Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, King's College London, London, United Kingdom.
| | - Asma Khalil
- Department of Obstetrics and Gynecology, St. George's, University of London, London, United Kingdom
| | - Nikos Kametas
- Harris Birthright Centre, King's College Hospital, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, United Kingdom
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Sisti G, Schiattarella A, Morlando M, Corwin A. Timing of delivery and blood pressure cut-off in chronic hypertension during pregnancy: State of art and new proposals. Int J Gynaecol Obstet 2021; 157:230-239. [PMID: 34161611 DOI: 10.1002/ijgo.13794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Pregnant women with chronic hypertension are recommended to deliver at 36-396/7 weeks. The American College of Cardiology and American Heart Association in 2017 lowered the blood pressure cut-off for stage I hypertension to 130/80 mm Hg. METHODS We performed a literature review on studies comparing elective induction of labor versus expectant management in pregnant women with chronic hypertension. In addition, we reviewed fetal and maternal outcomes in pregnant women with blood pressure of 120-139/80-89 or 130-139/80-89 mm Hg. RESULTS We found two randomized clinical trials and one retrospective observational study comparing elective delivery of pregnant women with chronic hypertension versus expectant management. The randomized trials favored expectant management and the observational study favored induction of labor. We found 15 retrospective cohort studies analyzing maternal and fetal outcomes in pregnant women with blood pressure cut-off lower than 140/90 mm Hg. There was a consistent finding of increased risk of any hypertensive disorder of pregnancy, gestational diabetes mellitus, and small-for-gestational-age neonate. CONCLUSION Randomized clinical trials are needed to assess the appropriate timing of delivery for women with stage I hypertension with a blood pressure cut-off of 130/80 mm Hg.
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Affiliation(s)
- Giovanni Sisti
- Department of Obstetrics and Gynecology, New York Health and Hospitals/Lincoln, Bronx, NY, USA
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania, Naples, Italy
| | - Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, University of Campania, Naples, Italy
| | - Andrew Corwin
- Department of Obstetrics and Gynecology, New York Health and Hospitals/Lincoln, Bronx, NY, USA
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Li J, Shao X, Song S, Liang Q, Liu Y, Qi X. Immediate versus delayed induction of labour in hypertensive disorders of pregnancy: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2020; 20:735. [PMID: 33243171 PMCID: PMC7690081 DOI: 10.1186/s12884-020-03407-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 11/10/2020] [Indexed: 11/26/2022] Open
Abstract
Background Mothers with hypertensive disorder of pregnancy can be managed with either immediate or delayed induction of labour with expectant monitoring of both mother and baby. There are risks and benefits associated with both the type of interventions. Hence, this review was conducted to compare outcomes of immediate and delayed induction of labour among women with hypertensive disorder of pregnancy based on disease severity and gestational age. Methods We conducted systematic searches in various databases including Medline, Cochrane Controlled Register of Trials (CENTRAL), Scopus, and Embase from inception until October 2019.Cochrane risk of bias tool was used to assess the quality of published trials. A meta-analysis was performed with random-effects model and reported pooled Risk ratios (RR) with 95% confidence intervals (CIs). Results Fourteen randomized controlled trials with 4244 participants were included. Majority of the studies had low or unclear bias risks. Amongst late onset mild pre-eclampsia patients, the risk of renal failure was significantly lower with immediate induction of labour (pooled RR: 0.36; 95%CI: 0.14 to 0.92). In severe pre-eclampsia patients, immediate induction of labour significantly reduced the risk of having small-for-gestational age babies compared to delayed induction of labour (pooled RR: 0.49; 95%CI: 0.29–0.84).Delayed induction was found to significantly reduce the risk of neonatal respiratory distress syndrome risk among late onset mild pre-eclampsia patients (pooled RR: 2.15; 95%CI: 1.14 to 4.06) None of the other outcomes demonstrated statistically significant difference between the two interventions. Conclusion Delayed induction of labour with expectant monitoring may not be inferior to immediate induction of labour in terms of neonatal and maternal outcomes. Expectant approach of management for late onset mild pre-eclampsia patients may be associated with decreased risk of neonatal respiratory distress syndrome, while immediate induction of labour among severe pre-eclampsia patients is associated with reduced risk of small-for-gestational age babies and among mild pre-eclampsia patients, it is associated with reduced risk of severe renal impairment. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-020-03407-8.
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Affiliation(s)
- Jia Li
- Department of Obstetrics, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Xuecheng Shao
- Department of Obstetrics, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Shurong Song
- Department of Obstetrics, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China.
| | - Qian Liang
- Department of Obstetrics, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Yang Liu
- Department of Obstetrics, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Xiaojin Qi
- Department of Obstetrics, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China
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Idris H, Duum NCN, Adamu UG, Abdullateef RM, Yabagi IA. Hypertensive Disorders in Pregnancy: Pattern and Obstetric Outcome in Bida, Nigeria. Niger Med J 2020; 61:42-47. [PMID: 32317821 PMCID: PMC7113814 DOI: 10.4103/nmj.nmj_29_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/20/2019] [Accepted: 09/11/2019] [Indexed: 11/11/2022] Open
Abstract
Context: Cases of hypertensive disorders in pregnancy (HDP) are an increase in developing economies. Identifying the pattern of HDP in a particular community and documenting their management outcome may allow for proper planning by all stakeholders. Aims: The objective was to determine the pattern and management outcome of hypertensive disorders among pregnant women. Settings and Design: This was a prospective cohort study involving 183 consecutive cases of HDP at Federal Medical Centre, Bida, Niger State, Nigeria, between September 2015 and August 2016. Subjects and Methods: Pregnant women with hypertension were recruited and managed according to the departmental protocol. They were followed up till 6 weeks after delivery; fetal and maternal outcomes were documented. Statistical Analysis Used: Data were analyzed using the SPSS software version 23. The level of statistical significance was set at P < 0.05. Results: A total of 1956 deliveries occurred during the study with 183 cases of HDP, giving an incidence of 9.4%. Pregnancy-induced hypertension alongside preeclampsia constitutes the majority of HDP during the study and had accounted for over 64%. Women who did not receive antenatal care in our center were at significantly greater risk of eclampsia (P = 0.000), abruption placentae (P = 0.003), maternal death (P = 0.002), very low-birth-weight (LBW) babies (P = 0.002), extremely LBW babies (P = 0.03), and perinatal death (P = 0.000). Conclusion: The need for prenatal screening that enables the early identification and prompt management of all expectant mothers with HDP is advised.
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Affiliation(s)
- Haruna Idris
- Department of Obstetrics and Gynaecology, Federal Medical Centre, Bida, Niger State, Nigeria
| | | | - Umar Gati Adamu
- Department of Internal Medicine, Federal Medical Centre, Bida, Niger State, Nigeria
| | | | - Isah Aliyu Yabagi
- Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja, Nigeria
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Coates D, Makris A, Catling C, Henry A, Scarf V, Watts N, Fox D, Thirukumar P, Wong V, Russell H, Homer C. A systematic scoping review of clinical indications for induction of labour. PLoS One 2020; 15:e0228196. [PMID: 31995603 PMCID: PMC6988952 DOI: 10.1371/journal.pone.0228196] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist. METHODS A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool. RESULTS 68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence. CONCLUSIONS While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.
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Affiliation(s)
- Dominiek Coates
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Angela Makris
- Department of Medicine, Western Sydney University, Sydney, Australia
- Women’s Health Initiative Translational Unit (WHITU), Liverpool Hospital, Liverpool, Australia
| | - Christine Catling
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Amanda Henry
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
- Department of Women’s and Children’s Health, St George Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW Medicine, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Deborah Fox
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Purshaiyna Thirukumar
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Vincent Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Research Science, University of New South Wales, Liverpool, Australia
| | - Hamish Russell
- South Western Sydney Local Health District, Sydney, Australia
| | - Caroline Homer
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
- Maternal and Child Health Program, Burnet Institute, Victoria, Australia
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Abstract
OBJECTIVE To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery. METHODS We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801). RESULTS Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57-0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69-1.17]). CONCLUSION Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.
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Bernardes TP, Zwertbroek EF, Broekhuijsen K, Koopmans C, Boers K, Owens M, Thornton J, van Pampus MG, Scherjon SA, Wallace K, Langenveld J, van den Berg PP, Franssen MTM, Mol BWJ, Groen H. Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:443-453. [PMID: 30697855 PMCID: PMC6594064 DOI: 10.1002/uog.20224] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/31/2018] [Accepted: 01/04/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy. METHODS CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention. RESULTS Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2 = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2 = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2 = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2 = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable). CONCLUSION In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T. P. Bernardes
- Epidemiology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - E. F. Zwertbroek
- Obstetrics and Gynaecology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - K. Broekhuijsen
- ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - C. Koopmans
- Obstetrics and Gynaecology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - K. Boers
- Obstetrics and GynaecologyBronovo HospitalThe HagueThe Netherlands
| | - M. Owens
- Obstetrics and GynecologyUniversity of Mississippi Medical CenterJacksonMIUSA
| | - J. Thornton
- Obstetrics and GynaecologyUniversity of NottinghamNottinghamUK
| | - M. G. van Pampus
- Obstetrics and GynaecologyOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - S. A. Scherjon
- Obstetrics and Gynaecology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - K. Wallace
- Obstetrics and GynecologyUniversity of Mississippi Medical CenterJacksonMIUSA
| | - J. Langenveld
- Obstetrics and GynaecologyZuyderland Medical CentreHeerlenThe Netherlands
| | - P. P. van den Berg
- Obstetrics and Gynaecology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - M. T. M. Franssen
- Obstetrics and Gynaecology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - B. W. J. Mol
- Obstetrics and GynaecologyMonash UniversityClaytonVictoriaAustralia
| | - H. Groen
- Epidemiology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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Abstract
OBJECTIVE To identify the gestational age of planned delivery in pregnancies complicated by chronic hypertension that minimizes the risk of perinatal death and severe adverse events. METHODS This was a retrospective cohort study of all singletons complicated by hypertension. Detailed patient-level information was collected by chart review, including indication for delivery. Planned delivery at 36-36 6/7, 37-37 6/7, 38-38 6/7, and 39-39 6/7 weeks of gestation was compared with expectant management beyond each respective gestational age. Patients were excluded for fetal anomalies, inaccurate dating, and major medical problems other than hypertension, diabetes, or renal disease. The primary outcome was a composite of stillbirth, neonatal death, assisted ventilation, cord pH less than 7.0, 5-minute Apgar score of 3 or less, and neonatal seizures. Secondary outcomes were preeclampsia, severe preeclampsia, primary cesarean delivery, and neonatal length of stay greater than 5 days. Groups were compared using Student's t test and χ tests. RESULTS Six hundred eighty-three women with hypertension reached 36 weeks of gestation. Patients with planned delivery at less than 39 weeks of gestation were more likely to have baseline renal disease. Before 37 weeks of gestation, planned delivery was associated with a statistically significant increase in the primary composite adverse neonatal outcome (10.0% compared with 2.6%, P=.04); after 38 weeks of gestation, expectant management was associated with a nonstatistically significant increase in the primary composite outcome (0% compared with 2.3%, P=.40). Expectant management beyond 39 weeks of gestation was associated with a statistically significant increase in severe preeclampsia (0% compared with 10.3%, P=.001). CONCLUSION Expectant management beyond 39 weeks of gestation was associated with increasing incidence of severe preeclampsia; planned delivery before 37 weeks of gestation was associated with an increase in adverse neonatal outcomes. Further well-powered studies are needed to delineate the optimal gestational age of delivery.
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Cluver C, Novikova N, Koopmans CM, West HM. Planned early delivery versus expectant management for hypertensive disorders from 34 weeks gestation to term. Cochrane Database Syst Rev 2017; 1:CD009273. [PMID: 28106904 PMCID: PMC6465052 DOI: 10.1002/14651858.cd009273.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypertensive disorders in pregnancy are significant contributors to maternal and perinatal morbidity and mortality. These disorders include well-controlled chronic hypertension, gestational hypertension (pregnancy-induced hypertension) and mild pre-eclampsia. The definitive treatment for these disorders is planned early delivery and the alternative is to manage the pregnancy expectantly if severe uncontrolled hypertension is not present, with close maternal and fetal monitoring. There are benefits and risks associated with both, so it is important to establish the safest option. OBJECTIVES To assess the benefits and risks of a policy of planned early delivery versus a policy of expectant management in pregnant women with hypertensive disorders, at or near term (from 34 weeks onwards). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth Trials Register (12 January 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials of a policy of planned early delivery (by induction of labour or by caesarean section) compared with a policy of delayed delivery ("expectant management") for women with hypertensive disorders from 34 weeks' gestation. Cluster-randomised trials would have been eligible for inclusion in this review, but we found none.Studies using a quasi-randomised design are not eligible for inclusion in this review. Similarly, studies using a cross-over design are not eligible for inclusion, because they are not a suitable study design for investigating hypertensive disorders in pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and risks of bias. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS We included five studies (involving 1819 women) in this review.There was a lower risk of composite maternal mortality and severe morbidity for women randomised to receive planned early delivery (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83, two studies, 1459 women (evidence graded high)). There were no clear differences between subgroups based on our subgroup analysis by gestational age, gestational week or condition. Planned early delivery was associated with lower risk of HELLP syndrome (RR 0.40, 95% CI 0.17 to 0.93, 1628 women; three studies) and severe renal impairment (RR 0.36, 95% CI 0.14 to 0.92, 100 women, one study).There was not enough information to draw any conclusions about the effects on composite infant mortality and severe morbidity. We observed a high level of heterogeneity between the two studies in this analysis (two studies, 1459 infants, I2 = 87%, Tau2 = 0.98), so we did not pool data in meta-analysis. There were no clear differences between subgroups based on our subgroup analysis by gestational age, gestational week or condition. Planned early delivery was associated with higher levels of respiratory distress syndrome (RR 2.24, 95% CI 1.20 to 4.18, three studies, 1511 infants), and NICU admission (RR 1.65, 95% CI 1.13 to 2.40, four studies, 1585 infants).There was no clear difference between groups for caesarean section (RR 0.91, 95% CI 0.78 to 1.07, 1728 women, four studies, evidence graded moderate), or in the duration of hospital stay for the mother after delivery of the baby (mean difference (MD) -0.16 days, 95% CI -0.46 to 0.15, two studies, 925 women, evidence graded moderate) or for the baby (MD -0.20 days, 95% CI -0.57 to 0.17, one study, 756 infants, evidence graded moderate).Two fairly large, well-designed trials with overall low risk of bias contributed the majority of the evidence. Other studies were at low or unclear risk of bias. No studies attempted to blind participants or clinicians to group allocation, potentially introducing bias as women and staff would have been aware of the intervention and this may have affected aspects of care and decision-making.The level of evidence was graded high (composite maternal mortality and morbidity), moderate (caesarean section, duration of hospital stay after delivery for mother, and duration of hospital stay after delivery for baby) or low (composite infant mortality and morbidity). Where the evidence was downgraded, it was mostly because the confidence intervals were wide, crossing both the line of no effect and appreciable benefit or harm. AUTHORS' CONCLUSIONS For women suffering from hypertensive disorders of pregnancy after 34 weeks, planned early delivery is associated with less composite maternal morbidity and mortality. There is no clear difference in the composite outcome of infant mortality and severe morbidity; however, this is based on limited data (from two trials) assessing all hypertensive disorders as one group.Further studies are needed to look at the different types of hypertensive diseases and the optimal timing of delivery for these conditions. These studies should also include infant and maternal morbidity and mortality outcomes, caesarean section, duration of hospital stay after delivery for mother and duration of hospital stay after delivery for baby.An individual patient meta-analysis on the data currently available would provide further information on the outcomes of the different types of hypertensive disease encountered in pregnancy.
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Affiliation(s)
- Catherine Cluver
- Stellenbosch University and Tygerberg HospitalDepartment of Obstetrics and Gynaecology, Faculty of Health SciencesPO Box 19063TygerbergWestern CapeSouth Africa7505
| | - Natalia Novikova
- Stellenbosch University and Tygerberg HospitalDepartment of Obstetrics and Gynaecology, Faculty of Health SciencesCape TownSouth Africa
| | - Corine M Koopmans
- University Medical Centre GroningenDepartment of Obstetrics and GynecologyHanzeplein 1GroningenNetherlands9700 RB
| | - Helen M West
- The University of LiverpoolInstitute of Psychology, Health and SocietyLiverpoolUK
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