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

Association of Maternal Medical Comorbidities with Duration of Expectant Management in Patients with Severe Preeclampsia

OBJECTIVE

This study aimed to estimate the association between number of maternal comorbidities and duration of expectant management and perinatal outcomes in patients with preeclampsia with severe features.

STUDY DESIGN

Retrospective cohort of patients with preeclampsia with severe features delivering live, nonanomalous singletons at 23 to 342/7 weeks' gestation at a single center from 2016 to 2018. Patients delivered for an indication other than severe preeclampsia were excluded. Patients were categorized based on the number (0, 1, or ≥2) of comorbidities present: chronic hypertension, pregestational diabetes, chronic kidney disease, and systemic lupus erythematosus. The primary outcome was proportion of potential expectant management time achieved, that is, days of expectant management achieved divided by total potential expectant management time (days from severe preeclampsia diagnosis to 340/7 weeks). Secondary outcomes included delivery gestational age, days of expectant management, and perinatal outcomes. Outcomes were compared in bivariable and multivariable analyses.

RESULTS

Of 337 patients included, 167 (50%) had 0, 151 (45%) had 1, and 19 (5%) had ≥2 comorbidities. Groups differed with respect to age, body mass index, race/ethnicity, insurance, and parity. The median proportion of potential expectant management achieved in this cohort was 1.8% (interquartile range: 0-15.4), and did not differ by number of comorbidities (adjusted β: 5.3 [95% confidence interval [CI]: -2.1 to 12.9] for 1 comorbidity vs. 0 and adjusted β: -2.9 [95% CI: -18.0 to 12.2] for ≥2 comorbidities vs. 0). There was no difference in delivery gestational age or duration of expectant management in days. Patients with ≥2 (vs. 0) comorbidities had higher odds of composite maternal morbidity (adjusted odds ratio: 3.0 [95% CI: 1.1-8.2]). There was no association between number of comorbidities and composite neonatal morbidity.

CONCLUSION

Among patients with preeclampsia with severe features, the number of comorbidities was not associated with duration of expectant management; however, patients with ≥2 comorbidities had higher odds of adverse maternal outcomes.

KEY POINTS

· Greater number of medical comorbidities were not associated with expectant management duration.. · Two or more medical comorbidities were associated with higher odds of adverse maternal outcomes.. · Expectant management should be undertaken cautiously in medically complicated patients..

Amount of Proteinuria and Duration of Expectant Management in Severe Preeclampsia

OBJECTIVE

The aim of the study is to evaluate the association between the amount of proteinuria at the time of diagnosis of preeclampsia with severe features (severe preeclampsia [SPE]) and duration of expectant management (EM) and other perinatal outcomes.

STUDY DESIGN

This is a retrospective cohort study of patients with SPE delivering live, non-anomalous singletons at 230/7 to 342/7 weeks' estimated gestational age (EGA) at a single tertiary center 2016 to 2018. Patients with proteinuria assessment (24-hour total urine protein or urine protein-to-creatinine ratio extrapolation) within 3 days of SPE diagnosis were included. Patients delivered for an indication other than SPE were excluded. Patients were categorized by amount of proteinuria (mg): none (≤300), mild (301-1,000), moderate (1,001-3,000), and massive (≥3,001). The primary outcome was the proportion of potential EM time achieved (%EM), i.e., days of EM divided by days from SPE diagnosis to 34 weeks. Secondary outcomes included delivery EGA, days of EM, and perinatal outcomes. Bivariable and multivariable analyses compared outcomes across groups.

RESULTS

Of 295 patients included, 21% had no proteinuria, 33% mild, 19% moderate, and 27% massive. Groups differed by EGA at diagnosis, age, parity, chronic hypertension, and renal disease. %EM was not significantly different between groups (adjusted β coefficient 4.1 [95% CI -5.3, 13.5] for mild proteinuria vs. none, -4.1 [95% CI -14.9, 6.6] for moderate proteinuria vs. none, and -5.6 [95% CI -16.0, 4.7] for massive proteinuria vs. none). Increasing proteinuria was associated with earlier delivery EGA but only days of EM in the mild versus no proteinuria groups. There was no significant association between proteinuria and maternal composite morbidity, but patients with mild and massive proteinuria had higher odds of neonatal composite morbidities compared with no proteinuria.

CONCLUSION

Among patients with SPE, proteinuria level was not consistently associated with duration of EM. However, patients with the greatest amounts of proteinuria may have worse neonatal and selected maternal outcomes.

KEY POINTS

· Amount of proteinuria was not associated with the duration of expectant management.. · Greater proteinuria was associated with earlier delivery in severe preeclampsia.. · Massive proteinuria in preeclampsia was associated with select adverse maternal and neonatal outcomes..

Pregnancy Outcomes of Conservative Management in Preeclampsia with Severe Features

Objective: To study the pregnancy outcomes of conservative treatment for preeclampsia with severe features. Methods: A retrospective study was conducted on pregnancies with preeclampsia with severe features at gestational age 23-34 weeks and that received conservative management at Chiang Mai University Hospital between January 2014 and August 2020. The women were divided into two groups: (1) pregnancy prolongation of at least 48 h and (2) pregnancy prolongation of less than 48 h. Results: Of the 100 recruited pregnancies, the median gestational age was 29 weeks (range 23-34). Of these, 65 cases (65%) had pregnancy prolongation of at least 48 h, and 35 cases (35%) had prolongation of less than 48 h. The median pregnancy prolongation was 2.9 days (range 4 h-27.7 days). Eighty-seven (88%) pregnant women experienced no complications. Multivariate analysis shows that high urine protein/creatinine ratio (UPCI) at admission was significantly associated with pregnancy prolongation of less than 48 h with an odds ratio for prolongation for at least 48 h of 0.86 (95% CI 0.75-0.99: p-value 0.04). Kaplan-Meier analysis shows that the mean time of prolongation was 3.6 days vs. 6.7 days, and median time of prolongation was 2.1 days vs. 4.4 days in the group of high and low UPCI (using cut-off 1.0), respectively. The number of prolonged days was significantly lower in the high UPCI group than in the low UPCI group (log-rank test, p = 0.01). The maternal and fetal outcomes between the two groups were not significantly different. The cesarean section rate was also comparable. The mean birth weight and gestational age at delivery were not significantly different, though they had a higher trend in the group of successful conservative management. Conclusion: The rate of pregnancy prolongation of at least 48 h with conservative management was 65%, with a median prolongation time of 2.9 days. A new insight gained from this study is that high UPCI at admission is an independent factor for prolongation of less than 48 h with conservative treatment. Nevertheless, the maternal and fetal outcomes between the two groups were not significantly different. Therefore, the benefit and risk of expectant management in actual practice of service settings in terms of maternal and fetal morbidity is still unclear.