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Timing of delivery and induction in pre-eclampsia Matthews Mathai

Timing of delivery and induction in pre-eclampsia Matthews Mathai. Principles of Management. Pre-eclampsia affects both the mother and the fetus Multisystem disorder Elevated blood pressure and proteinuria are among the many other findings

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Timing of delivery and induction in pre-eclampsia Matthews Mathai

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  1. Timing of delivery and induction in pre-eclampsiaMatthews Mathai

  2. Principles of Management • Pre-eclampsia affects both the mother and the fetus • Multisystem disorder • Elevated blood pressure and proteinuria are among the many other findings • Only definitive treatment for pre-eclampsia is the delivery of the baby and the placenta

  3. Timing of delivery • Fetal considerations • Prematurity • Stillbirth • Hypoxia • Placental abruption • Newborn asphyxia • Maternal considerations • Worsening of disease • Complications

  4. Timing of delivery • Mild or severe disease? • Early delivery with severe disease • Preterm or term? • Delivery more likely if term

  5. Timing based on severity of disease • "Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery must occur within 12 hours of onset of convulsions in eclampsia. ALL cases of severe pre-eclampsia should be managed actively" • Managing Complications in Pregnancy and Childbirth, 2000

  6. Expectant care for severe pre-eclampsia before term? • Cochrane review: Churchill & Duley (2002) • Two trials – South Africa & USA; 133 women • Women had 24-48 h period of stabilization • Steroids, magnesium sulphate and antihypertensives, if necessary • Randomized if eligibility criteria met • Interventionist group – induction/CS • Expectant: delivery at 34 wk or earlier if deterioration

  7. Expectant care for severe pre-eclampsia before term? • Insufficient data for reliable conclusions on maternal adverse outcomes, stillbirths and newborn deaths • Eclampsia, renal failure, pulmonary oedema, HELLP syndrome, CS, placental abruption • Interventionist group had • More HMD RR 2.3 (95% CI 1.39-3.81) • More NEC RR 5.54 (95% CI 1.04-29.56) • More likely to need NICU admission RR 1.32 (95% CI 1.3-1.55) • Less likely to be SGA RR 0.36 (0.14-0.90)

  8. Expectant care for severe pre-eclampsia before term? • Authors' conclusion • "There are insufficient data for any reliable recommendation about which policy of care should be used for women with severe early onset pre-eclampsia. Further large trials are needed." • Global context for consideration • Availability of NICU facilities • Accessibility • Costs of care • Long term survival

  9. Timing based on severity of disease • "In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms" • Managing Complications in Pregnancy and Childbirth, 2000

  10. Delivery in mild pre-eclampsia • Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial • Koopmans et al, Lancet 2009; 374: 979-88 • 756 women with singleton pregnancies at 36-41 weeks • Primary outcome: Composite measure of poor maternal outcome • Death, eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, abruption, progression to severe hypertension or proteinuria, PPH > 1L

  11. Delivery in mild pre-eclampsia • Induction group (n=377) • Induced within 24 h of randomization • ARM + oxytocin if Bishop score > 6 • Cervical ripening with PG or balloon catheter if score < 6 • Expectant group (n=379) • Monitoring with frequent monitoring of BP, proteinuria, fetal health status. • Induce if worsening of disease, PROM > 48 h, fetal distress or gestation > 41 wk • Koopmans et al, Lancet 2009; 374: 979-88

  12. Delivery in mild pre-eclampsia • 117 (31%) of women allocated to induction of labour developed poor maternal outcome compared to 166 (44%) allocated to expectant monitoring (RR 0.71; 95% CI 0.59-0.86) • No cases of maternal or neonatal death or eclampsia reported • "Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks' gestation." • Koopmans et al, Lancet 2009; 374: 979-88

  13. Induction techniques - Summaries • Recommended: • Oral misoprostol 25 mcg every 2 h • Low dose vaginal misoprostol 25 mcg every 6 h • Low does vaginal prostaglandins • Balloon catheter • Combination of balloon catheter plus oxytocin as an alternative method when PGs (including misoprostol) are not available or contraindicated • Oral or vaginal misoprostol for IUD in third trimester • Sweeping membranes for reducing formal induction of labour • WHO recommendations for induction of labour 2011

  14. Induction techniques - Summaries • Not recommended • Amniotomy alone • Misoprostol in women with previous caesarean section • WHO recommendations for induction of labour 2011

  15. Current recommendations • Deliver within 24 h for severe pre-eclampsia • Expectant management with monitoring for mild pre-eclampsia until 36 wk; induce labour after 37 wk • Induction methods include amniotomy, oxytocin, prostaglandins including misoprostol and balloon catheter • Managing Complications in Pregnancy and Childbirth, 2000

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