Planned delivery or expectant management in preeclampsia: an individual participant data meta-analysis - 20/07/22

Doi : 10.1016/j.ajog.2022.04.034

Alice Beardmore-Gray, MBBS ^a,^⁎ , Paul T. Seed, MSc, CStat ^a, Jessica Fleminger, MEng ^a, Eva Zwertbroek, MD, PhD ^b, Thomas Bernardes, MD, PhD ^c, Ben W. Mol, PhD ^d,^e, Cheryl Battersby, PhD, FRCPCH ^f, Corine Koopmans, MD, PhD ^g, Kim Broekhuijsen, MD, PhD ^h, Kim Boers, MD, PhD ⁱ, Michelle Y. Owens, MD ^j, Jim Thornton, MD ^k, Marcus Green ^l, Andrew H. Shennan, MD ^a, Henk Groen, PhD ^c, Lucy C. Chappell, PhD ^a
^a Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, United Kingdom
^b Departments of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
^c Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
^d Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
^e Aberdeen Centre for Women's Health Research, School of Medicine, University of Aberdeen, Aberdeen, United Kingdom
^f Department of Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
^g Department of Obstetrics and Gynaecology, Medisch Spectrum Twente, Enschede, The Netherlands
^h Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
ⁱ Department of Gynaecology, Haaglanden Medical Centre, The Hague, The Netherlands
^j Department of Obstetrics and Gynecology, University of Mississippi Medical Centre, Jackson, MS
^k Department of Obstetrics and Gynaecology, University of Nottingham, Nottingham, United Kingdom
^l Action on Preeclampsia, Evesham, Worcestershire, United Kingdom

^∗Corresponding author: Alice Beardmore-Gray, MBBS.

Abstract

Objective

Pregnancy hypertension is a leading cause of maternal and perinatal mortality and morbidity. Between 34⁺⁰ and 36⁺⁶ weeks gestation, it is uncertain whether planned delivery could reduce maternal complications without serious neonatal consequences. In this individual participant data meta-analysis, we aimed to compare planned delivery to expectant management, focusing specifically on women with preeclampsia.

Data Sources

We performed an electronic database search using a prespecified search strategy, including trials published between January 1, 2000 and December 18, 2021. We sought individual participant-level data from all eligible trials.

Study Eligibility Criteria

We included women with singleton or multifetal pregnancies with preeclampsia from 34 weeks gestation onward.

Methods

The primary maternal outcome was a composite of maternal mortality or morbidity. The primary perinatal outcome was a composite of perinatal mortality or morbidity. We analyzed all the available data for each prespecified outcome on an intention-to-treat basis. For primary individual patient data analyses, we used a 1-stage fixed effects model.

Results

We included 1790 participants from 6 trials in our analysis. Planned delivery from 34 weeks gestation onward significantly reduced the risk of maternal morbidity (2.6% vs 4.4%; adjusted risk ratio, 0.59; 95% confidence interval, 0.36–0.98) compared with expectant management. The primary composite perinatal outcome was increased by planned delivery (20.9% vs 17.1%; adjusted risk ratio, 1.22; 95% confidence interval, 1.01–1.47), driven by short-term neonatal respiratory morbidity. However, infants in the expectant management group were more likely to be born small for gestational age (7.8% vs 10.6%; risk ratio, 0.74; 95% confidence interval, 0.55–0.99).

Conclusion

Planned early delivery in women with late preterm preeclampsia provides clear maternal benefits and may reduce the risk of the infant being born small for gestational age, with a possible increase in short-term neonatal respiratory morbidity. The potential benefits and risks of prolonging a pregnancy complicated by preeclampsia should be discussed with women as part of a shared decision-making process.

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Key words : expectant management, fetal growth restriction, infant outcomes, neonatal outcomes, obstetrics, planned delivery, preeclampsia, pregnancy hypertension, preterm birth, respiratory distress syndrome

Plan

	H.G. and L.C.C. are joint senior authors.
	B.W.M. is supported by a National Health and Medical Research Council Investigator grant (GNT1176437). B.W.M. reports consultancy for ObsEva. B.M.W. has received research funding from Ferring and Merck. The other authors declare no conflict of interest.
	The authors received no funding for this study. P.T.S. is partly funded by Tommy’s (registered charity number 1060508) and by Applied Research Collaboration South London (National Institute of Health and Care Research).
	International Prospective Register of Systematic Reviews registration date: October 20, 2020; registration number: CRD42020206425.

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Vol 227 - N° 2

P. 218 - août 2022 Retour au numéro

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Planned delivery or expectant management in preeclampsia: an individual participant data meta-analysis - 20/07/22

Abstract

Objective

Data Sources

Study Eligibility Criteria

Methods

Results

Conclusion

Plan

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