Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis.
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.
['Bernardes|T P|TP|', 'Zwertbroek|E F|EF|https://orcid.org/0000-0002-2416-9973', 'Broekhuijsen|K|K|', 'Koopmans|C|C|', 'Boers|K|K|', 'Owens|M|M|', 'Thornton|J|J|', 'van Pampus|M G|MG|', 'Scherjon|S A|SA|', 'Wallace|K|K|', 'Langenveld|J|J|', 'van den Berg|P P|PP|', 'Franssen|M T M|MTM|', 'Mol|B W J|BWJ|https://orcid.org/0000-0001-8337-550X', 'Groen|H|H|']
D000328:Adult D002585:Cesarean Section D004461:Eclampsia D005260:Female D005865:Gestational Age D017359:HELLP Syndrome D006801:Humans D007231:Infant, Newborn D011225:Pre-Eclampsia D011247:Pregnancy D011256:Pregnancy Outcome D047928:Premature Birth D016032:Randomized Controlled Trials as Topic D012127:Respiratory Distress Syndrome, Newborn D012307:Risk Factors D057832:Watchful Waiting
expectant management immediate delivery pre-eclampsia RDS HELLP syndrome