Timing of delivery and induction in
pre-eclampsia
Matthews Mathai
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
Timing of delivery
 Fetal considerations
– Prematurity
– Stillbirth
• Hypoxia
• Placental abruption
– Newborn asphyxia
 Maternal considerations
– Worsening of disease
• Complications
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
Timing of delivery
 Mild or severe disease?
– Early delivery with
severe disease
 Preterm or term?
– Delivery more likely if
term
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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)
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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 0.590.86)
 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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
Induction techniques - Summaries
 Not recommended
– Amniotomy alone
– Misoprostol in women with previous caesarean section
• WHO recommendations for induction of labour 2011
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011
Current recommendations
 Deliver within 24 h for severe preeclampsia
 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
Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn
Care,
| Addis Ababa, Feb 21, 2011