Immediate versus delayed induction of labour in hypertensive disorders of pregnancy: a systematic review and meta-analysis

Abstract

Background Mothers with hypertensive disorder of pregnancy can be managed with either immediate or delayed induction of labour with expectant monitoring of both mother and baby. There are risks and benefits associated with both the type of interventions. Hence, this review was conducted to compare outcomes of immediate and delayed induction of labour among women with hypertensive disorder of pregnancy based on disease severity and gestational age. Methods We conducted systematic searches in various databases including Medline, Cochrane Controlled Register of Trials (CENTRAL), Scopus, and Embase from inception until October 2019.Cochrane risk of bias tool was used to assess the quality of published trials. A meta-analysis was performed with random-effects model and reported pooled Risk ratios (RR) with 95% confidence intervals (CIs). Results Fourteen randomized controlled trials with 4244 participants were included. Majority of the studies had low or unclear bias risks. Amongst late onset mild pre-eclampsia patients, the risk of renal failure was significantly lower with immediate induction of labour (pooled RR: 0.36; 95%CI: 0.14 to 0.92). In severe pre-eclampsia patients, immediate induction of labour significantly reduced the risk of having small-for-gestational age babies compared to delayed induction of labour (pooled RR: 0.49; 95%CI: 0.29–0.84).Delayed induction was found to significantly reduce the risk of neonatal respiratory distress syndrome risk among late onset mild pre-eclampsia patients (pooled RR: 2.15; 95%CI: 1.14 to 4.06) None of the other outcomes demonstrated statistically significant difference between the two interventions. Conclusion Delayed induction of labour with expectant monitoring may not be inferior to immediate induction of labour in terms of neonatal and maternal outcomes. Expectant approach of management for late onset mild pre-eclampsia patients may be associated with decreased risk of neonatal respiratory distress syndrome, while immediate induction of labour among severe pre-eclampsia patients is associated with reduced risk of small-for-gestational age babies and among mild pre-eclampsia patients, it is associated with reduced risk of severe renal impairment.

Pregnancy Outcomes of Conservative Management in Preeclampsia with Severe Features

“…Based on a systematic review [2,17], the benefit of expectant management is still unclear. Though expectant management resulted in pregnancy prolongation of approximately 7-15 days, perinatal mortality rate was comparable in some studies [4,7,9,16], including a large RCT reported by Vigil-De Gracia et al [7] in spite of 10-day prolongation, and slightly decreased in some studies [1,5,13,17]. Likewise, maternal morbidity was comparable in most studies [1,4,13,14] and increased in some studies [5,7,9].…”

Practical guide for the management of hypertensive disorders during pregnancy

“…In preeclampisa or eclampsia delivery seems to be the only definite therapy and stabilization of BP before operative birth is important for maternal complications. Immediate delivery could be one possible approach in women, especially beyond the 37 weeks of gestation [63], but so as the delayed delivery with expectant monitoring [64]. Especially for women with nonsevere hypertension, there is not a consensus regarding the timing of delivery.…”

“…Latest data show that in case of late onset mild preeclampsia, the choice of expectant approach seems logical and has been associated with a lower risk of neonatal respiratory distress syndrome. The choice of immediate delivery is associated with reduced risk of small-for-gestational age babies in case of severe preeclampsia and reduced risk of severe renal impairment in case of mild preeclampsia [64]. Regarding maternal outcomes, immediate delivery in nonsevere preeclampsia offers lower risk of adverse event by 14% and intensive care cost unit by 23%, at the period of late prematurity [65].…”