Pregnancy outcomes of expectant management of stable mild to moderate chronic hypertension as compared with planned delivery

Hamed, Hossam O.; Al-Sheeha, Muneera; Abu-Elhasan, Ahmad M.; Elmoniem, Alaa E. Abd; Kamal, Manal Mohamed

doi:10.1016/j.ijgo.2014.04.010

Cited by 15 publications

(18 citation statements)

References 26 publications

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“…There were two perinatal deaths in the included trials, both from GRIT, one in each group. Inclusion of aggregate data from Hamed et al . on placental abruption, intrauterine growth restriction, NICU admission, and perinatal mortality did not change these results significantly (Table ).…”

Section: Resultsmentioning

confidence: 94%

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Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta‐analysis

Bernardes

Zwertbroek

Broekhuijsen

et al. 2019

Ultrasound in Obstet & Gyne

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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 http://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.

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Section: Resultsmentioning

confidence: 94%

“…*References (Refs): HYPITAT‐I, Koopmans (2009); DIGITAT, Boers (2010); Hamed (2014); Deliver or Deliberate, Owens (2014); HYPITAT‐II, Broekhuijsen (2015); GRIT, GRIT Study Group (2003).…”

Section: Resultsmentioning

confidence: 99%

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta‐analysis

Bernardes

Zwertbroek

Broekhuijsen

et al. 2019

Ultrasound in Obstet & Gyne

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“…In relation to hypertensive disorders broadly, Cluver et al [118] conducted a Cochrane review comparing planned early birth versus EM from 34 weeks to term. The review identified five RCTs, with a total of 1819 women [134][135][136][137][138]. Both the HYPITAT-I (Hypertension and Preeclampsia Intervention Trial at Term) and HYPITAT-II trials were included [134,135].…”

Section: Hypertension/preeclampsiamentioning

confidence: 99%

“…The HYPITAT-II trial compared IOL at 34-36+6 weeks to EM until 37 weeks for pregnant women with gestational hypertension, mild preeclampsia, or deteriorating chronic hypertension [134]. Three further RCTs compared planned early birth via IOL or CS versus EM for pregnant women with mild preeclampsia or gestational hypertension [136,138] or moderate essential chronic hypertension [137]. The review found a lower risk of composite maternal mortality and severe morbidity for women randomised to receive planned early birth.…”

Section: Hypertension/preeclampsiamentioning

confidence: 99%

A systematic scoping review of clinical indications for induction of labour

Coates¹,

Makris²,

Catling³

et al. 2020

PLoS ONE

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Background The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist. Methods A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool. Results 68 studies were included which related to post-term pregnancy (15), hypertension/preeclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42

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“…Searching ClinicalTrials.gov and PubMed using the search terms “chronic hypertension,” “pregnancy,” and “induction of labor,” we identified a single randomized control trial investigating the gestational age of delivery in women with chronic hypertension (11) where 74 women were randomized to elective delivery at 37 weeks versus expectant management until 41 weeks. No difference was found in the risk of severe preeclampsia between groups; however, as the average gestational age at delivery in the planned delivery was 35 weeks, the lack of difference may be due to management choices and the risk of preeclampsia between recruitment and delivery, rather than lack of benefit to delivery at 37 weeks.…”

Section: Discussionmentioning

confidence: 99%

Gestational Age of Delivery in Pregnancies Complicated by Chronic Hypertension

Biggio

Anderson

Tita

2016

Obstetrics &Amp; Gynecology

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Objective To identify the gestational age of planned delivery in pregnancies complicated by chronic hypertension that minimizes the risk of perinatal death and severe adverse events. Methods This was a retrospective cohort study of all singletons complicated by hypertension. Detailed patient-level information was collected by chart review, including indication for delivery. Planned delivery at 36–36.6, 37–37.6, 38–38.6, and 39–39.6 weeks was compared to expectant management beyond each respective gestational age. Patients were excluded for fetal anomalies, inaccurate dating, and major medical problems other than hypertension, diabetes or renal disease. The primary outcome was a composite of stillbirth, neonatal death, assisted ventilation, cord pH<7.0, 5-minute Apgar ≤3, and neonatal seizures. Secondary outcomes were preeclampsia, severe preeclampsia, primary cesarean, and infant length of stay >5 days. Groups were compared using Student’s t-test and χ2 tests. Results Six hundred eighty three women with hypertension reached 36 weeks. Patients with planned delivery <39 weeks were more likely to have baseline renal disease. Prior to 37 weeks, planned delivery was associated with a statistically significant increase in the primary composite adverse neonatal outcome (10.0% versus 2.6%, p=0.04); after 38 weeks, expectant management was associated with a non-statistically significant increase in the primary composite outcome (0% versus 2.3%, p=0.40). Expectant management beyond 39 weeks was associated with a statistically significant increase in severe preeclampsia (0 versus 10.3%, p=0.001). Conclusion Expectant management beyond 39.0 weeks was associated with increasing incidence of severe preeclampsia; planned delivery prior to 37 weeks was associated with an increase in adverse neonatal outcomes. Further, well-powered studies are needed to delineate the optimal gestational age of delivery.

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Pregnancy outcomes of expectant management of stable mild to moderate chronic hypertension as compared with planned delivery

Abstract: Mild to moderate chronic hypertension could be managed expectantly up to 41 weeks if SPE did not develop.

Cited by 15 publications

References 26 publications

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta‐analysis

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta‐analysis

A systematic scoping review of clinical indications for induction of labour

Gestational Age of Delivery in Pregnancies Complicated by Chronic Hypertension

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