Should we offer expectant management in cases of severe preterm preeclampsia with fetal growth restriction?

Shear, Roberta; Rinfret, Denyse; Leduc, Line

doi:10.1016/j.ajog.2004.10.621

Cited by 67 publications

(30 citation statements)

References 16 publications

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“…4 Moreover, in some of the definitions of preeclampsia, FGR has also been considered a characteristic of severity of the disorder. [5][6][7] Most studies on the complicated association between FGR and preeclampsia concentrated mostly on the maternal and neonatal outcomes of the hypertensive and preeclamptic pregnancies with or without FGR. 5,[8][9][10] Only few studied the FGR as a cohort and compared pregnancy outcomes or risk factors, in respect to normotensive FGR (N-FGR) versus hypertensive FGR (H-FGR).…”

Section: Introductionmentioning

confidence: 99%

Pregnancy Outcome and Placental Findings in Pregnancies Complicated by Fetal Growth Restriction With and Without Preeclampsia

et al. 2015

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Section: Introductionmentioning

confidence: 99%

Pregnancy Outcome and Placental Findings in Pregnancies Complicated by Fetal Growth Restriction With and Without Preeclampsia

et al. 2015

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“…2,5,6 The coexistence, temporal changes and prognostic implications of abnormal ultrasound and Doppler findings are now well described in placental insufficiency, [7][8][9] but while knowledge of umbilical artery Doppler results 10 is of clear clinical benefit, the use of other ultrasound and Doppler parameters has not yet been shown to improve perinatal outcome. In preterm pre-eclampsia, some studies have investigated the prognostic value of such parameters close to delivery, [11][12][13][14][15][16][17] but combinations of parameters, their inter-relations and the influence of confounding variables in this setting have not been investigated widely. [18][19][20] Before one can assume that assessment of fetoplacental blood flow patterns should affect the management of preterm pre-eclampsia, it needs to be established which findings contribute independently to the ultimate prognosis, either at the time of diagnosis or during serial reassessment.…”

Section: Introductionmentioning

confidence: 99%

Severe early onset pre-eclampsia: prognostic value of ultrasound and Doppler assessment

Geerts

Odendaal

2007

J Perinatol

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Objective: Assess the prognostic value of ultrasound and Doppler parameters in severe preterm pre-eclampsia.Study design: Prospective cohort study in Cape Town, South Africa, involving 113 women with severe pre-eclampsia between 24 and 34 weeks of gestation and managed expectantly when suitable. Serial ultrasound and multivessel Doppler assessments were performed 2 to 3 times weekly. Observations included fetal weight estimation, growth pattern, amniotic fluid volume, appearance of the heart and bowel, pulsatility index of the uterine, umbilical and middle cerebral arteries and ductus venosus. Perinatal outcome (death or neurological compromise, n ¼ 12) and major morbidity (n ¼ 62) were related to findings at recruitment and on the last assessment preceding delivery.Results: In univariate analysis, fetal growth asymmetry and waveform analysis of all three fetal vessels significantly correlated with both end points. The initial fetal weight estimation with a cutoff weight of 1080 g had the highest sensitivity (83.3%) and negative predictive value (97.5%) for poor outcome (P<0.001) while the final ductus venosus pulsatility index had the highest specificity (92%) and positive predictive value (33%). The combination of a raised placentocerebral ratio and ductus venosus pulsatility index close to delivery had the highest (57.1%) positive predictive value. Logistic regression showed the best overall predictive model for poor outcome to be a combination of initial fetal weight estimation and final ductus venosus pulsatility index (overall accuracy 94.6%, RR 20.20 (7.36, 55.41)). The initial fetal weight estimation with a cutoff weight of 1283 g provided the best correct prediction of major morbidity (83.2% overall accuracy, sensitivity 79.0%, specificity 88.2%, positive and negative predictive values of 89.1 and 77.6% respectively). This was better than using the gestational age at recruitment or delivery, birth weight or any of the Doppler results. The prediction of morbidity was not improved by the addition of any other variable in logistic regression analysis. Conclusion:For the short-term outcome measures assessed in this study, the estimated fetal weight at the time of diagnosis is the most important prognostic factor in severe pre-eclampsia with some additional value of ductus venosus assessment.

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“…Antenatal corticosteroids are administered to improve fetal lung maturation whenever preterm delivery is anticipated. As steroids achieve their optimal effect after 48 hours, 25,26 clinicians tend to postpone delivery until this time unless complications have occurred or are anticipated. Neonatal morbidity from early preterm delivery could be reduced by stabilising the woman's condition and, if possible, by delaying delivery.…”

Section: Management Of Early-onset Pre-eclampsiamentioning

confidence: 99%

Development and validation of Prediction models for Risks of complications in Early-onset Pre-eclampsia (PREP): a prospective cohort study

Thangaratinam

Allotey

Marlin

et al. 2017

Health Technol Assess

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BackgroundThe prognosis of early-onset pre-eclampsia (before 34 weeks’ gestation) is variable. Accurate prediction of complications is required to plan appropriate management in high-risk women.ObjectiveTo develop and validate prediction models for outcomes in early-onset pre-eclampsia.DesignProspective cohort for model development, with validation in two external data sets.SettingModel development: 53 obstetric units in the UK. Model transportability: PIERS (Pre-eclampsia Integrated Estimate of RiSk for mothers) and PETRA (Pre-Eclampsia TRial Amsterdam) studies.ParticipantsPregnant women with early-onset pre-eclampsia.Sample sizeNine hundred and forty-six women in the model development data set and 850 women (634 in PIERS, 216 in PETRA) in the transportability (external validation) data sets.PredictorsThe predictors were identified from systematic reviews of tests to predict complications in pre-eclampsia and were prioritised by Delphi survey.Main outcome measuresThe primary outcome was the composite of adverse maternal outcomes established using Delphi surveys. The secondary outcome was the composite of fetal and neonatal complications.AnalysisWe developed two prediction models: a logistic regression model (PREP-L) to assess the overall risk of any maternal outcome until postnatal discharge and a survival analysis model (PREP-S) to obtain individual risk estimates at daily intervals from diagnosis until 34 weeks. Shrinkage was used to adjust for overoptimism of predictor effects. For internal validation (of the full models in the development data) and external validation (of the reduced models in the transportability data), we computed the ability of the models to discriminate between those with and without poor outcomes (c-statistic), and the agreement between predicted and observed risk (calibration slope).ResultsThe PREP-L model included maternal age, gestational age at diagnosis, medical history, systolic blood pressure, urine protein-to-creatinine ratio, platelet count, serum urea concentration, oxygen saturation, baseline treatment with antihypertensive drugs and administration of magnesium sulphate. The PREP-S model additionally included exaggerated tendon reflexes and serum alanine aminotransaminase and creatinine concentration. Both models showed good discrimination for maternal complications, with anoptimism-adjustedc-statistic of 0.82 [95% confidence interval (CI) 0.80 to 0.84] for PREP-L and 0.75 (95% CI 0.73 to 0.78) for the PREP-S model in the internal validation. External validation of the reduced PREP-L model showed good performance with ac-statistic of 0.81 (95% CI 0.77 to 0.85) in PIERS and 0.75 (95% CI 0.64 to 0.86) in PETRA cohorts for maternal complications, and calibrated well with slopes of 0.93 (95% CI 0.72 to 1.10) and 0.90 (95% CI 0.48 to 1.32), respectively. In the PIERS data set, the reduced PREP-S model had ac-statistic of 0.71 (95% CI 0.67 to 0.75) and a calibration slope of 0.67 (95% CI 0.56 to 0.79). Low gestational age at diagnosis, high urine protein-to-creatinine ratio, increased serum urea concentration, treatment with antihypertensive drugs, magnesium sulphate, abnormal uterine artery Doppler scan findings and estimated fetal weight below the 10th centile were associated with fetal complications.ConclusionsThe PREP-L model provided individualised risk estimates in early-onset pre-eclampsia to plan management of high- or low-risk individuals. The PREP-S model has the potential to be used as a triage tool for risk assessment. The impacts of the model use on outcomes need further evaluation.Trial registrationCurrent Controlled Trials ISRCTN40384046.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Should we offer expectant management in cases of severe preterm preeclampsia with fetal growth restriction?

Cited by 67 publications

References 16 publications

Pregnancy Outcome and Placental Findings in Pregnancies Complicated by Fetal Growth Restriction With and Without Preeclampsia

Pregnancy Outcome and Placental Findings in Pregnancies Complicated by Fetal Growth Restriction With and Without Preeclampsia

Severe early onset pre-eclampsia: prognostic value of ultrasound and Doppler assessment

Development and validation of Prediction models for Risks of complications in Early-onset Pre-eclampsia (PREP): a prospective cohort study

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