Timing of delivery and induction in pre-eclampsia Matthews Mathai

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Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011

Timing of delivery and induction in pre-eclampsia

Matthews Mathai

Timing of delivery and induction in pre-eclampsia

Matthews Mathai

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Principles of ManagementPrinciples 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

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Timing of delivery Timing of delivery

Fetal considerations– Prematurity – Stillbirth

• Hypoxia• Placental abruption

– Newborn asphyxia

Maternal considerations– Worsening of disease

• Complications

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Timing of delivery Timing of delivery

Mild or severe disease?– Early delivery with

severe disease

Preterm or term?– Delivery more likely if

term

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Timing based on severity of disease 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

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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

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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)

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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

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Timing based on severity of disease Timing based on severity of disease

"In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms"


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Delivery in mild pre-eclampsiaDelivery 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

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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

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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 0.59-0.86)

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

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Induction techniques - SummariesInduction 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

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Induction techniques - SummariesInduction techniques - Summaries

Not recommended– Amniotomy alone– Misoprostol in women with previous caesarean section

• WHO recommendations for induction of labour 2011

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Current recommendationsCurrent recommendations

Deliver within 24 h for severe pre-eclampsia

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


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Timing of delivery and induction in pre-eclampsia Matthews Mathai