Expectant Monitoring for Late Preterm Hypertensive Disorders

Caroline Helwick

February 07, 2014

NEW ORLEANS — In women with late preterm hypertensive disorders of pregnancy, routine delivery does not decrease the risk for severe adverse maternal outcomes, compared with expectant monitoring, a new study suggests. However, it does increase the risk for neonatal respiratory distress syndrome.

"Personally, with the results of this study, I would advise that the mother be monitored," said Kim Broekhuijsen, MD, from the University of Groningen in the Netherlands.

"The management dilemma is balancing maternal risks with fetal and neonatal risks," she explained. "We don't have evidence of a difference in maternal outcomes between immediate delivery and expectant monitoring," but we know the risk for neonatal problems will increase with immediate delivery.

 
We don't have evidence of a difference in maternal outcomes between immediate delivery and expectant monitoring.
 

Dr. Broekhuijsen presented results from the open-label randomized controlled HYPITAT II trial here at the Society for Maternal-Fetal Medicine 34th Annual Meeting.

Hypertensive disorders of pregnancy occur in 4% to 13% of all pregnancies. About one quarter of these disorders are diagnosed in late preterm pregnancy, and they account for up to 25% of late preterm births. However, data are limited on the effectiveness of immediate delivery for these women.

In their study, Dr. Broekhuijsen and her colleagues evaluated whether delivery would reduce adverse maternal outcomes without compromising neonatal outcomes.

Study Details

The HYPITAT II researchers assessed women at 51 Dutch hospitals who had gestational hypertension, pre-eclampsia, or deteriorating chronic hypertension and were at 34 to 37 weeks of gestation.

From this cohort, 352 women were randomized to immediate delivery (induction of labor or cesarean delivery within 24 hours) and 351 were randomized to expectant monitoring until 37 weeks' gestation.

The primary maternal outcome was a composite measure of thromboembolic disease, pulmonary edema, HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count), eclampsia, placental abruption, and maternal mortality. The primary neonatal outcome was respiratory distress syndrome.

Maternal and Neonatal Outcomes

Adverse outcomes were similar for women who underwent immediate delivery and those who were monitored (1.1% vs 3.1%). The main difference was in the development of HELLP syndrome (0.9% vs 1.7%; relative risk [RR], 0.36; 95% confidence interval [CI], 0.12 - 1.1), but this was not statistically significant, Dr. Broekhuijsen reported.

There was, however, a significant difference in neonatal outcomes. More infants in the immediate-delivery group developed respiratory distress syndrome than in the monitored group (5.7% vs 1.7%; RR, 3.3; 95% CI, 1.4 - 8.2). Admission to the neonatal intensive care unit was also greater in the immediate-delivery group (7.4% vs 3.7%; 95% CI, 1.0 - 3.8), as was neonatal morbidity of any kind, although not significantly (49% vs 36%; RR, 1.4; 95% CI, 1.1 - 1.7).

Approximately 30% of each group underwent cesarean delivery. In the monitored group, the chief indication for delivery was attainment of 37 weeks' gestation (57%); the second most common indication was the development of severe hypertension (30%).

On the basis of these findings, the researchers advise monitoring for women with nonsevere hypertensive disorders of pregnancy who are at 34 to 37 weeks of gestation.

"I would tell the patient that there could be a risk for an adverse outcome for her if we monitor her expectantly, but this difference was so small in our study that we are not sure it is an actual difference or the result of chance," Dr. Broekhuijsen explained.

James Martin, MD, professor of obstetrics and gynecology and director of maternal and fetal medicine at the University of Mississippi Medical Center in Jackson, was asked to comment on the study for Medscape Medical News. He has published widely on hypertensive disorders of pregnancy.

The results from HYPITAT II are "consistent with what we have found in Jackson in similar studies that we are publishing," he said.

"The mean time of delivery after expectant management was about 7 days, and that's not a long period of time. We have found that within 3 to 4 days, most of the pathology begins to present itself," he added.

But questions remain. "How long should we watch these patients once we make the diagnosis? Should our monitoring be more intensive in the first 7 days? Because it seems that the patients who are going to get very ill do so sooner rather than later," said Dr. Martin.

He concluded that "this is all consistent with what we are recommending. Wait until 37 weeks to deliver, unless events occur prior to this time point that push you toward an earlier delivery."

Dr. Broekhuijsen and Dr. Martin have disclosed no relevant financial relationships.

Society for Maternal-Fetal Medicine (SMFM) 34th Annual Meeting: Abstract 2. Presented February 6, 2014.

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