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Meta-Analysis
. 2017 Jan 15;1(1):CD009273.
doi: 10.1002/14651858.CD009273.pub2.

Planned early delivery versus expectant management for hypertensive disorders from 34 weeks gestation to term

Catherine Cluver  1 , Natalia Novikova  2 , Corine M Koopmans  3 , Helen M West  4
Affiliations
Meta-Analysis

Planned early delivery versus expectant management for hypertensive disorders from 34 weeks gestation to term

Catherine Cluver et al. Cochrane Database Syst Rev. .

Abstract

Background: Hypertensive disorders in pregnancy are significant contributors to maternal and perinatal morbidity and mortality. These disorders include well-controlled chronic hypertension, gestational hypertension (pregnancy-induced hypertension) and mild pre-eclampsia. The definitive treatment for these disorders is planned early delivery and the alternative is to manage the pregnancy expectantly if severe uncontrolled hypertension is not present, with close maternal and fetal monitoring. There are benefits and risks associated with both, so it is important to establish the safest option.

Objectives: To assess the benefits and risks of a policy of planned early delivery versus a policy of expectant management in pregnant women with hypertensive disorders, at or near term (from 34 weeks onwards).

Search methods: We searched Cochrane Pregnancy and Childbirth Trials Register (12 January 2016) and reference lists of retrieved studies.

Selection criteria: Randomised trials of a policy of planned early delivery (by induction of labour or by caesarean section) compared with a policy of delayed delivery ("expectant management") for women with hypertensive disorders from 34 weeks' gestation. Cluster-randomised trials would have been eligible for inclusion in this review, but we found none.Studies using a quasi-randomised design are not eligible for inclusion in this review. Similarly, studies using a cross-over design are not eligible for inclusion, because they are not a suitable study design for investigating hypertensive disorders in pregnancy.

Data collection and analysis: Two review authors independently assessed eligibility and risks of bias. Two review authors independently extracted data. Data were checked for accuracy.

Main results: We included five studies (involving 1819 women) in this review.There was a lower risk of composite maternal mortality and severe morbidity for women randomised to receive planned early delivery (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83, two studies, 1459 women (evidence graded high)). There were no clear differences between subgroups based on our subgroup analysis by gestational age, gestational week or condition. Planned early delivery was associated with lower risk of HELLP syndrome (RR 0.40, 95% CI 0.17 to 0.93, 1628 women; three studies) and severe renal impairment (RR 0.36, 95% CI 0.14 to 0.92, 100 women, one study).There was not enough information to draw any conclusions about the effects on composite infant mortality and severe morbidity. We observed a high level of heterogeneity between the two studies in this analysis (two studies, 1459 infants, I2 = 87%, Tau2 = 0.98), so we did not pool data in meta-analysis. There were no clear differences between subgroups based on our subgroup analysis by gestational age, gestational week or condition. Planned early delivery was associated with higher levels of respiratory distress syndrome (RR 2.24, 95% CI 1.20 to 4.18, three studies, 1511 infants), and NICU admission (RR 1.65, 95% CI 1.13 to 2.40, four studies, 1585 infants).There was no clear difference between groups for caesarean section (RR 0.91, 95% CI 0.78 to 1.07, 1728 women, four studies, evidence graded moderate), or in the duration of hospital stay for the mother after delivery of the baby (mean difference (MD) -0.16 days, 95% CI -0.46 to 0.15, two studies, 925 women, evidence graded moderate) or for the baby (MD -0.20 days, 95% CI -0.57 to 0.17, one study, 756 infants, evidence graded moderate).Two fairly large, well-designed trials with overall low risk of bias contributed the majority of the evidence. Other studies were at low or unclear risk of bias. No studies attempted to blind participants or clinicians to group allocation, potentially introducing bias as women and staff would have been aware of the intervention and this may have affected aspects of care and decision-making.The level of evidence was graded high (composite maternal mortality and morbidity), moderate (caesarean section, duration of hospital stay after delivery for mother, and duration of hospital stay after delivery for baby) or low (composite infant mortality and morbidity). Where the evidence was downgraded, it was mostly because the confidence intervals were wide, crossing both the line of no effect and appreciable benefit or harm.

Authors' conclusions: For women suffering from hypertensive disorders of pregnancy after 34 weeks, planned early delivery is associated with less composite maternal morbidity and mortality. There is no clear difference in the composite outcome of infant mortality and severe morbidity; however, this is based on limited data (from two trials) assessing all hypertensive disorders as one group.Further studies are needed to look at the different types of hypertensive diseases and the optimal timing of delivery for these conditions. These studies should also include infant and maternal morbidity and mortality outcomes, caesarean section, duration of hospital stay after delivery for mother and duration of hospital stay after delivery for baby.An individual patient meta-analysis on the data currently available would provide further information on the outcomes of the different types of hypertensive disease encountered in pregnancy.

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Conflict of interest statement

CK is an author of an included study in this review (Koopmans 2009). All decisions relating to this study (assessment for inclusion/exclusion, risk of bias and data extraction) were carried out by the other members of the review team who are not directly involved in the study.

HW is paid to work on Cochrane reviews by a grant to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

CC: none known.

NN: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 1 Composite maternal mortality and morbidity.
1.2
1.2. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 2 Composite infant mortality and morbidity.
1.3
1.3. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 3 Maternal mortality.
1.4
1.4. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 4 Eclampsia.
1.5
1.5. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 5 Pulmonary oedema.
1.6
1.6. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 6 Severe renal impairment.
1.7
1.7. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 7 HELLP syndrome.
1.8
1.8. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 8 Thromboembolic disease.
1.9
1.9. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 9 Abruptio placentae.
1.10
1.10. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 10 Postpartum haemorrhage.
1.11
1.11. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 11 Severe hypertension.
1.12
1.12. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 12 Caesarean section.
1.13
1.13. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 13 Assisted delivery (ventouse/forceps).
1.14
1.14. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 14 Maternal morbidity of caesarean section.
1.15
1.15. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 15 Maternal morbidity related to induction of labour.
1.16
1.16. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 16 Admission to a high care or intensive care unit.
1.17
1.17. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 17 Fetal death.
1.18
1.18. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 18 Neonatal death.
1.19
1.19. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 19 Grade III or IV intraventricular or intracerebral haemorrhage.
1.20
1.20. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 20 Nectrotising enterocolitis.
1.21
1.21. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 21 Respiratory distress syndrome.
1.22
1.22. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 22 Small‐for‐gestational age.
1.23
1.23. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 23 Neonatal seizures.
1.24
1.24. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 24 Apgar score less than seven at five minutes.
1.25
1.25. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 25 Cord blood pH less than 7.1 or as defined by trial authors.
1.26
1.26. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 26 Surfactant use.
1.27
1.27. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 27 Neonatal intensive care unit or high care unit admission.
1.28
1.28. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 28 Early neonatal sepsis.
1.29
1.29. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 29 Duration of hospital stay after delivery for mother (days).
1.30
1.30. Analysis
Comparison 1 Planned early delivery versus expectant management (all women), Outcome 30 Duration of hospital stay after delivery for baby (days).
2.1
2.1. Analysis
Comparison 2 Planned early delivery versus expectant management (by gestational age), Outcome 1 Composite maternal mortality and morbidity.
2.2
2.2. Analysis
Comparison 2 Planned early delivery versus expectant management (by gestational age), Outcome 2 Respiratory distress syndrome.
2.3
2.3. Analysis
Comparison 2 Planned early delivery versus expectant management (by gestational age), Outcome 3 Composite infant mortality and morbidity.
3.1
3.1. Analysis
Comparison 3 Planned early delivery versus expectant management (by each gestational week), Outcome 1 Composite maternal mortality and morbidity.
3.2
3.2. Analysis
Comparison 3 Planned early delivery versus expectant management (by each gestational week), Outcome 2 Respiratory distress syndrome.
3.3
3.3. Analysis
Comparison 3 Planned early delivery versus expectant management (by each gestational week), Outcome 3 Composite infant mortality and morbidity.
4.1
4.1. Analysis
Comparison 4 Planned early delivery versus expectant management (by condition), Outcome 1 Composite maternal mortality and morbidity.
4.2
4.2. Analysis
Comparison 4 Planned early delivery versus expectant management (by condition), Outcome 2 Respiratory distress syndrome.
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