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Meta-Analysis
. 2018 Oct 5;10(10):CD003106.
doi: 10.1002/14651858.CD003106.pub3.

Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation

David Churchill  1 , Lelia Duley, Jim G Thornton, Mahmoud Moussa, Hind Sm Ali, Kate F Walker
Affiliations
Meta-Analysis

Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation

David Churchill et al. Cochrane Database Syst Rev. .

Abstract

Background: Severe pre-eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs remote from term, between 24 and 34 weeks' gestation. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to ensure that the development of serious maternal complications, such as eclampsia (fits) and kidney failure are prevented. Others prefer a more expectant approach, delaying delivery in an attempt to reduce the mortality and morbidity for the child that is associated with being born too early.

Objectives: To evaluate the comparative benefits and risks of a policy of early delivery by induction of labour or by caesarean section, after sufficient time has elapsed to administer corticosteroids, and allow them to take effect; with a policy of delaying delivery (expectant care) for women with severe pre-eclampsia between 24 and 34 weeks' gestation.

Search methods: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 27 November 2017, and reference lists of retrieved studies.

Selection criteria: Randomised trials comparing the two intervention strategies for women with early onset, severe pre-eclampsia. Trials reported in an abstract were eligible for inclusion, as were cluster-trial designs. We excluded quasi-randomised trials.

Data collection and analysis: Three review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. We assessed the quality of the evidence for specified outcomes using the GRADE approach.

Main results: We included six trials, with a total of 748 women in this review. All trials included women in whom there was no overriding indication for immediate delivery in the fetal or maternal interest. Half of the trials were at low risk of bias for methods of randomisation and allocation concealment; and four trials were at low risk for selective reporting. For most other domains, risk of bias was unclear. There were insufficient data for reliable conclusions about the comparative effects on most outcomes for the mother. Two studies reported on maternal deaths; neither study reported any deaths (two studies; 320 women; low-quality evidence). It was uncertain whether interventionist care reduced eclampsia (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.06 to 15.58; two studies; 359 women) or pulmonary oedema (RR 0.45, 95% CI 0.07 to 3.00; two studies; 415 women), because the quality of the evidence for these outcomes was very low. Evidence from two studies suggested little or no clear difference between the interventionist and expectant care groups for HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome (RR 1.09, 95% CI 0.62 to 1.91; two studies; 359 women; low-quality evidence). No study reported on stroke. With the addition of data from two studies for this update, there was now evidence to suggest that interventionist care probably made little or no difference to the incidence of caesarean section (average RR 1.01, 95% CI 0.91 to 1.12; six studies; 745 women; Heterogeneity: Tau² = 0.01; I² = 63%).For the baby, there was insufficient evidence to draw reliable conclusions about the effects on perinatal deaths (RR 1.11, 95% CI 0.62 to 1.99; three studies; 343 women; low-quality evidence). Babies whose mothers had been allocated to the interventionist group had more intraventricular haemorrhage (RR 1.94, 95% CI 1.15 to 3.29; two studies; 537 women; moderate-quality evidence), more respiratory distress caused by hyaline membrane disease (RR 2.30, 95% CI 1.39 to 3.81; two studies; 133 women), required more ventilation (RR 1.50, 95% CI 1.11 to 2.02; two studies; 300 women), and were more likely to have a lower gestation at birth (mean difference (MD) -9.91 days, 95% CI -16.37 to -3.45 days; four studies; 425 women; Heterogeneity: Tau² = 31.74; I² = 76%). However, babies whose mothers had been allocated to the interventionist group were no more likely to be admitted to neonatal intensive care (average RR 1.19, 95% CI 0.89 to 1.60; three studies; 400 infants; Heterogeneity: Tau² = 0.05; I² = 84%). Babies born to mothers in the interventionist groups were more likely to have a longer stay in the neonatal intensive care unit (MD 7.38 days, 95% CI -0.45 to 15.20 days; three studies; 400 women; Heterogeneity: Tau² = 40.93, I² = 85%) and were less likely to be small-for-gestational age (RR 0.38, 95% CI 0.24 to 0.61; three studies; 400 women). There were no clear differences between the two strategies for any other outcomes.

Authors' conclusions: This review suggested that an expectant approach to the management of women with severe early onset pre-eclampsia may be associated with decreased morbidity for the baby. However, this evidence was based on data from only six trials. Further large, high-quality trials are needed to confirm or refute these findings, and establish if this approach is safe for the mother.

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Conflict of interest statement

David Churchill: None

Lelia Duley: LD has been awarded an NIHR research grant for a programme of work on care at very preterm birth.

Jim G Thornton: Jim Thornton is an author on one of the included studies (Thornton 2004 (GRIT)). However, he was not involved in any assessment, data extraction, or data analysis of this trial.

Mahmoud Moussa: None

Hind SM Ali: None

Kate F Walker: None

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 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 1 Maternal death.
1.2
1.2. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 2 Eclampsia.
1.3
1.3. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 3 Pulmonary oedema.
1.4
1.4. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 4 HELLP syndrome.
1.5
1.5. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 5 Death of the baby (all stillbirths, neonatal, and infant deaths).
1.6
1.6. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 6 Death of the baby (subgrouped by time of death).
1.7
1.7. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 7 Intraventricular haemorrhage or hypoxic ischaemic encephalopathy.
1.8
1.8. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 8 Caesarean section.
1.9
1.9. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 9 Renal failure.
1.10
1.10. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 10 Placental abruption.
1.11
1.11. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 11 Hyaline membrane disease.
1.12
1.12. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 12 Baby ventilated.
1.13
1.13. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 13 Gestation at birth (days).
1.14
1.14. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 14 Necrotising enterocolitis.
1.15
1.15. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 15 Small‐for‐gestational age.
1.16
1.16. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 16 Low Apgar score at five minutes (< 7 at five minutes).
1.17
1.17. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 17 Neonatal seizures.
1.18
1.18. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 18 Measures of long‐term growth & development (cerebral palsy).
1.19
1.19. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 19 Measures of long‐term growth & development (poor hearing, use of hearing aid).
1.20
1.20. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 20 Measures of long‐term growth & development (impaired vision).
1.21
1.21. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 21 Admission to neonatal intensive care unit.
1.22
1.22. Analysis
Comparison 1 Interventionist care versus expectant (delayed delivery) care for severe pre‐eclampsia, Outcome 22 Length of stay in neonatal intensive care unit (days).
See this image and copyright information in PMC

Update of

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