Aggressive Versus Expectant Management of Severe Preeclampsia Remote from Term 28-34 Weeks.

INTRODUCTION: Preeclampsia is a multisystem disorder characterised by raised blood pressure and proteinuria. It complicates 5-8% of pregnancy and is a major cause of maternal and perinatal morbidity and mortality. (ACOG 2002², Sibai et al 1997 (39) Traditionally approach of balancing the interests of the mother with those of the fetus has been adopted in the management of preterm pregnancies with mild preeclampsia. Severe preeclampsia conversely has been delivered without delay regardless of fetal consideration. With improved methods of monitoring maternal and fetal well being, several investigators begun to challenge the traditional view that women with severe preeclampsia need be delivered expeditiously. Recent approach advocates conservative management in a selected group of women with severe preeclampsia remote from term with the aim of improving perinatal outcome without compromising maternal safety. AIM OF THE STUDY: 1. To compare the merits and demerits of aggressive and expectant management of women with severe Preeclampsia remote from term 28 – 34 weeks. 2. To determine which is more beneficial by comparing perinatal and maternal outcome by statistical analysis by Chi square test. MATERIAL AND METHODS: Study design : Prospective. Study period : Sep.2003 – Aug 2005. Sample: Group A: - Patients of severe PE remote from term 28 34 weeks treated aggressively that is glucocorticoid therapy followed by delivery in 48 hrs. All patients who delivered within 96 hrs of admission were noted. Group B: - Patients of the same group treated expectantly i.e glucocorticoid therapy, intensive maternal and fetal monitoring followed by delivery only for specific maternal or fetal indication beyond 96hours. Sample size : 97 patients of group A who delivered after 48hours of glucocorticoid therapy and 92 patients of groupB were compared. SELECTION CRITERIA - Inclusion Criteria : All subjects had 1) GA 28 - 34 weeks. 2) Severe pre eclampsia defined as i) Blood pressure > 160/110 with proteinuria> 2+, ii. Blood pressure > 150/100 with proteinuria >3+, iii.Blood pressure > 140/90 with proteinuria with c/o Headache or oliguria. Exclusive Criteria : 1. Women with medical complications, 2. Rupture of membrane, 3. Preterm labour, 4. Multifetal gestation, 5. Fetal compromise/ fetal death, 6. Platelet count < 1, 00,000/ Mic.L or HELLP, 7.Eclampsia, 8.Fetal congenital mal formation. Babies born without completing steroids are not compared with exp. Group. • Severe preeclampsia contributes 1% of all deliveries. In our study there were 259 patients of severe preeclampsia remote from term. Among them 189 patients who had full dose of steroids were compared. • Most of them were primis. • Most of them were in age group 25 to 34 years. • Mean gestational age on admission was 31 weeks. • 36% had recurrent preeclampsia. • 15.8% (29) patients had family history of preeclampsia. • Mean body mass index was 27.4. • Mean systolic BP 160 mmHg and mean diastolic BP being 106 mmHg. • Most of them needed 1000 – 1500 mg of alpha methyl dopa and 15-20mg of nifedipine for BP control. • Most patient had normal fundus. • Major maternal complications were higher in the expectant group, proved to be statistically non significant. 4 Patients had HELLP. 8 Patients had ABRUPTION. • 1 Needed renal dialysis in expectant group. There was no Maternal death and no eclampsia in both the groups. • Most of them delivered by 8-11hrs by inducing labor. • 65% terminated for maternal indication 35% for fetal indication. • LSCS rate was higher in expectant group (47.8% vs 15.5%) But this was mainly contributed by post cesarean pregnancy in expectant group. • Perinatal loss was significantly lower in expectant group 30.4% vs 55.7% proved to the statistically significant P (<0.001). • Perinatal loss is not influenced by cesarean section in expectant group as 42.8% perinatal death was contributed by LSCS and 57.2% by vaginal delivery statistically not significant. • Expectant group had higher birth weight than aggressive significant. 51% had birth weight > 1.5kg maximum being 2.4kg • Mean birth weight being 1.58kg. • Mean gestational age at delivery 32weeks. • Mean prologation of pregnancy is 8.6 days. • Perinatal mortality was higher in the patients delivered <48hrs of steroids. • Expectant group had relativety low admission of babies to NICU (92% vs 100%), lower mean stay of hospitalization (8 days vs 14 days ). • Babies in expectant group had higher survival rate (74.4% vs 55.8%). CONCLUSION: The conservative approach to the management of severe preclampsia remote from term results in a good obstetric outcome for most fetuses, in view of 1. Higher birth weight, 2. Lower perinatal mortality, 3. Lesser neonatal complications but this must be balanced against the significant risk of morbidity to the mothers. The success rate of expectant management will depend on both fetal gestational age and maternal and fetal conditions at the time of hospitalization. Since maternal and perinatal complications are significantly increased in these patients, expectant management should be carried out in well selected patients only at tertiary centers with adequate maternal and neonatal intensive care facilities. Finally patients with preeclampsia are at increased risk for recurrence of preeclampsia in subsequent pregnancies.