A limitation of this study is that all women with preeclampsia were considered the same—that is, no distinction was made between severe and nonsevere preeclampsia, and a significant proportion of women had severe hypertension at enrollment, which would make them ineligible for expectant management anyway.
The maternal composite outcome was driven mostly by severe hypertension and progression to severe preeclampsia (likely driven by severe hypertension). All other maternal outcomes were very rare or did not happen; however, the incidence of delivery indications for various preeclampsia-related complications was higher in the expectant management group.
The takeaway
In the absence of biomarkers for risk stratification and treatment of preeclampsia, delivering women who have a diagnosis of preeclampsia at or beyond 34 weeks’ gestation may be a viable option for preventing maternal complications.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
In the United States, preeclampsia is categorized as severe or nonsevere, and gestational age at delivery depends on the type of preeclampsia. Clinicians should discuss expectant management after 34 weeks with patients who have preeclampsia without severe features, noting that this may decrease the chances for adverse maternal outcomes (mostly severe hypertension) at the cost of neonatal intensive care unit admission, which may depend on local practices. Attention also should be paid to particular patient populations (such as obese and African American women) who are at higher risk for developing adverse maternal outcomes. This may be particularly relevant in a smaller hospital setting in which patient follow-up may not be universal or access to a maternal-fetal medicine specialist may not be available to discuss management plans.
My personal take: I work in a large tertiary medical center. I worry about added prematurity, especially among women with superimposed preeclampsia where the diagnosis may be unclear. In my practice, we monitor patients with preeclampsia very closely, and with any signs of severe features we deliver them after 34 weeks. We follow ACOG guidelines for managing preeclampsia based on severity of disease and gestational age. I am not planning to immediately change my practice based on this study by Chappell and colleagues, and I will wait for results of long-term effects on neonatal outcomes, studies using biomarkers for risk assessment of women at risk for adverse outcomes, and opinions from ACOG and the Society for Maternal-Fetal Medicine about this management plan.
SAROSH RANA, MD, MPH