Early onset severe pre-eclampsia: Expectant management at a secondary hospital in close association with a tertiary institution
Objectives: Early onset severe pre-eclampsia is ideally managed in a tertiary setting. We investigated the possibility of safe management at secondary level, in close co-operation with the tertiary centre. Design: Prospective case series over 39 months. Setting: Secondary referral centre. Population: All women (n = 131) between 24 and 34 weeks of gestation with severe pre-eclampsia, where both mother and fetus were otherwise stable. Methods: After admission, frequent intensive but non-invasive monitoring of mother and fetus was performed. Women were delivered on achieving 34 weeks, or if fetal distress or major maternal complications developed. Transfer to the tertiary centre was individualised. Main outcome measures: Prolongation of gestation, maternal complications, perinatal outcome and number of tertiary referrals. Results: Most women [n = 116 (88.5%)] were managed entirely at the secondary hospital. Major maternal complications occurred in 44 (33.6%) cases with placental abruption (22.9%) the most common. One maternal death occurred and two women required intensive care admission. A mean of 11.6 days was gained before delivery with the mean delivery gestation being 31.8 weeks. The most frequent reason for delivery was fetal distress (55.2%). There were four intrauterine deaths. The perinatal mortality rate (≥1000 g) was 44.4/1000, and the early neonatal mortality rate (≥500 g) was 30.5/1000. Conclusions: The maternal and perinatal outcomes are comparable to those achieved by other tertiary units. This model of expectant management of early onset, severe pre-eclampsia is encouraging but requires close co-operation between secondary and tertiary institutions. Referrals to the tertiary centre were optimised, reducing their workload and costs, and patients were managed closer to their communities.