Early onset pre-eclampsia with severe features necessitating fetal delivery: outcome of pregnancies with birthweight 1000-1800g at Tygerberg Hospital 2017
Date
2021-12
Authors
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Journal ISSN
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Publisher
Stellenbosch : Stellenbosch University
Abstract
Introduction: Expectant management of early onset pre-eclampsia (EOPE) is an
established practice at Tygerberg Hospital and some other tertiary institutions in South
Africa. Its outcome has been documented in several studies. However, neonatal care
has improved since many of these studies were done, e.g., nasal continuous positive
airway pressure (NCPAP) plus intubation, surfactant, and extubation (InSurE)
(introduced in 2006 at Tygerberg) and therapeutic hypothermia introduced in 2008. It
is plausible that an interventionist approach (delivery after 48 hours of optimal maternal
and fetal preparation, stabilisation of mother, antenatal corticosteroids and MgSO4 for
neuroprotection, fetal evaluation with ultrasound, Doppler and electronic fetal
monitoring) with access to good neonatal care can yield the same outcome without
subjecting the mother to the additional dangers of expectant management. The women
who do not qualify for expectant management (due to maternal or fetal contra-
indications) can be a good proxy for an interventionist approach to EOPE. The outcome
of ELBW (<1000g) babies at Tygerberg has been described previously.
Methods: This was an observational cross-sectional study using data from the
routinely collected PPIP database, electronic labour ward register and clinical data
from patient folders. All pregnancies complicated by pre-eclampsia with a birthweight
of 1000-1800g born at least 24 hours after admission in 2017 at Tygerberg Hospital
were identified. Patients admitted for formal expectant management were excluded.
By folder review, routine provincial admission and discharge data and mortality data,
clinical outcome and neonatal survival were investigated.
Findings: 139 Women were identified by total population sampling. The presenting
diagnosis was EOPE (122 women, [88%]) LOPE (14 women [10%]) or eclampsia (3
women [2%]). Intra-uterine growth restriction (IUGR) was diagnosed in 41% of cases
before delivery. The time to delivery was on average 81 hours. In total, 65 (46.7%) of
deliveries were due to fetal indications. Maternal indications for early delivery in the
remaining 74 women were: pregnancy that reached 34 weeks (n=28), specialist
opinion (n=13), HELLP syndrome (n=7), pulmonary oedema (n=7), severe maternal
ascites (n=6), uncontrollable hypertension (n=5), maternal request (n=3), eclampsia
(n=3) or acute renal injury (n=2). There were no intrapartum deaths and only two
neonatal deaths. The rest of the babies were discharged alive from hospital. For 22
babies, there were no accounts of follow-up visits in the province. Thirty babies iii
attended the neurodevelopmental clinic for follow-ups. Of these, three had spastic
cerebral palsy and two had fine or gross motor delay. The rest had no major disabilities
noted. The remaining 84 babies all had contact with health services during the months
after discharge, with minor problems. The mean number of neonatal days in hospital
was 20 and ranged from 2 days to 116 days.
Conclusion: Neonatal outcomes were acceptable and overall survival was better than
the initial study done at Tygerberg Hospital (with 12 neonatal deaths in babies >1000g
in the group of 340 women managed expectantly in 1992-1997). With these findings,
a rethink of management strategies for pregnancies complicated by severe early onset
pre-eclampsia is warranted and a randomised trial is recommended as the next step.
AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar
AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar
Description
Thesis (MMed)--Stellenbosch University, 2021.
Keywords
Preeclampsia, Newborn infants -- Death, Pregnant women -- Care