Int J Clin Exp Med

8/18/2019 Int J Clin Exp Med

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Int J Clin Exp Med. 2015; 8(10): 19325–19331.

Publised !nline 2015 "#t 15.

Does aggressive and expectant management of severe preeclampsiaaffect the neurologic development of the infant?

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Abstract

Objective: To compare and evaluate the influences of expectant and aggressive management

of severe preeclampsia on the first year neurologic development of the infants in pregnancies

between 27 and 34 wees of pregnancy! "ethods: #eventy women with severe preeclampsia

between 27 and 34 wees of gestation were included in the study! 37 patients were managedaggressively $%roup &' and 33 patients were managed expectantly $%roup 2'!

%lucocorticoids( magnesium sulfate infusion and antihypertensive drugs were administered to

each group! )fter glucocorticoid administration was completed %roup & was delivered either

by cesarean section or vaginal delivery! *n %roup 2 magnesium sulfate infusion was stopped

after glucocorticoid administration was completed! )ntihypertensive drugs were given( bed

rest and intensive fetal monitori+ation were continued in this group! ,esults: The average

wees of gestation( one minute and five minute apgar scores and hospitali+ation time in

intensive care unit were similar in both groups $ P - .!./'! Three neonatal complications in

%roup 2 and five in %roup & were detected according to the 0enver 0evelopmental#creening Test1** and one pathologic case was detected in both groups following neurologic

examination! eonatal mortality was seen in seven patients in %roup & and one in %roup 2!

There were no significant differences between groups in terms of neonatal mortality and

morbidity and maternal morbidity $ P - .!./'! The average latency period was 3!4/ /!4

days in %roup 2 and none in %roup &! 5onclusion: There was no significant difference in the

first year neurological development of infants whose mothers underwent either expectant and

aggressive management for severe preeclampsia!

Keywords: #evere preeclampsia( aggressive management( expectant management(

neurologic development! t!:

Introduction

6ypertensive diseases are the most commonly seen medical complications in pregnancy and

have incidence between /1&. 8&9! The actual incidence of preeclampsia is not nown but is

approximately /1 82(39!

"aternal and perinatal morbidities significantly increased with severe preeclampsia 83(49!

#evere preeclampsia is related to increased maternal mortality $.!2' and morbidities $/'such as sei+ures( pulmonary edema( acute renal and liver failure( disseminated intravascular

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ertekin%20AA%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Kapudere%20B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Eken%20MK%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Eken%20MK%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x00130%3Blhan%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x00130%3Blhan%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=D%26%23x00131%3Brman%20%26%23x0015e%3B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=D%26%23x00131%3Brman%20%26%23x0015e%3B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Sarg%26%23x00131%3Bn%20MA%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Sarg%26%23x00131%3Bn%20MA%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Deniz%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Deniz%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Deniz%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Karatekin%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Karatekin%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Karatekin%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3B%26%23x000f6%3B%26%23x0011f%3Bendez%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3B%26%23x000f6%3B%26%23x0011f%3Bendez%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3B%26%23x000f6%3B%26%23x0011f%3Bendez%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Api%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b4http://www.ncbi.nlm.nih.gov/pubmed/?term=Kapudere%20B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Eken%20MK%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x00130%3Blhan%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=D%26%23x00131%3Brman%20%26%23x0015e%3B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Sarg%26%23x00131%3Bn%20MA%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Sarg%26%23x00131%3Bn%20MA%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Deniz%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Karatekin%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3B%26%23x000f6%3B%26%23x0011f%3Bendez%20E%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Api%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b4http://www.ncbi.nlm.nih.gov/pubmed/?term=Ertekin%20AA%5Bauth%5D


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coagulopathy $0*5'( and stroe! These complications are most commonly seen before 32

wees gestational age or in patients who have other systemic illness 8/9!

*n severe preeclampsia( maternal and fetal conditions generally worsen and only delivery can

stop this progression! arly diagnosis and appropriate management can improve maternal and

fetal conditions! 0elivery should be planned for pregnant women who develop the disease

after 34 wees of gestation because of increased morbidity and mortality of women and

increased ris to the fetus $intrauterin growth restriction $*;%,'( hypoxemia( and death'!

0elivery must be considered immediately in the event of eclampsia( multiorgan dysfunction(

severe *;%, $< / percentile'( ablatio placenta and non1reassuring non1stress test $#T' 8=(79!

*f both maternal and fetal conditions are stable( there is no consensus on the management of

severe preeclamptic women before 34 wees of gestation! *n these patients( some authors

accept birth as definitive treatment independent from the gestational age( whereas others

suggest delivery if maternal and fetal indications present 8=(79!

>abor is always acceptable for the mother( but it may not always be ideal for the fetus! Our

aim in this study was to compare expectant and aggressive management of pregnant women

with severe preeclampsia between 27 and 34 wees of gestation( and to evaluate the influence

of these on the first year of neurologic development in the infants!

! t!:

Materials and methods

This is a prospective cohort study and was conducted by examining hospitali+ed patients in?eynep @amil Aomen and 5hildren 0iseases( ducation and ,esearch 6ospital( 0epartment

of Obstetrics and %ynecology( between Banuary &( 2.&.( and Banuary &( 2.&2! The study

group consisted of 7. pregnant women with severe preeclampsia between 27134 wees of

gestation! "ultiple pregnancies were excluded from the study! )ll patients were followed up

in the hospital! 5omplete blood count $5C5'( aspartate aminotransferase $)#T'( alanine

aminotransferase $)>T'( urea( creatinine( lactate dehydrogenase $>06'( uric acid( total

protein and albumin( protein in spot urine( and 241hour urine protein levels were measured!

#evere preeclampsia signs were determined as: systolic blood pressure D &=. mm6gE

diastolic blood pressure D &&. mm6gE D / gram proteinuria in 24 hour urine collectionEoliguria $F /.. m>G24 hour diuresis'E severe *;%,E central nervous system dysfunction or

symptoms of liver capsule distensionE hepatocellular damage $serum transaminase levels

rising 2 times above normal values'E and thrombocytopenia $< &.....Gmm3'!

Thirty1three women were assigned to expectant management and 37 women were assigned to

aggressive management! Coth expectant and agressive management groups received &2 mg

betamethasone and a second &2 mg dose was administered 24 hours later! "agnesium sulfate

infusion and antihypertensive therapy were started for both groups! )fter bethamethasone

therapy was completed( the aggressive management group $n H 37' were delivered either bycesarean $5G#' or vaginal delivery with induction! *n the expectant management group $n H

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33'( magnesium sulfate infusion was stopped( antihypertensive drugs were completed( and

bed rest and intensive fetal monitari+ation were continued!

Ietal cardiotocography was evaluated every = hours and ultrasound was performed once a

wee for fetal monitoring! 5C5( )#T( )>T( >06( urea( creatinine( uric acid( total protein(

and albumin analysis were performed daily! *ndications for termination of pregnancy were:

reaching 34 wees gestation( and fetal distress and maternal indications $hemolysis( elevated

liver en+ymes( low platelet count $6>>J' syndrome( renal morbidity( uncontrolled

hypertension( prodromal symptoms( and antepartum hemorrhage!

,enal morbidity was determined as deterioration of renal function $elevation of urea and

creatinine( electrolyte imbalance' and oliguria or anuria! >iver morbidity was determined as

elevation of liver en+ymes( prolongation of bleeding time( and hypoalbuminemia! )ll patients

who were diagnosed as having 6>>J syndrome were managed aggressively! Ietal distress

was diagnosed when repetitive late decelerations and decreased variability in #T occurred!*;%, was not an indication for delivery per se but was handled as a supporting factor of

other indications to terminate the pregnancy!

Type of delivery( indication for birth( birth weight( &st and /th minute apgar scores( neonatal

intensive care reKuirement and hospitali+ation time in intensive care unit( complications and

managements of all patients were recorded! *nfants were evaluated using the 0enver

0evelopmental #creening Test1** by a child development specialist and their neurologic

examination was performed by a neurologist at &2 months!

The 0enver 0evelopmental #creening Test1** $00#T1**' 81&.9 is a development scale!00#T1** assesses a childLs development in 4 general areas( &! personal1socialE 2! languageE 3!

fine motor1adaptiveE and 4! gross motor abilities of the infant! #creening with this scale

produces 3 scores: normal( suspect( and untestable $these children refuse participation in

some items that M/ of age1matched children could pass'!

Statistical analysis

#tatistical evaluation of the study data was made with #tatistical Jacage for the #ocial

#ciences $#J##' for Aindows 2.. #tatistical #oftware $;tah( ;#)'! #tudentLs t1test( "ann1

Ahitney ; test were used for comparison of parameters! Ior comparing Kualitative data( 5hi1sKuare test( NatesLs continuity correction and IisherLs exact tests were used! ) value of P <

.!./ was considered statistically significant!

! t!:

Results

The mean age of the patients was 27!=& /!/. years! The mean pregnancy wee of patients

was 3.!= 2!4&! The average latency period was 3!4/ /!4 days!

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The patientsL average wees of gestation were 3&!.M 2!/3 in the expectant management

group and 3.!=4 2!3& in the aggressive management group! There was no statistically

significant difference bewteen the average wees of gestation of both groups $ P - .!./'! Cirth

weight of neonates in both groups showed no statistically significant difference $ P - .!./'!

)pgar scores $&1/ minute' were not significanty different relative to the management groups$ P - .!./' $Table &'!

Table &

valuation of maternal demographic features( pregnancy wee( birth weight and )J%),

scores

Cirth weights of / $&/!&' newborns in the expectant management group and 4 $&.!' in

the aggressive management group could not be measured because of the need for neonatal

resuscitation!

Iive women were diagnosed as having 6>>J syndrome and all were in the aggressive

management group( which was statistically significant $ P < .!./'! Ietal distress( *;%,(

uncontrolled hypertension( renal morbidity( prodromal symptoms( and antepartum

hemorrhage were not statistically significantly different between the management groups

$ P - .!./' $Table 2'!

Table 2

*ndications of 0elivery and Jregnancy Termination )ccording to "anagement %roups

The hospitali+ation time in the neonatal intensive care unit( respiratory distress( sepsis and

intracranial hemorrhage( and surfactant reKuirement were not statistically significantly

different according to the management groups $ P - .!./'! The neonatal mortality ratio in the

aggressive management group was more than the expectant management group( but it was

not statistically significant $ P - .!./' $Table 3'!

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Table 3

valuation of fetal parameters

The 00#T1** results and neurologic examination findings were not statistically significantly

different between the management groups $ P - .!./' $Table 4'! "aternal renal and liver

morbidities were not statistically significantly different between the management groups $ P -

.!./' $Table /'!

Table 4

eurologic evaluation of the nfants

Table /

valuation of maternal parameters

! t!:

Discussion

Jreeclampsia is one of the most important reasons for maternal and perinatal mortality and

morbidity! "aternal and perinatal mortality and morbidity increase in severe forms of

preeclampsia and delivery is the only treatment! Ietal lung development is supposed to be

completed after 34 wees of gestationE therefore( some physicians share a common idea about

delivery in severe preeclampsia after this wee! 6owever( early termination of pregnancy in

severe preeclampsia for decreasing maternal mortality and morbidity can cause increased

perinatal mortality and morbidity 8&139!

*n the past( it was believed that the neonates who were born from severe preeclamptic

pregnancies had low mortality and morbidity compared with neonates born from

normotensive women at the same gestational wee! *t was believed that pulmonary and

neurologic maturation were increased due to in1utero stress! 6owever( in recent years( case1

control studies have not shown increased lung and neurologic maturation in neonates born

from preeclamptic pregnancies 8&&1&39!

)dvances in maternal and neonatal monitori+ation remove most physicians from the idea of

delivering severe preeclamptic pregnancies immediately! *mprovement in neonatal outcomes

after corticosteroid prophylaxis has led many physicians to wait for the use of corticosteroids!

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Termination of pregnancy after prophylaxis or expectant approach is still a matter of debate!

%estational age( fetal and maternal status direct the management!

Odendaal et al evaluated / severe preeclamptic women between 2134 wees of gestation in

a randomi+ed prospective study and the average latency period was 7!& days 8&49! *n another

randomi+ed prospective study of #ibai et al( M/ pregnant women between 2132 wees of

gestation were examined and the average latency period was &/!4 daysE delivery wee and

birth weight were significantly increased in the expectant group 8&/9! The latency period

between hospitali+ation and delivery was different between the studies! *n a non1randomi+ed

study by Odendaal et al( the authors reviewed &2M preeclamptic women < 34 wees of

gestation( the latency period was && days 8&=9( was M!/ days in a retrospective study by Olah

et al 8&79( and &4 days in the study of Pisser et al 8&9! 6all et al reported on 34. women

between 24134 wees of gestation who presented with early1onset severe preeclampsia and

managed with expectant management and found that pregnancies were prolonged && days

before delivery 8&M(2.9! 6addad et al performed a prospective observational study of 23M

women with severe preeclampsia and the prolongation time of pregnancy was classified

according to gestational weesE prolongation time was = days below 2M wees( 4 days

between 2M13& wees( and 4 days between 32133 wees 82&9!

*n our study the latency period ranged between &12 days and the average latency period was

3!4/ days! The latency period in our study was calculated from post corticosteroid

administration as in the studies of #ibai 8&/9 and 6addad 82&9! *n some studies it was

determined as the time between hospitali+ation and delivery 8&412.9!

Ahen deciding the type of delivery( it was suggested that maternal and fetal conditions(

wees of gestation( and CishopLs cervical score should be considered 8&9! *n a study of

#arsam et al( severe preeclamptic women between 24134 wees of gestation were evaluated!

*n the expectant management group there were 27 5G# and &2 vaginal births( and in the

aggressive management group there were 27 5G# and &2 vaginal deliveries 8229! *n our study(

the number of 5G# were higher than in the literature! "ost of our patients had low CishopLs

scores and were < 34 wees of gestationE these may be the cause of the high percentage of 5#

in our study! Ahen maternal and fetal deterioration or complications occur in severe

preeclampsia( maternal and fetal morbidity and mortality are high! )s a result( the majority of

physicians hesitate to wait for vaginal birth because of complications both for fetus and

mother! Thus 5G# was preferred for terminating the pregnancy as Kuicly as possible!

6owever( this does not imply that we advocate the termination of severe preeclampsia by

cesarean sectionE vaginal delivery may be an option for severe preeclampsia under

appropriate conditions!

#arsman et al conducted a study with 74 severe preeclamptic women and they compared one

minute )pgar scores( which were /!./ in the expectant management group and 3!/= in the

aggressive management groupE a statistically significant difference was determined between

the two groups 8229! *n our study( a statistically significant difference was not determined inthe &st and /th minute )pgar scores of the neonates!

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Odendaal et al observed that fewer neonates needed ventilation in the expectant management

group than in the aggressive management group( they also determined that neonatal

complications were reduced in the expectant management group 8&49! #ibai et al found

shorter hospitali+ation time in the intensive care unit and fewer neonatal complications in

their study 8&/9! #arsman et al detected significant differences between the expectant andaggressive management groups in terms of ,0#! *n the aggressive management group( &.

fetal deaths occurred and two $2.!/' were related with ,0#E in the expectant management

group( 4 fetal deaths occurred and two were related with ,0# 8229! *n our study( when other

fetal parameters were evaluated( no significant differences were determined between the

groups in terms of neonatal intensive care unit admission rate and duration of hospitali+ation

in the neonatal intensive care unit! eonatal mortality was seen in 7 patients in the aggressive

management group and & in the expectant management groupE however( the difference did

not reach statistical significance! ,elative to surfactant reKuirement( respiratory distress

syndrome( sepsis( and intracranial hemorrage( there were no significant differences betweenthe groups!

The main parameter of our study was neurologic morbidity of neonates! Ior this purpose( the

00#Test1** and neurologic examinations were performed when the infants completed the

first year! )ccording to these parameters( no significant difference was determined between

the expectant and aggressive management groups!

Ahen maternal outcomes were analy+ed( maternal mortality( pulmonary edema( eclampsia(

neurologic morbidity( postpartum hemorrhage( and hypertensive sei+ures were not observed

in our study( and there was no reKuirement for the intensive care unit! Only two patientsdeveloped renal morbidity in the aggressive management group but renal failure did not

develop in these patients and there was no reKuirement for dialysis! >iver morbidity was

observed in & patient in the expectant management group and / in the aggressive

management group! o severe maternal morbidity developed in either group and there was

no statistically significant difference between the groups!

! t!:

Conclusion

To the best of our nowledge( there were no statistically significant differences between the

expectant and aggressive management groups in terms of neonatal and maternal morbidity

and mortalityE neonatal mortality was very close but did not reach significance $ P H .!./'!

5orticosteroid administration in the aggressive management group gave good results in terms

of perinatal morbidity! *n our study( we assigned severe preeclamptic women between 27134

wees of gestation to expectant and aggressive management groups and determined no

significant difference in terms of neonatal neurologic morbidity! Aith reference to our study(

termination of pregnancy in severe preeclampsia might be considered for pregnancies < 34

wees of gestation after corticosteroid treatment is completed!! t!:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/#b22http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694471/


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Acknoledgements

* would lie to express my sincere thans to all colleagues and ihal Q+demir who helped

with the statistical analysis!

! t!:

Disclosure of conflict of interest

one!

! t!:

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