The Risk of Adverse Maternal and Perinatal Outcomes Following Aggressive Versus Conservative Management of Early Onset Pre-eclampsia With Severe Features at Kenyatta National Hospital

Abstract

BACKGROUND: Preeclampsia refers to onset of hypertension after 20 weeks of gestation in a previously normotensive patient in presence proteinuria, platelet count <100,000/microL, elevated serum creatinine, at least twice liver transaminases, pulmonary edema, new-onset and persistent headache not accounted for by alternative diagnoses and not responding to usual doses of analgesics, and visual symptoms such as blurred vision, flashing lights or sparks, or scotomata. Preeclampsia complicates 5-8% of pregnancy. In addition, it is among the leading causes of morbidity and mortality to both the mother and the perinate. The management of preeclampsia without severe features has ordinarily been based on the count of balancing the interests of the mother with those of the fetus. Conversely, Preeclampsia with Severe Features (PES) has been managed by expedited fetus delivery the gestation age notwithstanding. In the contemporary era, the availability of improved approaches for monitoring both maternal and fetal progress has increased criticisms for the traditional approach of expedited delivery (aggressive management). The bottom line argument is that mothers who are stable but with early-onset PES (24-34 weeks) can have their delivery delayed cautiously (conservative management) with the aim of improving perinatal outcomes without compromising maternal safety. In previous studies in USA, the average latency period was 15.4 days without eclampsia or perinatal death following expectant management. Also, expectant management had decreased the incidence of admission to the new born unit and neonatal complications. Although a few regional studies have been conducted in South Africa, Odendaal et al and Hall et al suggest similar outcomes. There are no studies to inform local guidelines, protocols and practice. In this retrospective cohort study, we sought to estimate the mean duration of latency for conservative management, and to compare the perinatal and maternal outcomes of conservative compared to aggressive management of early-onset PES at KNH so as to inform development of guidelines, protocols and practice. OBJECTIVE: 14 To compare the risk of adverse maternal and perinatal outcomes of women undergoing aggressive versus conservative management of early-onset PES at Kenyatta National Hospital between January 2014 and December 2019 METHODS: The study was a retrospective cohort study with data collected from medical records of pregnant women with PES at 24 – 34 weeks gestation from 1st January 2014 to 31st December 2019. A total of 452 pregnant women with PES at 24 – 34 weeks gestation of whom, 226 underwent conservative management and 226 underwent aggressive managementwere sampled consecutively and followed until delivery to assess for perinatal and maternal outcomes. Conservative management was defined as prolonging pregnancy to improve perinatal outcomes in pregnant women with early-onset PES who have completed the dose of antenatal corticosteroids and 24 hours post-admission and are in stable condition. Aggressive management was defined as administration of antenatal corticosteroids followed by immediate delivery of pregnant women with early-onset PES so as to reduce the risk of adverse maternal outcomes. Baseline socio-demographics were compared using t-test for continuous data and frequency and proportions for categorical variables. Simple logistic regression was used to compare association between type of management (aggressive or conservative) and outcome (perinatal or maternal outcome) and crude odds ratio with 95% confidence interval were used for its presentation. Multiple logistic regression analysis was carried out to determine the factors affecting the association between outcome and exposure.P value of 0.05 was considered statistically significant. The data was analyzed using STATA 15and presented inform of charts, tables, and as narrative. RESULTS: Between January 2014 and December 2019, a total of3,619 medical records of pregnant women with PES at 24 – 34 weeks gestation, admitted betweenJanuary 2014 and December 2019 were extracted and reviewed. Of these, 640 records were assessed for eligibility of which, 452 met the eligibility criteria. 226 were in the conservative and 226 were in the aggressive arm of 15 management.188 were excluded due to missing data. The mean (sd) prolongation of pregnancy was 16. 4(16.6).On multi-variate analysis, babies born to women who underwent aggressive management had a 1.4 times greater odds of developing adverse perinatal outcomes than those born to women on conservative management with an OR of 1.41 ,95% C/I of (0.95-2.15) which was not statistically significant.In multi-variate analysis, women on aggressive management had a 2.4 times higher odds of developing adverse maternal outcomes than those on conservative management with an OR of 2.39, 95% C/I of (1.24-4.60) which was statistically significant. CONCLUSION: This study has showed that aggressive management was associated with 2.4 times higher risk of developing adverse maternal outcomes compared with conservative management of early-onset PES. The risk of adverse perinatal outcomes was found to be non-statistically significantly greater in the A/M arm compared to the C/M arm of early-onset PES. In addition, conservative management of early-onset PES had a mean(standard deviation) prolongation of pregnancy of 16.4(16.6) days. RECOMMENDATIONS: Pregnant women with early-onset PES eligible for conservative management should be offered under close monitoring and advised that it takes on average two weeks from admission to delivery with a decreasedodds of risk of maternal adverse outcomes. The study results will be instrumental in informing policy and local guidelines on management of early-onset pre-eclampsia with severe features. In addition, a larger prospective study with a prolonged follow-up period of newborns should be conducted in the future to provide better insight on the outcomes.