Expectant management of severe preeclampsia remote from term: a structured systematic review.
OBJECTIVE
To compare outcomes associated with expectant vs. interventionist care of severe preeclampsia in observational studies.


METHODS
Medline (01/1980-07/2007), bibliographies of retrieved papers, personal files, Cochrane Database of Systematic Reviews.


METHODS
Expectant or interventionist care of preeclampsia at <34 wk. TABULATION, INTEGRATION, RESULTS: Data abstraction independently by two reviewers. Median [IQR] of clinical maternal/perinatal outcomes presented.


RESULTS
72 publications, primarily from tertiary care centres in Dutch and developed world sites. Expectant care of severe preeclampsia <34 wk (39 cohorts, 4,650 women), for which 40% of women are eligible, is associated with pregnancy prolongation of 7-14 d, and few serious maternal complications (median <5%), similar to interventionist care (2 studies, 42 women). Complication rates are higher with HELLP <34wk (12 cohorts, 438 women) and severe preeclampsia <28wk (6 cohorts, 305 women), similar to interventionist care (6 cohorts, 467 women and 2 cohorts, 70 women, respectively). Expectant care of HELLP <34 wk (12 cohorts, 438 women) is associated with fewer days gained (median 5), but more serious maternal morbidity (e.g., eclampsia, median 15%). More than half of women have at least temporary improvement of HELLP. In the developed world, expectant (vs. interventionist) care of severe preeclampsia or HELLP <34 wk is associated with reduced neonatal death and complications. Stillbirth is higher in Dutch and developing world sites where viability thresholds are higher. For preeclampsia <24wk (4 cohorts), perinatal mortality is >80%. No predictors of adverse maternal/perinatal outcomes were identified (13 studies).


CONCLUSIONS
Future research should establish the best maternal/fetal monito regimen and indications for delivery with expectant care. A definitive RCT is needed.
Magee
L A
LA
Departments of Medicine, University of British Columbia, Vancouver, BC, V6H 3N1, Canada.
Yong
P J
PJ
Espinosa
V
V
Côté
A M
AM
Chen
I
I
von Dadelszen
P
P
D005260:Female; D005865:Gestational Age; D017359:HELLP Syndrome / Q000628:therapy*; D006801:Humans; D015999:Multivariate Analysis; D011225:Pre-Eclampsia / Q000628:therapy*; D011247:Pregnancy; D012720:Severity of Illness Index; D016896:Treatment Outcome