title: The impact of fetal growth restriction on latency in the setting of expectant management of preeclampsia.
abstract: BACKGROUND
  Fetal growth restriction is a common complication of preeclampsia. Expectant management for qualifying patients has been found to have acceptable maternal safety while improving neonatal outcomes. Whether fetal growth restriction influences the duration of latency during expectant management of preeclampsia is unknown.
  
  
  OBJECTIVE
  The objective of the study was to determine whether fetal growth restriction is associated with a reduced interval to delivery in women with preeclampsia being expectantly managed prior to 34 weeks.
  
  
  METHODS
  We performed a retrospective cohort of singleton, live-born, nonanomalous deliveries at the University of Cincinnati Medical Center between 2008 and 2013. Patients were included in our analysis if they were diagnosed with preeclampsia prior to 34 completed weeks and if the initial management plan was to pursue expectant management beyond administration of steroids for fetal lung maturity. Two study groups were determined based on the presence or absence of fetal growth restriction. Patients were delivered when they developed persistent neurological symptoms, severe hypertension refractory to medical therapy, renal insufficiency, nonreassuring fetal status, pulmonary edema, or hemolysis elevated liver low platelet syndrome or when they reached 37 weeks if they remained stable without any other indication for delivery. Our primary outcome was the interval from diagnosis of preeclampsia to delivery, measured in days. Secondary outcomes included indications for delivery, rates of induction and cesarean delivery, development of severe morbidities of preeclampsia, and select neonatal outcomes. We performed a multivariate logistic regression analysis comparing those with fetal growth restriction with those with normally grown fetuses to determine whether there is an association between fetal growth restriction and a shortened interval to delivery, neonatal intensive care unit admission, prolonged neonatal stay, and neonatal mortality.
  
  
  RESULTS
  A total of 851 patients met the criteria for preeclampsia, of which 199 met inclusion criteria, 139 (69%) with normal growth, and 60 (31%) with fetal growth restriction. Interval to delivery was significantly shorter in women with fetal growth restriction, median (interquartile range) of 3 (1.6) days vs normal growth, 5 (2.12) days, P < .001. The association between fetal growth restriction and latency less than 7 days remained significant, even after post hoc analysis controlling for confounding variables (adjusted odds ratio, 1.66 [95% confidence interval, 1.12-2.47]). There were no differences in the development of severe disease (85.9 vs 91.7%, P = .26), need for intravenous antihypertensive medications (47.1 vs 46.7%, P = .96), and the development of severe complications of preeclampsia (51.1 vs 42.9%, P = .30) in normally grown and growth-restricted fetuses, respectively. Fewer women with fetal growth restriction attained their scheduled delivery date, 3 of 60 (5.0%), compared with normally grown fetuses,12 of 139 (15.7%), P = .03. Admission to the neonatal intensive care unit, neonatal length of stay, and neonatal mortality were higher when there was fetal growth restriction; however, after a logistic regression analysis, these associations were no longer significant.
  
  
  CONCLUSIONS
  Fetal growth restriction is associated with a shortened interval to delivery in women undergoing expectant management of preeclampsia when disease is diagnosed prior to 34 weeks. These data may be helpful in counseling patients regarding the expected duration of pregnancy, guiding decision making regarding administration of steroids and determining the need for maternal transport.
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: David
authors.initials: D
authors.lastname: McKinney
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Heather
authors.initials: H
authors.lastname: Boyd
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Amanda
authors.initials: A
authors.lastname: Langager
authors.affiliation: University of Cincinnati, Cincinnati, OH.
authors.forename: Michael
authors.initials: M
authors.lastname: Oswald
authors.affiliation: University of North Carolina, Chapel Hill, NC.
authors.forename: Abbey
authors.initials: A
authors.lastname: Pfister
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH. Electronic address: eaglercr@ucmail.uc.edu.
authors.forename: Carri R
authors.initials: CR
authors.lastname: Warshak
mesh_terms: D000328:Adult; D001724:Birth Weight; D002585:Cesarean Section / Q000706:statistics & numerical data*; D005260:Female; D005317:Fetal Growth Retardation / Q000209:etiology*; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D007751:Labor, Induced / Q000706:statistics & numerical data*; D011225:Pre-Eclampsia / Q000175:diagnosis / Q000628:therapy*; D011247:Pregnancy; D012189:Retrospective Studies; D013997:Time Factors; D057832:Watchful Waiting; D055815:Young Adult
keywords: expectant management of preeclampsia; fetal growth restriction; preeclampsia