Download PDF
Am J Perinatol 2024; 41(S 01): e1521-e1530
DOI: 10.1055/s-0043-1768232
Original Article

Association of Maternal Medical Comorbidities with Duration of Expectant Management in Patients with Severe Preeclampsia

Gabriella D. Cozzi 
1   Division of Maternal Fetal Medicine Center for Women's Reproductive Health, University of Alabama at Birmingham, Alabama
2   Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
,
Ashley N. Battarbee 
1   Division of Maternal Fetal Medicine Center for Women's Reproductive Health, University of Alabama at Birmingham, Alabama
2   Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
,
Aalok R. Sanjanwala
1   Division of Maternal Fetal Medicine Center for Women's Reproductive Health, University of Alabama at Birmingham, Alabama
2   Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
,
Brian M. Casey
1   Division of Maternal Fetal Medicine Center for Women's Reproductive Health, University of Alabama at Birmingham, Alabama
2   Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
,
Akila Subramaniam
1   Division of Maternal Fetal Medicine Center for Women's Reproductive Health, University of Alabama at Birmingham, Alabama
2   Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
› Author Affiliations Funding Effort for A.N.B. was supported by a grant from the The Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant number: K23HD103875).
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective This study aimed to estimate the association between number of maternal comorbidities and duration of expectant management and perinatal outcomes in patients with preeclampsia with severe features.

Study Design Retrospective cohort of patients with preeclampsia with severe features delivering live, nonanomalous singletons at 23 to 342/7 weeks' gestation at a single center from 2016 to 2018. Patients delivered for an indication other than severe preeclampsia were excluded. Patients were categorized based on the number (0, 1, or ≥2) of comorbidities present: chronic hypertension, pregestational diabetes, chronic kidney disease, and systemic lupus erythematosus. The primary outcome was proportion of potential expectant management time achieved, that is, days of expectant management achieved divided by total potential expectant management time (days from severe preeclampsia diagnosis to 340/7 weeks). Secondary outcomes included delivery gestational age, days of expectant management, and perinatal outcomes. Outcomes were compared in bivariable and multivariable analyses.

Results Of 337 patients included, 167 (50%) had 0, 151 (45%) had 1, and 19 (5%) had ≥2 comorbidities. Groups differed with respect to age, body mass index, race/ethnicity, insurance, and parity. The median proportion of potential expectant management achieved in this cohort was 1.8% (interquartile range: 0–15.4), and did not differ by number of comorbidities (adjusted β: 5.3 [95% confidence interval [CI]: −2.1 to 12.9] for 1 comorbidity vs. 0 and adjusted β: −2.9 [95% CI: −18.0 to 12.2] for ≥2 comorbidities vs. 0). There was no difference in delivery gestational age or duration of expectant management in days. Patients with ≥2 (vs. 0) comorbidities had higher odds of composite maternal morbidity (adjusted odds ratio: 3.0 [95% CI: 1.1–8.2]). There was no association between number of comorbidities and composite neonatal morbidity.

Conclusion Among patients with preeclampsia with severe features, the number of comorbidities was not associated with duration of expectant management; however, patients with ≥2 comorbidities had higher odds of adverse maternal outcomes.

Key Points

  • Greater number of medical comorbidities were not associated with expectant management duration.

  • Two or more medical comorbidities were associated with higher odds of adverse maternal outcomes.

  • Expectant management should be undertaken cautiously in medically complicated patients.

Keywords

preeclampsia - hypertension - diabetes - chronic kidney disease - systemic lupus erythematosus - cesarean delivery - placental abruption - pulmonary edema - maternal death

Supplementary Material



Publication History

Received: 09 July 2022

Accepted: 24 February 2023

Article published online:
18 April 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Sibai BM. Publications Committee, Society for Maternal-Fetal Medicine. Evaluation and management of severe preeclampsia before 34 weeks' gestation. Am J Obstet Gynecol 2011; 205 (03) 191-198
    CrossrefPubMedGoogle Scholar
  • 2 Magee LA, Yong PJ, Espinosa V, Côté AM, Chen I, von Dadelszen P. Expectant management of severe preeclampsia remote from term: a structured systematic review. Hypertens Pregnancy 2009; 28 (03) 312-347
    CrossrefPubMedGoogle Scholar
  • 3 Odendaal HJ, Pattinson RC, Bam R, Grove D, Kotze TJ. Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial. Obstet Gynecol 1990; 76 (06) 1070-1075
    PubMedGoogle Scholar
  • 4 Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial. Am J Obstet Gynecol 1994; 171 (03) 818-822
    CrossrefPubMedGoogle Scholar
  • 5 Vigil-De Gracia P, Reyes Tejada O, Calle Miñaca A. et al. Expectant management of severe preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter clinical trial. Am J Obstet Gynecol 2013; 209 (05) 425.e1-425.e8
    CrossrefPubMedGoogle Scholar
  • 6 American College of Ostetricians and Gynecologists. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122 (05) 1122-1131
    CrossrefPubMedGoogle Scholar
  • 7 Gestational Hypertension and Preeclampsia. Gestational hypertension and preeclampsia: ACOG Practice Bulletin Summary, Number 222. Obstet Gynecol 2020; 135 (06) 1492-1495
    CrossrefPubMedGoogle Scholar
  • 8 Churchill D, Duley L, Thornton JG, Moussa M, Ali HS, Walker KF. Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation. Cochrane Database Syst Rev 2018; 10 (10) CD003106
    CrossrefPubMedGoogle Scholar
  • 9 Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Chappell LC. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ 2014; 348: g2301
    CrossrefPubMedGoogle Scholar
  • 10 Gilbert WM, Young AL, Danielsen B. Pregnancy outcomes in women with chronic hypertension: a population-based study. J Reprod Med 2007; 52 (11) 1046-1051
    PubMedGoogle Scholar
  • 11 Lisonkova S, Joseph KS. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease. Am J Obstet Gynecol 2013; 209 (06) 544.e1-544.e12
    CrossrefPubMedGoogle Scholar
  • 12 Nzelu D, Dumitrascu-Biris D, Kay P, Nicolaides KH, Kametas NA. Severe hypertension, preeclampsia and small for gestational age in women with chronic hypertension diagnosed before and during pregnancy. Pregnancy Hypertens 2018; 14: 200-204
    CrossrefPubMedGoogle Scholar
  • 13 Panaitescu AM, Syngelaki A, Prodan N, Akolekar R, Nicolaides KH. Chronic hypertension and adverse pregnancy outcome: a cohort study. Ultrasound Obstet Gynecol 2017; 50 (02) 228-235
    CrossrefPubMedGoogle Scholar
  • 14 Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy 2003; 22 (02) 203-212
    CrossrefPubMedGoogle Scholar
  • 15 Oppermann MLDR, Alessi J, Hirakata VN, Wiegand DM, Reichelt AJ. Preeclampsia in women with pregestational diabetes - a cohort study. Hypertens Pregnancy 2020; 39 (01) 48-55
    CrossrefPubMedGoogle Scholar
  • 16 Sibai BM, Caritis S, Hauth J. et al; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Risks of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes mellitus. Am J Obstet Gynecol 2000; 182 (02) 364-369
    CrossrefPubMedGoogle Scholar
  • 17 Hui D, Hladunewich MA. Chronic kidney disease and pregnancy. Obstet Gynecol 2019; 133 (06) 1182-1194
    CrossrefPubMedGoogle Scholar
  • 18 Zhang JJ, Ma XX, Hao L, Liu LJ, Lv JC, Zhang H. A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy. Clin J Am Soc Nephrol 2015; 10 (11) 1964-1978
    CrossrefPubMedGoogle Scholar
  • 19 Dong Y, Yuan F, Dai Z, Wang Z, Zhu Y, Wang B. Preeclampsia in systemic lupus erythematosus pregnancy: a systematic review and meta-analysis. Clin Rheumatol 2020; 39 (02) 319-325
    CrossrefPubMedGoogle Scholar
  • 20 Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin J Am Soc Nephrol 2010; 5 (11) 2060-2068
    CrossrefPubMedGoogle Scholar
  • 21 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
    CrossrefPubMedGoogle Scholar
  • 22 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71 (19) e127-e248
    CrossrefPubMedGoogle Scholar
  • 23 Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita ATN. Chronic hypertension in pregnancy. Am J Obstet Gynecol 2020; 222 (06) 532-541
    CrossrefPubMedGoogle Scholar
  • 24 American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2020 . Diabetes Care 2020; 43 (Suppl. 01) S14-S31
    CrossrefPubMedGoogle Scholar
  • 25 Sanjanwala AR, Jauk VC, Cozzi GD. et al. Outcomes before and after adopting guidelines for expectant management of severe preeclampsia. Am J Perinatol 2022; 39 (02) 172-179
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Duvekot JJ, Duijnhoven RG, van Horen E. et al; TOTEM study collaboration group. Temporizing management vs immediate delivery in early-onset severe preeclampsia between 28 and 34 weeks of gestation (TOTEM study): an open-label randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100 (01) 109-118
    CrossrefPubMedGoogle Scholar
  • 27 Venkatesh KK, Strauss RA, Westreich DJ, Thorp JM, Stamilio DM, Grantz KL. Adverse maternal and neonatal outcomes among women with preeclampsia with severe features <34 weeks gestation with versus without comorbidity. Pregnancy Hypertens 2020; 20: 75-82
    CrossrefPubMedGoogle Scholar
  • 28 Lecarpentier E, Tsatsaris V, Goffinet F, Cabrol D, Sibai B, Haddad B. Risk factors of superimposed preeclampsia in women with essential chronic hypertension treated before pregnancy. PLoS One 2013; 8 (05) e62140
    CrossrefPubMedGoogle Scholar
  • 29 Nzelu D, Dumitrascu-Biris D, Nicolaides KH, Kametas NA. Chronic hypertension: first-trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational age. Am J Obstet Gynecol 2018; 218 (03) 337.e1-337.e7
    CrossrefPubMedGoogle Scholar
  • 30 Buyon JP, Kim MY, Guerra MM. et al. Predictors of pregnancy outcomes in patients with lupus: a cohort study. Ann Intern Med 2015; 163 (03) 153-163
    CrossrefPubMedGoogle Scholar
  • 31 Giannakou K, Evangelou E, Papatheodorou SI. Genetic and non-genetic risk factors for pre-eclampsia: umbrella review of systematic reviews and meta-analyses of observational studies. Ultrasound Obstet Gynecol 2018; 51 (06) 720-730
    CrossrefPubMedGoogle Scholar
  • 32 Shen M, Smith GN, Rodger M, White RR, Walker MC, Wen SW. Comparison of risk factors and outcomes of gestational hypertension and pre-eclampsia. PLoS One 2017; 12 (04) e0175914
    CrossrefPubMedGoogle Scholar
  • 33 Jackson RA, Gibson KA, Wu YW, Croughan MS. Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis. Obstet Gynecol 2004; 103 (03) 551-563
    CrossrefPubMedGoogle Scholar
  • 34 Qin J, Liu X, Sheng X, Wang H, Gao S. Assisted reproductive technology and the risk of pregnancy-related complications and adverse pregnancy outcomes in singleton pregnancies: a meta-analysis of cohort studies. Fertil Steril 2016; 105 (01) 73-85.e1 , 6
    CrossrefPubMedGoogle Scholar