Maternal and perinatal outcome of preeclampsia with an onset before 24 weeks’ gestation: Audit in a tertiary referral center

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Abstract

Objective

Preeclampsia, with an onset before 24 weeks’ gestation is a rare but severe condition in pregnancy with little data of maternal and perinatal outcome, particularly after expectant management. We therefore, evaluated pregnancy outcome in these women at our department where temporising management was introduced as the standard policy in early onset preeclampsia.

Study design

We analysed retrospectively all consecutive women with preeclampsia, with an onset before 24 weeks’ gestation, between 1 January 1993 and 31 December 2002 at a tertiary university referral center.

Results

Twenty-six pregnancies, of which two were twin pregnancies, resulted in 65% of the women in at least one major maternal complication: maternal death (n = 1), HELLP syndrome (n = 16), eclampsia (n = 5) and pulmonary edema (n = 4). Thirty percent of these women presented already with serious morbidity at admission. The median prolongation of the pregnancy was 24 days (range 3–46 days). The overall perinatal mortality was 82%: 19 fetal deaths and 4 neonatal deaths.

Conclusion

Early onset preeclampsia, with an onset before 24 weeks’ gestation, results in considerable maternal and perinatal morbidity and mortality. Therefore, expectant management should not be considered as a routine treatment option in these patients.

Introduction

Severe, very early onset preeclampsia is associated with high mortality and morbidity for both mother and child. Although the etiology of preeclampsia is unknown [1], delivery of the fetus and placenta is the only way of arresting this serious disease. Delivery may benefit the mother but is not in the interest of the fetus, if remote from term. The main cause of neonatal mortality and morbidity in patients with severe preeclampsia is prematurity [2]. Therefore, expectant or “conservative” management with temporizing treatment was introduced in order to lengthen gestation, which may be associated with enhanced perinatal survival. Expectant management of preeclampsia includes variable periods of using pharmacological agents for controlling hypertension with accurate, maternal hemodynamic monitoring and the prophylaxis of eclampsia by magnesium sulfate. Corticosteroids are administered to enhance fetal lung maturity. Maternal and fetal surveillance is conducted at regular intervals and delivery is indicated for worsening maternal and fetal conditions. Prolongation of pregnancy has been described with an average of 2 weeks [3], [4] with longer periods gained at earlier gestation [5], [6]. However, the number of reported patients with very early onset preeclampsia treated expectantly is very small [3], [4], [6], [7] Therefore, data remain limited on the maternal morbidity and mortality and on how many of these pregnancies will result in a take home baby. At our department a protocol of temporizing management of severe, early onset preeclampsia was instituted in 1985, consisting of volume expansion and vasodilatation guided by Swan Ganz catheter for continuous blood pressure measurements [4]. Since 1993 temporizing treatment was guided by a central venous line instead of a Swan Ganz catheter. In the present study all women with preeclampsia with an onset before 24 weeks’ gestation, admitted between 1993 and 2003, were evaluated for their maternal and perinatal outcome.

Section snippets

Materials and methods

From 1 January 1993 until 31 December 2002 information of all 26 consecutive women who had preeclamspia with an onset before 24 weeks’ gestation at the Erasmus Medical Center Rotterdam were recruited from a computer database and patient charts. Data were collected from 1993 since an automated database was available.

Preeclampsia was defined as blood pressure ≥140 mmHg systolic or ≥90 mmHg diastolic measured on at least two occasions in women normotensive before 20 weeks’ gestation and proteinuria

Results

During the 10-year study period, 14,212 women were delivered in the Erasmus Medical Center Rotterdam. Twenty-six women were admitted because of preeclampsia with an onset before 24 weeks’ gestation and therefore, eligible for the study. None of the patients was offered termination of pregnancy. The median prolongation of pregnancy was 24 days (range 3–46 days).

Discussion

We describe 26 pregnancies complicated by preeclampsia, admitted before 24 weeks’ gestation, managed expectantly. One maternal death occurred. This patient was actually not eligible for temporizing management because of her poor clinical condition at admission. At admission eight patients presented with severe morbidity (eight HELLP syndrome of which three in combination with eclampsia). After initiation of temporizing management another nine patients developed severe morbidity; eight patients

Acknowledgement

CJM de Groot is supported as “Clinical Fellow” by the Netherlands Organization for Scientific Research (NWO).

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