Expectant management of preeclampsia with severe features diagnosed at less than 24 weeks

Kristen A Cagino; Rylee D Trotter; Katherine E Lambert; Saloni C Kumar; Baha M Sibai

doi:10.1016/j.ajog.2024.04.031

Expectant management of preeclampsia with severe features diagnosed at less than 24 weeks

Am J Obstet Gynecol. 2024 Apr 30:S0002-9378(24)00557-X. doi: 10.1016/j.ajog.2024.04.031. Online ahead of print.

Authors

Kristen A Cagino¹, Rylee D Trotter², Katherine E Lambert², Saloni C Kumar², Baha M Sibai²

Affiliations

¹ Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas. Electronic address: Kristen.a.cagino@uth.tmc.edu.
² Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas.

PMID: 38697342
DOI: 10.1016/j.ajog.2024.04.031

Abstract

Background: The recent ACOG practice bulletin offers no guidance on management of preeclampsia with severe features (PreE with SF) less than 24 weeks. Historically, immediate delivery was recommended due to poor perinatal outcomes and high maternal morbidity. Recently, advances in neonatal resuscitation have led to increased survival at peri-viable gestational ages.

Study design: We aimed to report perinatal and maternal outcomes after expectant management of PreE with SF at < 24 weeks.

Methods: This was a retrospective case series of PreE with SF at < 24 weeks at a Level IV center between 2017-2023. Individuals requiring delivery within 24 hours of diagnosis were excluded. Perinatal and maternal outcomes were analyzed. Categorical variables from our database were compared to previously published data using chi squared tests.

Results: There were 41 individuals diagnosed with PreE with SF < 24 weeks. After excluding for delivery within 24 hours, 30 individuals (73%) were evaluated. Median gestational age at diagnosis was 22 weeks (IQR 22-23 weeks). 16% had assisted reproductive technology, 27% had chronic hypertension, 13% had pregestational diabetes, 30% had prior preeclampsia, and 73% had BMI >30 kg/m². Median latency at 22 and 23 weeks was 7 (IQR 4-23) and 8 days (IQR 4-13 days). Neonatal survival was 44% (95% CI 3-85%) for PreE with SF onset at 22 weeks and 29% (95% CI 1-56%) at 23 weeks. There were two cases of acute kidney injury (7%) and two cases of pericardial/pleural effusions (7%). Overall perinatal survival < 24 weeks was 30% in our current study versus 7% in previous reports (p=0.02).

Conclusion: For cases of expectant management of PreE with SF at < 24 weeks, our findings show an increased rate of perinatal survival with decreased maternal morbidity compared to previously published data. This information may be used when counseling on expectant management of PreE with SF < 24 weeks.

Keywords: acute kidney injury; bronchopulmonary dysplasia; eclampsia; heart failure; hypertension; intraventricular hemorrhage; latency period; necrotizing enterocolitis; peri-viability; pericardial or pleural effusion; perinatal survival; pulmonary edema; small for gestational age; stroke.