Insights from outside BJOG

A woman diagnosed with pre-eclampsia between 34 and 37 weeks’ gestation presents a clinical challenge. Prior to 34 weeks, the risks of prematurity are high and conservative management is followed if possible, whereas after 37 weeks the risks of maternal deterioration outweigh the neonatal risks and delivery is usually indicated. To guide clinicians, a trial was undertaken in nearly 50 maternity units in the UK where women presenting with preeclampsia during this critical gestational window were allocated to immediate delivery or conservative therapy, and both maternal and fetal/neonatal outcomes were monitored (Chappell et al. Lancet 2019;394:1181–90). From the total cohort of 900 women, those in the immediate delivery group had fewer severe hypertensive episodes (65%) compared with those treated conservatively (75%), which the authors interpret as being strong evidence suggesting that planned delivery reduces maternal morbidity. Fetal/neonatal negative outcomes, based primarily on the need for neonatal unit admission, were higher in the induction group (42%) compared with the expectant management group (34%). The number of serious adverse events to mother and baby in each group was similar, at approximately 1%. Other considerations were a caesarean section rate above 50% in both groups and higher costs (13%) in the expectant management group, primarily due to inpatient care prior to delivery. It should be noted that these data are from high-income situations where options for the mother and safeguards for the neonate are available. This research reiterates the high-risk nature of the 2–3% of pregnancies that develop pre-eclampsia and that appropriate facilities must be provided for dealing with maternal and neonatal complications. Where these do exist, there is room for shared decision making on the timing of the delivery. Epidemiologically, it can be anticipated that the incidence of pre-eclampsia will increase as it is linked to maternal age and is often superimposed on chronic hypertension. Both of these indices are rising – at least in high-income countries such as the USA, according to a long-term study (Ananth et al. Hypertension 2019; 74:1089–95). Surprisingly, although chronic hypertension rates are increasing by 6% per annum, the authors do not link this rise to elevated trends in body mass index.