Kim Broekhuijsen1, Gert-Jan van Baaren2, Maria G van Pampus3, Wessel Ganzevoort2, J Marko Sikkema4, Mallory D Woiski5, Martijn A Oudijk6, Kitty W M Bloemenkamp7, Hubertina C J Scheepers8, Henk A Bremer9, Robbert J P Rijnders10, Aren J van Loon11, Denise A M Perquin12, Jan M J Sporken13, Dimitri N M Papatsonis14, Marloes E van Huizen15, Corla B Vredevoogd16, Jozien T J Brons17, Mesrure Kaplan18, Anton H van Kaam19, Henk Groen20, Martina M Porath21, Paul P van den Berg22, Ben W J Mol23, Maureen T M Franssen22, Josje Langenveld24. 1. Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands. Electronic address: k.broekhuijsen@gmail.com. 2. Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands. 3. Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands. 4. Department of Obstetrics and Gynaecology, ZGT Almelo, Almelo, Netherlands. 5. Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands. 6. Department of Obstetrics, University Medical Center Utrecht, Utrecht, Netherlands. 7. Department of Obstetrics, Leiden University Medical Center, Leiden, Netherlands. 8. Department of Obstetrics and Gynaecology, Grow, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands. 9. Department of Obstetrics and Gynaecology, Reinier de Graaf Gasthuis, Delft, Netherlands. 10. Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands. 11. Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, Netherlands. 12. Department of Obstetrics and Gynaecology, Medical Center Leeuwarden, Leeuwarden, Netherlands. 13. Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands. 14. Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Breda, Netherlands. 15. Department of Obstetrics and Gynaecology, HagaZiekenhuis, The Hague, Netherlands. 16. Department of Obstetrics and Gynaecology, Medical Center Haaglanden, The Hague, Netherlands. 17. Department of Obstetrics and Gynaecology, Medisch Spectrum Twente, Enschede, Netherlands. 18. Department of Obstetrics and Gynaecology, Röpcke-Zweers Hospital, Hardenberg, Netherlands. 19. Department of Neonatology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, Netherlands. 20. Department of Epidemiology-HPC FA40, University of Groningen, University Medical Center Groningen, Groningen, Netherlands. 21. Department of Obstetrics and Gynaecology, Maxima Medical Center, Veldhoven, Netherlands. 22. Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands. 23. The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia. 24. Department of Obstetrics and Gynaecology, Atrium Medical Centre Parkstad, Heerlen, Netherlands.
Abstract
BACKGROUND: There is little evidence to guide the management of women with hypertensive disorders in late preterm pregnancy. We investigated the effect of immediate delivery versus expectant monitoring on maternal and neonatal outcomes in such women. METHODS: We did an open-label, randomised controlled trial, in seven academic hospitals and 44 non-academic hospitals in the Netherlands. Women with non-severe hypertensive disorders of pregnancy between 34 and 37 weeks of gestation were randomly allocated to either induction of labour or caesarean section within 24 h (immediate delivery) or a strategy aimed at prolonging pregnancy until 37 weeks of gestation (expectant monitoring). The primary outcomes were a composite of adverse maternal outcomes (thromboembolic disease, pulmonary oedema, eclampsia, HELLP syndrome, placental abruption, or maternal death), and neonatal respiratory distress syndrome, both analysed by intention-to-treat. This study is registered with the Netherlands Trial Register (NTR1792). FINDINGS:Between March 1, 2009, and Feb 21, 2013, 897 women were invited to participate, of whom 703 were enrolled and randomly assigned to immediate delivery (n=352) or expectant monitoring (n=351). The composite adverse maternal outcome occurred in four (1·1%) of 352 women allocated to immediate delivery versus 11 (3·1%) of 351 women allocated to expectant monitoring (relative risk [RR] 0·36, 95% CI 0·12-1·11; p=0·069). Respiratory distress syndrome was diagnosed in 20 (5·7%) of 352 neonates in the immediate delivery group versus six (1·7%) of 351 neonates in the expectant monitoring group (RR 3·3, 95% CI 1·4-8·2; p=0·005). No maternal or perinatal deaths occurred. INTERPRETATION: For women with non-severe hypertensive disorders at 34-37 weeks of gestation, immediate delivery might reduce the already small risk of adverse maternal outcomes. However, it significantly increases the risk of neonatal respiratory distress syndrome, therefore, routine immediate delivery does not seem justified and a strategy of expectant monitoring until the clinical situation deteriorates can be considered. FUNDING: ZonMw.
RCT Entities:
BACKGROUND: There is little evidence to guide the management of women with hypertensive disorders in late preterm pregnancy. We investigated the effect of immediate delivery versus expectant monitoring on maternal and neonatal outcomes in such women. METHODS: We did an open-label, randomised controlled trial, in seven academic hospitals and 44 non-academic hospitals in the Netherlands. Women with non-severe hypertensive disorders of pregnancy between 34 and 37 weeks of gestation were randomly allocated to either induction of labour or caesarean section within 24 h (immediate delivery) or a strategy aimed at prolonging pregnancy until 37 weeks of gestation (expectant monitoring). The primary outcomes were a composite of adverse maternal outcomes (thromboembolic disease, pulmonary oedema, eclampsia, HELLP syndrome, placental abruption, or maternal death), and neonatal respiratory distress syndrome, both analysed by intention-to-treat. This study is registered with the Netherlands Trial Register (NTR1792). FINDINGS: Between March 1, 2009, and Feb 21, 2013, 897 women were invited to participate, of whom 703 were enrolled and randomly assigned to immediate delivery (n=352) or expectant monitoring (n=351). The composite adverse maternal outcome occurred in four (1·1%) of 352 women allocated to immediate delivery versus 11 (3·1%) of 351 women allocated to expectant monitoring (relative risk [RR] 0·36, 95% CI 0·12-1·11; p=0·069). Respiratory distress syndrome was diagnosed in 20 (5·7%) of 352 neonates in the immediate delivery group versus six (1·7%) of 351 neonates in the expectant monitoring group (RR 3·3, 95% CI 1·4-8·2; p=0·005). No maternal or perinatal deaths occurred. INTERPRETATION: For women with non-severe hypertensive disorders at 34-37 weeks of gestation, immediate delivery might reduce the already small risk of adverse maternal outcomes. However, it significantly increases the risk of neonatal respiratory distress syndrome, therefore, routine immediate delivery does not seem justified and a strategy of expectant monitoring until the clinical situation deteriorates can be considered. FUNDING: ZonMw.
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