1. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Timing of delivery and induction in pre-eclampsia Matthews Mathai

2. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Principles of Management Pre-eclampsia affects both the mother and the fetus Multisystem disorder Elevated blood pressure and proteinuria are among the many other findings Only definitive treatment for pre-eclampsia is the delivery of the baby and the placenta

3. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Timing of delivery Fetal considerations –Prematurity –Stillbirth Hypoxia Placental abruption –Newborn asphyxia Maternal considerations –Worsening of disease Complications

4. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Timing of delivery Mild or severe disease? –Early delivery with severe disease Preterm or term? –Delivery more likely if term

5. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Timing based on severity of disease "Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery must occur within 12 hours of onset of convulsions in eclampsia. ALL cases of severe pre-eclampsia should be managed actively" –Managing Complications in Pregnancy and Childbirth, 2000

6. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Expectant care for severe pre-eclampsia before term? Cochrane review: Churchill & Duley (2002) Two trials – South Africa & USA; 133 women Women had 24-48 h period of stabilization –Steroids, magnesium sulphate and antihypertensives, if necessary –Randomized if eligibility criteria met Interventionist group – induction/CS Expectant: delivery at 34 wk or earlier if deterioration

7. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Expectant care for severe pre-eclampsia before term? Insufficient data for reliable conclusions on maternal adverse outcomes, stillbirths and newborn deaths –Eclampsia, renal failure, pulmonary oedema, HELLP syndrome, CS, placental abruption Interventionist group had –More HMD RR 2.3 (95% CI 1.39-3.81) –More NEC RR 5.54 (95% CI 1.04-29.56) –More likely to need NICU admission RR 1.32 (95% CI 1.3-1.55) –Less likely to be SGA RR 0.36 (0.14-0.90)

8. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Expectant care for severe pre-eclampsia before term? Authors' conclusion –"There are insufficient data for any reliable recommendation about which policy of care should be used for women with severe early onset pre-eclampsia. Further large trials are needed." Global context for consideration –Availability of NICU facilities –Accessibility –Costs of care –Long term survival

9. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Timing based on severity of disease "In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms" –Managing Complications in Pregnancy and Childbirth, 2000

10. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Delivery in mild pre-eclampsia Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial –Koopmans et al, Lancet 2009; 374: 979-88 –756 women with singleton pregnancies at 36-41 weeks –Primary outcome: Composite measure of poor maternal outcome Death, eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, abruption, progression to severe hypertension or proteinuria, PPH > 1L

11. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Delivery in mild pre-eclampsia Induction group (n=377) –Induced within 24 h of randomization –ARM + oxytocin if Bishop score > 6 –Cervical ripening with PG or balloon catheter if score < 6 Expectant group (n=379) –Monitoring with frequent monitoring of BP, proteinuria, fetal health status. –Induce if worsening of disease, PROM > 48 h, fetal distress or gestation > 41 wk –Koopmans et al, Lancet 2009; 374: 979-88

12. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Delivery in mild pre-eclampsia 117 (31%) of women allocated to induction of labour developed poor maternal outcome compared to 166 (44%) allocated to expectant monitoring (RR 0.71; 95% CI 0.59- 0.86) No cases of maternal or neonatal death or eclampsia reported "Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks' gestation." –Koopmans et al, Lancet 2009; 374: 979-88

13. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Induction techniques - Summaries Recommended: –Oral misoprostol 25 mcg every 2 h –Low dose vaginal misoprostol 25 mcg every 6 h –Low does vaginal prostaglandins –Balloon catheter –Combination of balloon catheter plus oxytocin as an alternative method when PGs (including misoprostol) are not available or contraindicated –Oral or vaginal misoprostol for IUD in third trimester –Sweeping membranes for reducing formal induction of labour WHO recommendations for induction of labour 2011

14. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Induction techniques - Summaries Not recommended –Amniotomy alone –Misoprostol in women with previous caesarean section WHO recommendations for induction of labour 2011

15. | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Current recommendations Deliver within 24 h for severe pre- eclampsia Expectant management with monitoring for mild pre-eclampsia until 36 wk; induce labour after 37 wk Induction methods include amniotomy, oxytocin, prostaglandins including misoprostol and balloon catheter –Managing Complications in Pregnancy and Childbirth, 2000