Vous êtes sur la page 1sur 7

http://informahealthcare.

com/jmf
ISSN: 1476-7058 (print), 1476-4954 (electronic)

J Matern Fetal Neonatal Med, Early Online: 17


! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.928689

ORIGINAL ARTICLE

Maternal outcomes according to mode of delivery in women with


severe preeclampsia: a cohort study
Melania M. R. Amorim1,2, Leila Katz1, Amanda S. Barros3, Tainara S. F. Almeida3, Alex Sandro R. Souza1,4, and
Anbal Faundes5
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14

1
Department of Maternal and Child Health, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil,
2
Department of Obstetrics, Universidade Federal de Campina Grande (UFCG), Campina Grande, Paraba, Brazil, 3Faculdade Pernambucana de
Saude (FPS), Recife, Pernambuco, Brazil, 4Department of Maternal and Child Health, Universidade Federal de Pernambuco (UFPE), Recife,
Pernambuco, Brazil, and 5Department of Obstetrics and Gynecology, Universidade de Campinas (UNICAMP), Campinas, Sao Paulo, Brazil,

Abstract Keywords
Objective: To determine the association between mode of delivery and maternal complications Caesarean, complications, delivery, labour,
in patients with severe preeclampsia. obstetrics, pre-eclampsia, prognosis
Methods: A prospective cohort study was conducted with 500 pregnant women with severe
preeclampsia. The mode of delivery, vaginal or caesarean section, was considered the exposure, History
while the postpartum maternal complications and severe maternal morbidity were the
outcomes. Logistic regression analysis was performed to determine the adjusted risk and 95% Received 27 August 2013
Revised 15 May 2014
For personal use only.

confidence intervals (95% CI) of maternal morbidity.


Results: Labour was spontaneous in 22.0% and induced in 28.2%, while 49.8% had an elective Accepted 23 May 2014
caesarean section. Ninety-five (67.4%) of the patients in whom labour was induced delivered Published online 27 June 2014
vaginally. Total Caesarean rate was 68.2%. The risk of severe maternal morbidity was
significantly greater in patients submitted to Caesarean section (54.0% versus 32.7%)
irrespective of the presence of labour. Factors that remained associated with severe maternal
morbidity following multivariate analysis were a diagnosis of HELLP syndrome after delivery
(OR 3.73; 95% CI: 1.559.88) and having a caesarean (OR 1.91; 95% CI: 1.524.57).
Conclusions: Caesareans are often performed in patients with severe preeclampsia and are
associated with significant postpartum maternal morbidity. Induction of labour should be
considered a feasible option in these patients.

Introduction premature babies, with lower complication rates and a shorter


duration of hospitalization. Furthermore, the rate of cerebral
The ideal mode of delivery in patients with severe
palsy of the newborn remains the same [6,8].
preeclampsia still remains to be established [1].
The therapeutic decision regarding mode of delivery is not
Preeclampsia is one of the most common reasons for the
easy, since obstetricians often have to deal with pregnancies
therapeutic interruption of pregnancy, since delivery consti-
that are still remote from term and with unfavourable cervical
tutes the only definitive treatment for the process [1].
conditions [6]. Additionally, both maternal clinical conditions
As preeclampsia often occurs in preterm pregnancies [2],
and foetal well-being may be compromised [9]. Nonetheless,
interruption is frequently indicated when labour is absent
most medical society guidelines recommend vaginal delivery
[3,4]. The global rate of caesarean sections is estimated to be
due to the benefits to the mother of this mode of delivery, the
high (around 70% or more in preterm pregnancies) because
high likelihood of success and the lower rates of complica-
many obstetricians prefer performing Caesareans in these
tions [1014]. Women with preeclampsia have a low tolerance
patients, even when foetal vitality is good [5,6].
for blood loss and a greater risk of haemorrhagic complica-
Nevertheless, it has yet to be proven that Caesareans
tions; therefore, in these women vaginal delivery may confer
improve neonatal outcome and they may be associated with
significant benefits [15].
poorer maternal outcome [7]. Observational studies suggest
The present study was carried out to evaluate the
that vaginal delivery may be better in the long term for
association between mode of delivery and maternal outcomes
among patients with severe preeclampsia.
Address for correspondence: Melania M. R. Amorim, MD, PhD,
Department of Obstetrics, Universidade Federal de Campina Grande Methods
(UFCG), Rua Neuza Borborema de Souza, 300, 58406-120 Campina
Grande, Paraba, Brazil. Tel: +558333212695. Fax: +558333212695. A prospective, cohort study was conducted in women with
E-mail: melania.amorim@gmail.com severe preeclampsia receiving care at Instituto de Medicina
2 M. M. R. Amorim et al. J Matern Fetal Neonatal Med, Early Online: 17

Integral Prof. Fernando Figueira (IMIP), a tertiary referral both; elevated hepatic enzyme activities (either alanine
center located in the city of Recife in northeastern Brazil, aminotransferase, aspartate aminotransferase, or both); patient
which is a major referral center for high risk obstetrics care in report of persistent headache or other cerebral or visual
the region and the only one that possesses an obstetric ICU. disturbances; patient report of persistent epigastric pain [16].
The caesarean rate of the unit is 40%. The study was Preeclampsia was considered to be pure when hypertension
conducted between August 2008 and July 2009 after having and proteinuria developed after 20 weeks in previously
been approved by the institutions Institutional Review Board normotensive patients, whereas preeclampsia was considered
under reference # 1199 on 26 June 2008. All the patients to be superimposed when it was diagnosed following the
included in the study voluntarily agreed to participate and appearance of proteinuria (300 mg in 24 h) in patients with a
gave their signed informed consent. STROBE recommenda- diagnosis of hypertension prior to 20 weeks or in patients
tions for reporting cohort studies were followed. Data were with hypertension and proteinuria prior to 20 weeks, in
extracted by the authors from medical charts and when there accordance with any of the following findings: sudden
were missing data, charts were again checked and the patient increase in proteinuria; sudden increase in blood pressure in
consulted about disagreement in information. a woman whose hypertension had previously been well
Sample size was calculated with open source software controlled; thrombocytopenia (platelet count 5100 000 cells/
(Openepi version 2.3, Atlanta,), assuming a rate of haemor- mm3) or increase in alanine aminotransferase or aspartate
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14

rhagic complications of 8% among patients submitted to aminotransferase to abnormal levels [16].


Caesarean sections and 1% among patients who had vaginal All patients were given standard care provided at the
deliveries (data from a previous pilot study carried out in our hospital for cases of severe preeclampsia [1] based on the
institution), with an alpha error of 5% and a power of 90%. recommendations outlined in the guidelines of the pertinent
Sample size was thus defined at 420 patients and this number international and national societies [1013,17], including use
was increased to 500 patients to cater for possible losses and of magnesium sulfate for prevention of eclampsia [1012,16].
exclusions. Investigators did not interfere in any way with the manage-
All pregnant women with confirmed diagnosis of severe ment adopted.
preeclampsia admitted in our hospital were included in the Conservative management was indicated for women with
study and followed after delivery until hospital discharge. less than 34 weeks of pregnancy and antenatal corticosteroid
Cases of haemorrhagic emergencies (placenta praevia and therapy with betamethasone (two 12 mg doses with a 24-h
For personal use only.

placental abruption), eclampsia, coma, inability to provide interval) was administered to accelerate foetal lung maturity.
informed consent to participate in the study and patients with Conservatively managed patients received oral antihyperten-
a diagnosis of other associated clinical conditions (diabetes, sive drugs, while foetal well-being was monitored by
collagen diseases or thrombophilia) were excluded from the ultrasonography, Doppler velocimetry and cardiotocography.
study. Associated clinical conditions were considered present The criteria for interrupting pregnancy were: gestational
when the patient had at admission previous diagnosis of the age 434 weeks, spontaneous labour, impaired foetal well-
condition or when during hospital stay the diagnosis was being or maternal complications (HELLP syndrome, uncon-
made. trolled hypertension). Very high blood pressure occurring
The mode of delivery, vaginal or Caesarean section, was prior to delivery were treated with injectable hydralazine
considered the independent variable, while the following (5 mg given as an intravenous bolus, up to a maximum dose of
postpartum maternal complications constituted the dependent 20 mg) and after delivery with captopril (25 mg orally) with
variables: haemorrhagic complications, puerperal infection, the objective of reducing pressure by approximately 20%. The
blood transfusion, hypertensive crisis, need for antihyperten- decision regarding mode of delivery was made by the
sive drugs, oliguria, acute pulmonary oedema, thrombo- attending team, although the institutions regulation manual
embolism, eclampsia, HELLP syndrome, severe maternal suggests inducing labour if there are no contraindications to
morbidity and duration of hospitalization longer than 7 d. The vaginal delivery [1], in agreement with the recommendations
following control variables (potential confounding factors) of the international and national societies [12].
were taken into consideration: maternal age, parity, body Labour induction was defined as the use of any method to
mass index (BMI), clinical form of preeclampsia (pure or artificially induce labour: either by pharmacological (mis-
superimposed), blood pressure levels, prepartum complica- oprostol or oxytocin) or mechanical (Foley catheter) means.
tions, severity of hypertension and HELLP syndrome Induction was considered to have been successful when the
diagnosed prior to delivery) and induction of labour. outcome was vaginal delivery. Elective Caesarean section was
Criteria defined by the National High Blood Pressure defined as a Caesarean performed in the absence of labour,
Education Program Working Group (2000) were taken into whereas an intrapartum Caesarean section was performed in
consideration for the diagnosis of severe preeclampsia, i.e. the presence of uterine contractions, either spontaneous or
presence of any one of the following signs or symptoms in induced. The indications for performing a Caesarean section
women with hypertension diagnosed after 20 weeks of are described in this study exactly as they were recorded on
pregnancy and proteinuria: blood pressure 160 mmHg the patients chart by the physician on duty responsible for the
systolic or 110 mmHg diastolic; proteinuria 2.0 g in 24 h procedure. They were later classified into groups for the
(2+ or 3+ on qualitative examination); increased serum purposes of analysis. If more than one indication had been
creatinine level (41.2 mg/dL); platelet count 5100 000 cells/ recorded, the main reason for performing the Caesarean
mm3, evidence of microangiopathic haemolytic anemia section was taken into consideration. All patients were
(with increased lactic acid dehydrogenase concentration), or followed during hospitalization until discharge and/or 30 d
DOI: 10.3109/14767058.2014.928689 Maternal outcomes in severe preeclampsia 3

postpartum in order to identify postpartum complications. of the relative risk of maternal complications according to the
Duration of hospitalization from delivery to discharge was type of delivery and a 95% confidence interval was established.
determined. Multivariate analysis with multiple logistic regression was
With respect to complications during pregnancy and performed to determine the risk of severe maternal morbidity
postpartum, uncontrolled hypertension or hypertensive crisis according to the mode of delivery, while controlling for
was defined as the 24-h presence of at least one very high potential confounding factors. A hierarchical model of
blood pressure urgently requiring administration of antihy- analysis was adopted, as recommended by Victora [22],
pertensive drugs (systolic pressure 180 mmHg or diastolic which included the following variables: maternal age, parity,
pressure 120 mmHg). HELLP syndrome was defined in BMI, clinical form of preeclampsia (pure or superimposed),
accordance with the criteria established by Sibai [17]. Acute gestational age at delivery, induced labour, spontaneous
pulmonary oedema was diagnosed according to a clinical labour, type of Caesarean section, (elective or intrapartum),
finding of severe dyspnea, production of pink frothy sputum prepartum complications (HELLP syndrome and uncontrolled
from the airways, excessive sweating and cyanosis, as well as hypertension) and prepartum blood pressure levels. Adjusted
moist rales present in lung fields [18]. Oliguria was diagnosed odds ratios (OR) were calculated, together with their 95%
when urinary output was less than 400 ml in 24 h, based on the confidence intervals (95% CI) for the variables that continued
criteria of acute kidney failure [19]. Thromboembolism was to be significantly associated with maternal morbidity.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14

defined as the presence of any thromboembolic event


confirmed by imaging tests and requiring anticoagulant
Results
therapy. The criteria defining postpartum severe maternal
morbidity were modified from World Health Organization During the study period, 831 cases of severe preeclampsia and
(WHO) in 2009 [20]. As severe preeclampsia per se is defined eclampsia were admitted to this hospital. Of these, 614
like potentially life-threatening conditions and we wanted patients were addressed for inclusion in the study, 525 of
to discriminate the most severe cases, we considered severe whom were considered eligible for the study and 89
maternal morbidity the presence of other indicators such as ineligible. The reasons for exclusion were: haemorrhagic
severe hypertension, hypertensive encephalopathy, postpar- emergencies (n 22), eclampsia (n 52), associated clinical
tum HELLP syndrome, endometritis, pulmonary oedema, conditions (n 13), coma or inability to provide informed
respiratory failure, seizures, sepsis, shock, thrombocytopenia consent to participate in the study (n 2). Of the eligible
For personal use only.

less than 100 000/ mm3, thyroid crisis and severe management patients, 500 agreed to participate and were evaluated.
indicators (blood transfusion, central venous access, hyster- The mean age of the patients included in the study was
ectomy, prolonged hospital stay, no anaesthetic intubation, 24.7 years, with 55% being under 25 years of age. Median
return to operating room and surgical intervention [20]. parity was zero, with 65% of the participants being prim-
Postpartum haemorrhage was defined as blood loss iparas. Around 18% of the patients had had a previous
1000 ml or haemorrhage that justified blood transfusion in caesarean section. Preeclampsia was considered pure in 77%
the opinion of the attending physician. Post-surgical haema- of participants and superimposed in 23%. Mean gestational
toma was defined as an accumulation of blood in the surgical age, both at admission and at delivery, was around 36 weeks.
wound requiring drainage. The percentage of premature deliveries was 42.4%. Mean
The patient was considered to have an infection when a prepartum blood pressure levels were around 173 mmHg for
clinical and laboratorial diagnosis of infection was made systolic pressure and 113 mmHg for diastolic pressure. With
postpartum (infection at the surgical site, endometritis, respect to prepartum complications 28% of patients had
urinary infection, lung infection or any other infection). uncontrolled hypertension. Mean duration of hospitalization
Infection of the surgical site was defined in accordance with (from delivery to discharge) was 6.6 4.3 d.
the criteria established by the Centers for Disease Control and Patients were older, had higher BMI, gestational age was
Prevention (CDC) and was classified as an incisional lower and systolic and diastolic blood pressure was higher in
infection (in the surgical wound itself) or related to organs the caesarean group (Table 1).
and spaces (intracavitary or deep infection) [20]. A diagnosis Labour was spontaneous in 110 patients (22%) and induced
of postpartum endometritis was based on the patient having a in 141 (28.2%), 95 of whom went on to have vaginal
temperature 438  C in the absence of any other cause other deliveries (67.4%). The total caesarean section rate was 68%;
than in the first 24 h postpartum or a temperature of 38.7  C with 249 patients (50%) having elective and 92 (18.4%)
in the first 24-h postpartum. Uterine sensitivity, purulent or intrapartum caesarean sections. The caesarean section rate
foul-smelling lochia and leukocytosis with left shift were following spontaneous labour was 42% (Table 2).
considered adjuvant criteria [21]. The methods used to induce labour were vaginal
Statistical analysis was performed using the public domain misoprostol in 64 patients (45.4%), oxytocin alone in 71
Epi Info software program, version 3.5.3 (Centers for Disease patients (50.3%), a Foley catheter alone in 4 patients (2.8%)
Control and Prevention, Atlanta, GA). Measures of central and a Foley catheter with oxytocin in 2 patients (1.4%). The
trend and dispersion were calculated for numerical variables, main indications for performing a caesarean section were
and frequencies for categorical variables. The statistical tests severe preeclampsia (57%), chronic foetal distress (15%),
used were Pearsons chi-square test and Fishers exact test, breech presentation (5.6%), dystocias and/or cephalopelvic
as appropriate, considering only two-tailed values of p. disproportion (6%), non-reassuring foetal heart rate (4.4%),
A significance level of 5% was adopted throughout the macrosomia (4%) and having had two or more previous
statistical analysis. Risk ratio (RR) was calculated as a measure caesarean sections (3.5%).
4 M. M. R. Amorim et al. J Matern Fetal Neonatal Med, Early Online: 17

An increased risk of various postpartum complications was Infection of surgical site (2.6%) occurred only in patients
found in patients submitted to Caesarean section. There was a submitted to Caesarean section (p 0.002). The groups were
greater incidence of postpartum haemorrhage (4.1% versus not significantly different with respect to the risk of
0.6%; p 0.024), post-surgical haematoma (8.2% versus endometritis (p 0.55) or of any kind of puerperal infection
0.6%; p 0.00009) and any haemorrhagic complication (RR 1.59; 95% CI: 0.604.22; p 0.35) (Table 3).
(12.3% versus 1.3%; p 0.00005). The risk of any haemor- Thromboembolic complications were rare, with one case
rhagic complication was almost 10 times higher in patients occurring in each group (p 0.54). Oliguria was significantly
submitted to caesarean section (RR 9.8; 95% CI: 2.440.0) more common in women submitted to caesarean section
and the need for blood transfusion was significantly higher (9.0% versus 4.0%; p 0.03). Very high blood pressure and
following caesarean section (8.2% versus 2.5%; p 0.006) the need for antihypertensive drugs were more common
(Table 3). following caesarean section (47.8% versus 30.2%; p 0.0002
and 80.9% versus 62.3%; p 0.000006, respectively). There
Table 1. Patients characteristics. was no significant difference in the rate of acute pulmonary
oedema (p 0.46) or postpartum HELLP syndrome
Vaginal (p 0.12) as a function of the type of delivery. Duration of
Caesarean delivery hospitalization was longer after caesarean delivery, with a
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14

Characteristics (n 341) (n 159) p


median of 7 d compared to 5 d for those who had a vaginal
Maternal age (years) 25.1 6.5 23.7 6.6 0.03* delivery. Hospitalization beyond 7 d was more common
(Mean, SD)
Parity (Median, IQR) 1.0 12 1.0 12 0.44y following caesarean section than after vaginal delivery
Gestational age (weeks) 36.1 3.5 36.8 3.4 0.04* (53% versus 23%; p50.0001) (Table 3).
(Mean, SD) The risk of severe maternal morbidity was 1.7 times higher
BMI (kg/m2) (Mean, SD) 31.4 5.4 29.6 5.3 0.003* in patients submitted to caesarean section (54.0% versus
SBP (mmHg) (Mean, SD) 175.2 18.9 169.6 16.2 0.001*
DBP (mmHg) (Mean, SD) 114.2 13.1 111.0 11.7 0.009* 32.7%; RR 1.65; 95% CI: 1.292.11) (Table 3). There was
no difference in the rate of severe maternal morbidity between
SD, standard deviation; IQR, interquartile range; BMI, body mass index; elective and intrapartum caesarean sections (55.0% versus
SBP, systolic blood pressure; DBP, diastolic blood pressure.
*Student t-test.
51.1%, respectively; p 0.52).
yMannWhitney test. When multiple logistic regression analysis was performed,
For personal use only.

the variables that remained significantly associated with


postpartum severe maternal morbidity were caesarean section
Table 2. Characteristics of labour and delivery. (OR 1.91; 95% CI: 1.524.57) and prepartum presence of
HELLP syndrome (OR 3.91; 95% CI: 1.559.88) (Table 4).
Labour N %
Spontaneous labour 110 22.0 Discussion
Induced labour 141 28.2
Elective caesarean 249 49.8 In the present study, a high caesarean section rate of almost
Vaginal delivery 159 31.8 70% was found in patients with severe preeclampsia.
Intrapartum caesarean 92 18.4 Caesarean sections were associated with increased maternal
 Caesarean following induction 46/141 32.6%
 Caesarean following spontaneous labour 46/110 41.8% morbidity, raising the risk of haemorrhagic and infectious
Total number of Caesarean sections 341 68.2 complications and the rate of postpartum hypertensive crises,
and prolonged hospitalization. The risk of severe maternal

Table 3. Postpartum maternal complications according to mode of delivery.

Caesarean (n 341) Vaginal delivery (n 159)


Complication N % N % RR 95% CI p NNH (CI 95%)
Postpartum haemorrhage 14 4.1 1 0.6 6.5 0.8649.2 0.024 29 (10020)
Post-surgical haematoma 28 8.2 1 0.6 13.1 1.7995.1 50.0001 13 (2510)
Any haemorrhagic complication 42 12.3 2 1.3 9.79 2.4039.95 50.0001 9 (147)
Blood transfusion 28 8.2 4 2.5 3.26 1.169.15 0.006 18 (10011)
Surgical site infection 9 2.6 0.002 NE*
Endometritis 12 3.5 4 2.5 1.40 0.464.27 0.55
Any puerperal infection 17 5.0 5 3.1 1.59 0.604.22 0.35
Thromboembolic disease 1 0.3 1 0.6 0.47 0.037.4 0.54
Oliguria 31 9.1 6 3.8 2.41 1.035.66 0.03 19 (10011)
Hypertensive crisis 163 47.8 48 30.2 1.58 1.222.06 0.0002 6 (134)
Need for antihypertensive drugs 276 80.9 99 62.3 1.30 1.141.48 50.0001 5 (104)
Acute pulmonary oedema 2 0.6 0.46
HELLP syndrome 9 2.6 1 0.6 4.20 0.5332.8 0.12
47 d of hospitalizationy 180 52.8 36 22.6 2.33 1.723.16 50.0001 3 (53)
Severe maternal morbidity 184 54.0 52 32.7 1.65 1.292.11 50.0001 5 (83)

RR, relative risk; CI, confidence interval; NNH, number necessary to harm.
*NE, Not estimated.
yDuration of hospitalization (median): Caesarean 8 d; Vaginal delivery 5 d.
DOI: 10.3109/14767058.2014.928689 Maternal outcomes in severe preeclampsia 5
Table 4. Risk factors for postpartum severe maternal morbidity infectious complications in the general population [25,26],
(multivariate analysis).
although more recent studies have suggested a reduction in
Standard
these risks when caesareans are scheduled in low-risk
Variable Coefficient error p OR 95% CI patients [27].
In the present study, in addition to the risk of haemorrhagic
Caesarean 1.06 0.33 0.0019 1.91 1.524.57
Prepartum HELLP 1.36 0.47 0.0040 3.91 1.559.88 and infectious complications, an increased risk of oliguria,
syndrome very high blood pressure and a need for antihypertensive
drugs were found in women with preeclampsia who were
Variables entering the model: maternal age, parity, body mass index,
clinical form of preeclampsia (pure or superimposed), gestational age submitted to a caesarean section, resulting in a significant
at delivery, induced labour, spontaneous labour, type of caesarean increase in the duration of hospitalization.
section (elective or intrapartum), uncontrolled hypertension, HELLP The present results are unsurprising, since preeclampsia
syndrome antepartum blood pressure levels. increases the risk of haemorrhagic complications [28] and
OR, odds ratio; CI, confidence interval.
caesarean sections may aggravate this risk further, particu-
larly in patients with thrombocytopenia [25,26]. Our results
morbidity persisted even after controlling for potential support the notion already reported that the best mode of
confounding factors and was 65% higher in patients submitted delivery in cases of preeclampsia and is by the vaginal route,
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14

to caesarean sections. precisely because of the increased risk of haemorrhagic


Patients were older and had higher BMI in the caesarean complications associated to caesarean delivery [1012].
group, although the difference found is not clinically signifi- The risk of infection is increased by both caesarean
cant. Patients did not differ regarding parity, but gestational sections and haemorrhage [29]. The more frequent finding of
age was lower in the c-section group. This finding can be oliguria may reflect the increased amount of blood loss in
explained because of the time from induction to delivery in caesarean sections [30] and any form of manipulation used to
the patients that achieve vaginal delivery. Systolic and treat these complications, in addition to the increased infusion
diastolic blood pressure was higher in the caesarean group, of liquids during the caesarean section, may explain the
and despite the difference not being clinically important, may increase in very high blood pressure episodes and in the need
be explained by the tendency that care takes usually for antihypertensive drugs following delivery.
demonstrate to be less tolerant and waiting for vaginal Studies suggest that prognosis is better with elective rather
For personal use only.

delivery in patients with uncontrolled blood pressure. than intrapartum caesarean sections in the general popula-
One can argue that these groups are very differents once tion [26]. Although the proportion of complications was lower
women who underwent caesarean section were older, at lower in the case of elective C-section as compared with intra-
gestational week, with higher BMI and pre delivery also partum C-section, we did not find statistically significant
systolic and diastolic blood pressure levels. All these differ- association in the present analysis of women with preeclamp-
ences together could explain at least in part why clinicians sia. The sample size, however, was not calculated aiming to
decided to perform a caesarean section, although none of identify such difference.
these findings are per se true indications for caesarean This finding strengthens the recommendation to attempt
section. However, our research question does not adress the induction of labour in cases of preeclampsia since it is often
risk factors for caesarean section in these patients, but the successful and may reduce the risks of complications if
consequences of performing a caesarean section in women delivery is vaginal. However, if an intrapartum caesarean
with severe preeclampsia. We intend to evaluate the factors section is necessary, the risk appears not to be higher than that
associated with caesarean section in these women in a later found with an elective caesarean section.
study. Relatively few studies have been published regarding the
This high caesarean section rate is compatible with rates mode of delivery in women with severe preeclampsia and they
described by other authors [23]; however, it is higher than generally fail to emphasize postpartum morbidity and to
rates reported in more recent studies [24]. Differences in the provide a clear definition of the analysed maternal outcomes
study population and in the mode of management of these [6,7,9]. To the best of our knowledge, the present study is the
patients at each institution may explain these findings. first to compare specific parameters of postpartum morbidity
Nevertheless, caesarean rates were high even when patients according to the mode of delivery in patients with severe
went into labour, either spontaneous (41.8%) or induced preeclampsia. Since this is a prospective study, it has more
(32.6%). The high proportion of cases in which indication for strength than retrospective studies, permitting the adoption of
caesarean section was only severe preeclampsia suggests that rigid diagnostic criteria both for severe preeclampsia and for
in many cases there was no real obstetric indication. On the the various morbidities analysed. Furthermore, an expressive
other hand, the 67% success rate of vaginal delivery after number of cases were included, with sufficient power to
labour induction in patients with severe preeclampsia confirm the outcomes evaluated, thus representing a signifi-
achieved in the present study was higher than that described cant contribution to obstetric practice and reinforcing the
in the literature, which ranges from 48% to 60% in this recommendations of the medical societies and the consensus
specific clinical situation [6,7,9]. on vaginal delivery in cases of severe preeclampsia.
Few studies have specifically analysed the association Nevertheless, since this is an observational, cohort study,
between postpartum maternal complications and mode of the level of evidence presented here is not as strong as that of
delivery in patients with preeclampsia. Caesarean section a randomized clinical trial. As the selection of patients for
constitutes a recognized risk factor for haemorrhagic and vaginal delivery or caesarean section was not randomized but
6 M. M. R. Amorim et al. J Matern Fetal Neonatal Med, Early Online: 17

was the responsibility of the team of attending physicians, References


various confounding factors may be involved. For example, 1. Noronha Neto C, Souza ASR, Amorim MMR. Tratamento da pre-
the decision to perform a caesarean section may be associated eclampsia baseado em evidencias [Evidence-based treatment of
with the presence of prepartum maternal complications and preeclampsia]. Rev Bras Ginecol Obstet 2010;32:45968.
these complications in themselves may be associated with a 2. Sibai BM. Chronic hypertension in pregnancy. Obstet Gynecol
2002;100:36977.
greater risk of postpartum maternal morbidity. 3. Mozurkewich E, Chilimigras J, Koepke E, et al. Indications for
Such possible bias was controlled using a multivariate induction of labour: a best-evidence review. BJOG 2009;116:
analysis and caesarean section remained as an independent 62636.
risk factor for postpartum complications after controlling for 4. Souza AS, Amorim MM, Feitosa FE. Comparison of sublingual
versus vaginal misoprostol for the induction of labour: a systematic
potentially confounding factors. The only other variable that review. BJOG 2008;115:13409.
persisted in the model was a prepartum diagnosis of HELLP 5. Catanzarite V, Quirk JG, Aisenbrey G. How do perinatologists
syndrome, which is a recognized risk factor for maternal manage preeclampsia? Am J Perinatol 1991;8:710.
complications in cases of preeclampsia; however, the effect 6. Alanis MC, Robinson CJ, Hulsey TC, et al. Early-onset severe
preeclampsia: induction of labour vs elective Caesarean delivery
of the caesarean section in itself continued to be signifi- and neonatal outcomes. Am J Obstet Gynecol 2008;199:262.e16.
cant, resulting in an almost two-fold adjusted risk of 7. Coppage KH, Polzin WJ. Severe preeclampsia and delivery
complications. outcomes: is immediate Caesarean delivery beneficial?
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14

The next step would be to perform controlled clinical Am J Obstet Gynecol 2002;186:9213.
8. Drife J. Mode of delivery in the early preterm infant (528 weeks).
trials, which will provide better quality evidence and clarify BJOG 2006;113:S815.
any doubts that may persist following observational studies. 9. Nassar AH, Adra AM, Chakhtoura N, et al. Severe preeclampsia
Although labour induction may represent a challenge in remote from term: labour induction or elective Caesarean delivery?
patients with severe preeclampsia, particularly in cases that Am J Obstet Gynecol 1998;179:121013.
10. National Collabourating Centre for Womens and Childrens
are remote from term and in whom cervical conditions are Health. Caesarean section. London (UK): National Institute for
unfavourable, we believe that it would be possible to perform Clinical Excellence (NICE); 2004:142.
a randomized clinical trial to compare labour induction with 11. ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice
elective caesarean section in these cases. bulletin. Diagnosis and management of preeclampsia and eclamp-
sia. Number 33. Obstet Gynecol 2002;99:15967.
Until this clinical trial is carried out and based on the 12. Magee LA, Helewa M, Moutquin JM, von Dadelszen P, for the
present findings together with other observational studies Hypertension Guideline Committee. Diagnosis, evaluation, and
For personal use only.

[6,7,9], we would suggest that, in addition to permitting management of the hypertensive disorders of pregnancy. SOGC
labour to progress when spontaneous contractions are present, Clinical Practice Guideline, No. 206. J Obstet Gynaecol Can 2008;
30:S148.
labour should be induced in cases of severe preeclampsia with 13. Blackwell SC, Redman ME, Tomlinson M, et al. Labour induction
an indication for interrupting the pregnancy, as long as there for the preterm severe pre-eclamptic patient: is it worth the effort?
are no contraindications to vaginal delivery. Indicating J Matern Fetal Med 2001;10:30511.
caesarean section only on the basis of a diagnosis of 14. Xenakis EM, Piper JM, Field N, Conway D, Langer O.
Preeclampsia: is induction of labour more successful? Obstet
preeclampsia should be avoided in patients with no associated Gynecol 1997;89:6003.
maternal or foetal risks, thus preventing the increased risk 15. Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and
of complications associated with caesarean sections severe obstetric morbidity in the United States. Obstet Gynecol
among women in whom induction of labour could be 2009;113:1299306.
16. Report of the National High Blood Pressure Education Program
considered. Working Group on High Blood Pressure in Pregnancy. Am J Obstet
Gynecol 2000;183:S122.
Acknowledgements 17. Sibai BM. The HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelets): much ado about nothing? Am J
The authors thank National Council for Scientific and Obstet Gynecol 1990;162:31116.
Technological Development (CNPq) for the financial support. 18. Gandhi SK, Powers JC, Nomeir AM, et al. The pathogenesis of
acute pulmonary edema associated with hypertension. N Engl J
Med 2001;344:1722.
Disclosure of interest 19. Liano F, Gallego A, Pascual J, et al. Prognosis of acute tubular
necrosis: an extended prospectively contrasted study. Nephron
National Counsel of Technological and Scientific 1993;63:2131.
Development (CNPq), Brazil. Melania Amorim conceived 20. Say L, Souza JP, Pattinson RC. WHO working group on Maternal
the study, developed the initial protocol, analysed the data, Mortality and Morbidity classifications: maternal near miss
jointly drafted the article and is guarantor. Leila Katz towards a standard tool for monitoring quality of maternal health
care. Best Pract Res Clin Obstet Gynaecol 2009;23:28796.
reviewed and amended the study protocol, contributed to 21. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for
enrolment of patients, interpreting data and writing the final Prevention of Surgical Site Infection, 1999. Centers for Disease
version of the article. Amanda de Souza Barros and Tainara Control and Prevention (CDC) Hospital Infection Control Practices
Sa Freire de Almeida participated in the development of the Advisory Committee. Am J Infect Control 1999;27:97132.
22. Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of
initial protocol, enrolled patients and collected data. Alex conceptual frameworks in epidemiological analysis: a hierarchical
Sandro Rolland de Souza reviewed the study protocol and approach. Int J Epidemiol 1997;26:2247.
contributed to statistical analysis and writing the final version 23. Dissanayake VH, Samarasinghe HD, Morgan L, et al. Morbidity
of the article. Anibal Faundes reviewed the study protocol and and mortality associated with pre-eclampsia at two tertiary care
hospitals in Sri Lanka. J Obstet Gynaecol Res 2007;33:5662.
the final version of the article. The study was approved by the 24. Gowri V, Al-Zakwani I. Prevalence of Caesarean delivery in
institutions Institutional Review Board under reference # preeclamptic patients with elevated uric acid. Hypertens Pregnancy
1199 on 26 June 2008. 2010;29:2315.
DOI: 10.3109/14767058.2014.928689 Maternal outcomes in severe preeclampsia 7
25. Villar J, Carroli G, Zavaleta N, et al. World Health Organization 28. Eskild A, Vatten LJ. Abnormal bleeding associated with pre-
2005 Global Survey on Maternal and Perinatal Health Research eclampsia: a population study of 315,085 pregnancies. Acta Obstet
Group. Maternal and neonatal individual risks and benefits Gynecol Scand 2009;88:1548.
associated with caesarean delivery: multicentre prospective study. 29. Machado Junior LC, Sevrin CE, Oliveira E, et al.
Br Med J 2007;335:1025. [Association between mode of delivery and maternal
26. Pallasmaa N, Ekblad U, Aitokallio-Tallberg A, et al. Caesarean complications in a public hospital in Greater
delivery in Finland: maternal complications and obstetric risk Metropolitan Sao Paulo, Brazil]. Cad Saude Publica 2009;25:
factors. Acta Obstet Gynecol Scand 2010;89:896902. 12432.
27. Geller EJ, Wu JM, Jannelli ML, et al. Neonatal outcomes associated 30. Ng SY, Ithnin F, Sia AT, Ng CC. Ergometrine administration for
with planned vaginal versus planned primary Caesarean delivery. post-partum haemorrhage in an undiagnosed pre-eclamptic.
J Perinatol 2010;30:25864. Anaesth Intensive Care 2008;36:11315.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14
For personal use only.