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Expectant management of severe preeclampsia:


Vigil-De Gracia et al
Ebony Boyce Carter, MD; George A. Macones, MD, MSCE, Associate Editor

The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to
practice, and implications for future research. Article discussed:

Vigil-De Gracia P, Reyes Tejada O, Calle Miñaca A, et al. Expectant management of severe preeclampsia remote from term. A randomized, multicenter clinical
trial. The MEXPRE Latin Study. Am J Obstet Gynecol 2013;209:425.e1-8.

DISCUSSION QUESTIONS
I n September 2011, the Society for
Maternal-Fetal Medicine (SMFM)
issued a committee opinion on expec-
until 24 hours postpartum in the prompt
delivery group. In the expectant man-
agement group, which remained under
- Why is this research question important?
tant management of severe preeclamp- close monitoring, delivery occurred at
- What was the study design? sia in specially-selected women who 34 weeks of gestation or when specific
are at less than 34 weeks’ gestation. maternal or fetal indications demanded
- What analytic approach was used?
The Society noted that, “with careful earlier intervention. The primary out-
- What were the study results? in-hospital maternal and fetal surveil- come was perinatal (fetal and neonatal)
lance,” expectant management might mortality.
- What is the study’s overall message?
improve neonatal outcomes. If the con- Figure 1 shows a Consolidated Stan-
- What direction should research take dition of the mother or fetus dete- dards of Reporting Trials (CONSORT)
now? riorates, delivery is likely warranted. flow diagram, which is a standardized
This recommendation was based on depiction of study participants’ passage
studies that were primarily conducted in through trial enrollment, allocation,
developed countries, so it is reasonable follow-up, and analysis. The diagram
to ask whether the SMFM recommen- shows that 3 women in the expectant
dations are generalizable to nations in management group did not complete
the developing world. This month, the study and were excluded from the
Journal Club members discussed an analysis. Two Journal Club participants
article by Vigil-De Gracia et al that pointed out that 2 of these patients,
addresses this question. who refused to stay in the hospital,
should have been included in the
From the Department of Obstetrics and Can expectant management improve intention-to-treat analysis, since patients’
Gynecology, Washington University in St. Louis, perinatal survival? inability to comply with expectant man-
St. Louis, MO:
The study was a randomized clinical agement could impact maternal and
Moderator
trial conducted at 8 tertiary teaching neonatal outcomes. Even with this
George A. Macones, MD, MSCE
hospitals in Latin America. Pregnant omission, the sample size in both groups
Mitchell and Elaine Yanow
Professor and Head women at 28-33 weeks’ gestation with was large enough to preserve statistical
severe preeclampsia, severe gestational power.
Discussants hypertension, or chronic hypertension
Ebony Carter, MD Maximizing outcomes when
with superimposed preeclampsia were
First-Year Fellow
included. Grouping these diagnoses resources are minimal
Lauren Theilen, MD allowed inclusion of a larger number The authors concluded that perinatal
Third-Year Resident of women with significant hyperten- mortality did not improve in the expec-
Heidi Fjeldstad sive disease. However, the authors tant management group. Despite a
Fourth-Year Medical Student acknowledged, and journal partici- significantly higher mean birthweight,
pants agreed, that distinctions be- neonates in the expectant management
The authors report no conflict of interest.
tween the underlying pathophysiology group were more likely to be small
0002-9378/free for gestational age than those in the
in these groups may affect pregnancy
ª 2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2013.09.031 outcomes. prompt delivery group. However, there
Patients were delivered 24-72 hours was a trend towards decreased total
See related article, page 425 after administration of glucocorticoids morbidity/mortality for gestational ages
and magnesium sulfate was continued 31 weeks in the expectant group when

NOVEMBER 2013 American Journal of Obstetrics & Gynecology 493


Journal Club www.AJOG.org

the data were stratified by gestational are better in infants born later at a size The majority of women in the world
age. This finding was not statistically that is small for gestational age or in live in resource limited areas with regard
significant but suggests further research infants who are born earlier at a low to health care. While discussants recog-
is needed to elucidate whether there is birthweight but at a size that is appro- nize the findings are only directly
a role for expectant management of priate for their gestational age. This generalizable to women with access to
preeclampsia in the very early preterm information, which would offer some tertiary care facilities in those countries,
population. sense of the future repercussions or the authors certainly make a valuable
Participants also agreed that future benefits of delaying birth, would be contribution towards applying evidence-
studies are needed to address whether helpful when making recommendations based principles of management of early
long-term outcomes, such as develop- regarding expectant management of severe PE to a larger cross-section of
mental milestones and infant mortality, preeclampsia. women in the world. -

494 American Journal of Obstetrics & Gynecology NOVEMBER 2013