Primi gravida at 31 weeks gestation with pregnancy-induced hypertension admitted with reduced fetal movements. Cardiotocography variablity less than 5 with unprovoked decelerations for 4 hours. Should management be to a) monitor the patient and complete the steroids and deliver b) do twice weekly doppler and deliver if flow is abnormal or c) deliver promptly, on the basis of CTG?
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No evidence comparing immediate delivery versus ongoing monitoring in women with pregnancy induced hypertension, reduced fetal movements and reduced CTG variability was identified.
The NICE guideline on hypertension in pregnancy (National Collaborating Centre) includes a chapter on management of gestational hypertension which says:
"There appear to be no advantages to immediate birth for women with gestational hypertension, other than the prevention of progression to severe hypertension. ... The decision on timing of birth should involve consideration of blood pressure and its treatment, potential complications associated with induction of labour, health of the fetus, other obstetric complications, and the woman’s preferences. The GDG’s view is that senior obstetric involvement is, therefore, required in the decision-making process."
The guideline also includes a chapter on fetal monitoring which says:
"While one study that dealt with hypertensive pregnancies appeared to show no benefit of umbilical artery Doppler velocimetry, other studies in generally high-risk pregnancies, of which hypertension was a component, demonstrated advantages in terms of reduced perinatal mortality and better decision-making. Although no formal health economic modelling was undertaken, the systematic review shows reductions in perinatal mortality and serious maternal and perinatal morbidity such that the GDG considered that it would almost certainly be cost effective. The GDG feels that these findings can be extrapolated to hypertensive pregnancies generally. There is a lack of evidence about the timing of the test and the frequency with which it should be repeated."
Several other guidelines for the management of hypertensive disorders in pregnancy list non-reassuring fetal status or fetal distress as an indication for delivery in women with pregnancy-induced hypertension/gestational hypertension. (European Society of Cardiology, Queensland Maternity and Neonatal Clinical Guidelines Program, Society of Obstetric Medicine of Australia and New Zealand.)
A Cochrane review of immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes (Stock) concludes:
"Currently there is insufficient evidence on the benefits and harms of immediate delivery compared with deferred delivery in cases of suspected fetal compromise at preterm gestations to make firm recommendations to guide clinical practice. Where there is uncertainty whether or not to deliver a preterm fetus with suspected fetal compromise, there seems to be no benefit to immediate delivery. Deferring delivery until test results worsen or increasing gestation favours delivery may improve the outcomes for mother and baby. More research is needed to guide clinical practice".
(Evidence level IV)
- European Society of Cardiology. ESC Guidelines on the management of cardiovascular diseases during pregnancy: The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European Heart Journal (2011) 32, 3147–3197
- National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence. Hypertension in pregnancy: the management of hypertensive disorders during pregnancy.
- Queensland Maternity and Neonatal Clinical Guidelines Program. Hypertensive disorders of pregnancy 2010
- Society of Obstetric Medicine of Australia and New Zealand. Guidelines for the management of hypertensive disorders of pregnancy 2008
- Stock SJ, Bricker L, Norman JE. Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD008968. DOI: 10.1002/14651858.CD008968.pub2. Abstract and full text (Restricted in some countries). Full text available to RCOG Fellows, Members and Trainees here.
Search date: September 2012
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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