Induction of Labor for Maternal Indications at a Periviable Gestational Age; Survey on Management, Reporting and Auditing amongst Dutch Maternal-Fetal Medicine Specialists and Neonatologists.

Background In cases of life-threatening maternal conditions in the periviable period, professionals may consider immediate delivery with fetal demise as a consequence of the treatment. We sought the opinion of involved medical professionals on management, reporting, and auditing in these cases. Methods We performed an online survey amongst all registered maternal-fetal medicine (MFM) specialists and neonatologists in the Netherlands. The survey presented two hypothetical cases of severe early-onset pre-eclampsia at periviable gestational ages. Management consisted of immediate termination or expectant management directed towards newborn survival. Findings In the case managed by immediate termination, 62% percent answered that fetal demise resulting from induction of labor for maternal indications should be audited only within the medical profession. In the case of expectant management, 17% of the participants agreed with this management. Some answers revealed a significant difference in opinion between the medical specialists. Conclusion Perspective of MFM specialists and neonatologists differs with regard to counseling prospect parents in case of severe early onset pre-eclampsia. The majority of professionals is willing to report late termination (after 24 weeks' gestation) for severe maternal disease to medical experts for internal audits but not for legal auditing.

Mode of Delivery in Severe Preeclampsia Before 28 Weeks' Gestation: A Systematic Review.

IMPORTANCE: Preeclampsia with an onset before 28 weeks' gestation poses dilemmas for the obstetrician with regard to the mode of delivery. OBJECTIVE: The aim of this study was to analyze the success rate of attempted vaginal delivery and the maternal and neonatal outcome according to the mode of delivery in women with preeclampsia and an indicated delivery before 28 weeks' gestation. EVIDENCE ACQUISITION: A comprehensive search was performed in the bibliographic databases PubMed, Embase.com, and Wiley Cochrane Library. The main outcome was success rate of attempted vaginal delivery. Secondary outcomes were maternal and neonatal outcomes. RESULTS: Eight studies describing a total of 800 women were included. Success rates of vaginal delivery varied from 1.8% to 80%, and rates for cesarean delivery after induction of labor varied from 13% to 51%. The rates for planned cesarean delivery varied from 0% to 73%. Two studies (n = 53) described no statistical significant differences in maternal outcomes. Two other studies (n = 107) report no statistical difference in neonatal outcome. CONCLUSIONS: Studies that report the success rate of attempted vaginal delivery are limited in size. However, giving the available evidence in the reported studies a trial of labor is a considerable option in counseling women with a pregnancy complicated by preeclampsia before 28 weeks' gestation due to the similar maternal and neonatal outcome. No differences in maternal or neonatal outcome were attributed to the mode of delivery, however, numbers are small.

Subsequent pregnancy outcome after mid-trimester termination of pregnancy for preeclampsia.

BACKGROUND: In this study we determined the outcome of subsequent pregnancies after termination of pregnancy for preeclampsia, with the purpose of presenting data useful for counselling these women on future pregnancies. STUDY DESIGN: The cohort consisted of 131 women with a history of termination of pregnancy for preeclampsia. RESULTS: Data of 79 pregnancies were available for analysis, including 13 women with chronic hypertension and 16 women with thrombophilia. There were seven miscarriages (8.8%) and 72 ongoing pregnancies. Low-dose aspirin was prescribed for 64 women (89%). The mean gestational age at delivery was 356/7 ± 4 weeks with a mean birth weight of 2571 ± 938 g. Overall recurrence rate for preeclampsia was 29% at a mean gestational age of 32 weeks. Thirty-eight women had an uncomplicated pregnancy (53%). The women with chronic hypertension had the highest recurrence rate of 38%. Neonatal mortality was 4%. CONCLUSION: The course of subsequent pregnancies after mid-trimester termination for preeclampsia is uncomplicated in 53% with a recurrence rate for preeclampsia of 29%. The mean gestational age at delivery was 11 weeks later and birth weight 2000 g higher than in the index pregnancy.

Terminating pregnancy for severe hypertension when the fetus is considered non-viable: a retrospective cohort study.

OBJECTIVE: To investigate frequency and practise of termination of pregnancy for early-onset hypertensive disorders where the fetus is considered to be non-viable. STUDY DESIGN: Retrospective cohort study in all Dutch tertiary perinatal care centres (n=10), between January 2000 and January 2014. All women who underwent termination of pregnancy, without fetal surveillance or intention to intervene for fetal reasons, for early-onset hypertensive disorders in pregnancy, were analyzed. Women eligible for this study were identified in the local delivery databases. Medical records were used to collect relevant data. RESULTS: Between January 2000 and January 2014, 2,456,584 women delivered in The Netherlands, of which 238,448 (9.7%) in a tertiary care centre. A total of 161 pregnancy terminations (11-12 per year) for severe early-onset preeclampsia were identified, including 6 women with a twin pregnancy. Mean gestational age at termination was 172 days (GA 244/7)±9.4 days. In 70% of cases termination was performed at or shortly after 24 weeks' gestation. 74.5% of women developed HELLP syndrome (n=96), eclampsia (n=10) or needed admission to an ICU (n=14). Birth weight was below 500g in 64% of cases. In 69% of the cases the estimated fetal weight was within a 10% margin of the actual birth weight. CONCLUSION: Termination of pregnancy for early-onset hypertensive disorders without intervention for fetal indication occurs approximately 12 times per year in The Netherlands. More data are needed to investigate contemporary best practice regarding termination of pregnancy for early-onset hypertensive indications at the limits of fetal viability. Considering the frequency of maternal complications, termination of pregnancy and not expectant management should be considered for all women presenting with severe early onset hypertensive disorders at the limits of fetal viability.