Title: Do ACOG Criteria for Expectant Management Predict Maternal Morbidity in Women with Severe Preeclampsia?

Authors: Rachel G. Sinkey, MD^1,2; Victoria C. Jauk, MPH¹; Aalok R. Sanjanwala, MD^1,2; Gabriella D. Cozzi, MD^1,2; David A. Becker, MD^1,2; Lorie M. Harper, MD, MCSI^1,2; Brian M. Casey, MD^1,2; Akila Subramaniam, MD, MPH^1,2

Institutions:

1. Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
2. Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama

Objective:

• To compare maternal morbidity in women with preeclampsia with severe features (SPE) in whom ACOG recommends immediate delivery compared to those eligible for expectant management (EM).

Study Design:

• Retrospective cohort
• Inclusion criteria:

• • Women with SPE
  • Liveborn, non-anomalous singletons
  • Gestational age between 23–34 weeks
  • Delivery at UAB
  • 1/2013-12/2017

• Women in whom ACOG recommended and had immediate delivery (EM INappropriate) were compared to those eligible for EM per ACOG regardless of management (EM appropriate).
• EM INappropriate included women with eclampsia, pulmonary edema, disseminated intravascular coagulation, uncontrolled severe hypertension, abnormal/nonviable fetus, abruption, fetal demise, platelet <100,000, liver function >2x upper limit of normal, serum creatinine >1.1, severe persistent right upper quadrant/epigastric pain, or new-onset cerebral/visual disturbances.
• Primary outcome – Maternal morbidity composite

• • ICU admission, stroke, other severe morbidities, and death

• Secondary outcomes

• • Postpartum hemoglobin (PP Hgb) < 7 g/dL
  • Maternal hospitalization length
  • Neonatal outcomes

• Analysis:

• • Chi-square and Student’s t-tests were used to compare outcomes between groups
  • Adjusted odds ratios (95% CIs) were calculated

Results:

• 543 women with SPE included in analysis
  • 332 (61%) were EM appropriate, 211 (39%) were EM Inappropriate
  • Similar baseline characteristics
  • EM INappropriate women:

• Significantly more likely to have composite maternal morbidity (4.7% vs 1.2%; aOR 5.0 [95% CI 1.4–18.7]).
• More likely to be admitted to the ICU (3.8% vs 0.9%; aOR 4.2 [1.1–16.2])
• More likely to have PP Hgb <7g/dL (4.3% vs 0.9%; aOR 5.1 (1.4–19.1)
• Neonatal outcomes were similar between groups

Conclusion:

• Women with SPE whom ACOG identifies as ineligible for EM have a 5-fold increased risk of maternal morbidity despite immediate delivery at a tertiary care center.
• Escalation of care and immediate delivery is essential among these women to reduce maternal morbidity and mortality.

Table 1: Maternal and neonatal outcomes among women with preeclampsia with severe features according to ACOG eligibility criteria for expectant management

* Model controls for admission diastolic blood pressure

‖ Endometritis, septic pelvic thrombophlebitis, Worsening Kidney disease necessitating postpartum transfer to renal service, postpartum hemorrhage, postpartum seizure, retinal detachment

• ^§Neonatal composite morbidity includes: mechanical ventilation > 24 hours, CPR, Grade III/IV IVH, NEC, RDS, Arterial pH < 7.1, 5-min Apgar < 3, HIE, Neonatal death. Although not presented, components of neonatal composite were not significantly different between groups.