Journal Club www.AJOG .

org

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

NOVEMBER 2013 American Journal of Obstetrics & Gynecology 493

Journal Club
the data were stratified by gestational
age. This finding was not statistically
significant but suggests further research
is needed to elucidate whether there is
a role for expectant management of
preeclampsia in the very early preterm
population.
Participants also agreed that future
studies are needed to address whether
long-term outcomes, such as develop-
mental milestones and infant mortality,
494 American Journal of Obstetrics & Gynecology NOVEMBER 2013
are better in infants born later at a size
that is small for gestational age or in
infants who are born earlier at a low
birthweight but at a size that is appro-
priate for their gestational age. This
information, which would offer some
sense of the future repercussions or
benefits of delaying birth, would be
helpful when making recommendations
regarding expectant management of
preeclampsia.
www.AJOG.org
The majority of women in the world
live in resource limited areas with regard
to health care. While discussants recog-
nize the findings are only directly
generalizable to women with access to
tertiary care facilities in those countries,
the authors certainly make a valuable
contribution towards applying evidence-
based principles of management of early
severe PE to a larger cross-section of
women in the world. -