Date of Award
2021
Document Type
Dissertation
Degree Name
Master of Medicine (MMed)
First Supervisor/Advisor
Dr. Sikolia Wanyonyi
Second Supervisor/Advisor
Dr. Angela Koech
Third Supervisor/Advisor
Dr. Geoffrey Omuse
Department
Obstetrics and Gynaecology (East Africa)
Abstract
Background: Chronic hypertension is independently associated with an increased incidence of adverse maternal and perinatal outcomes. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The optimal timing of delivery for women with this condition has not been adequately addressed by the available literature.
Objective: To review the literature that assesses the benefits and risks of a policy of planned delivery versus expectant management in pregnant women with non-severe chronic hypertension at 37 weeks gestation. Our primary outcomes were composite maternal outcome (super-imposed pre-eclampsia, placental abruption, maternal admission to intensive care unit and composite perinatal outcome (stillbirth, admission to neonatal intensive care unit). Secondary outcomes were superimposed pre-eclampsia, placental abruption, maternal admission to the intensive care unit, stillbirth, and admission to the neonatal intensive care unit. Research Design and Search
Methods: A systematic review with a narrative synthesis. We carried out an electronic search of different databases including CENTRAL, MEDLINE, and EMBASE. We set out to include randomized trials and cohort studies comparing planned early delivery and expectant management at 37 weeks gestation. We conducted a risk of bias assessment for each of the outcomes of interest. The quality of the evidence for the specified outcomes was assessed using the GRADE approach.
Results: We screened a total of 8830 titles and abstracts and 15 articles were selected for full text review. We found one study that was eligible for inclusion. This was a randomized controlled trial with 76 participants with similar baseline clinical characteristics. Half of them were assigned to planned delivery at 37 weeks of gestation while the other half was assigned to expectant management up to 41 weeks of gestation. There was no significant difference in the rate of super-imposed pre-eclampsia between the two groups (OR =0.9 (95% CI 0.2 to 2.3) p-value 0.9). Similarly, no significant difference in the rate of placental abruption was observed between the two groups. (OR =1.0 (95% CI 0.2 to 5.2) p-value 1.0). For these two outcomes, the risk of bias was high and the findings were based on a low degree of certainty of the evidence. The rate of admission to the neonatal intensive care unit was higher in the planned delivery compared to the expectant management group (OR = 5.4 (95% CI 1.4 to 21.0); p-value 0.01.). There were some concerns about the risk of bias for this outcome and these findings were based on a moderate degree of the certainty of the evidence.
Conclusion: In women with non-severe chronic hypertension in pregnancy, a policy of expectant management up to 41 weeks gestation was more favorable than planned delivery at 37 weeks gestation. There was no significant difference in the rates of super-imposed pre-eclampsia, or placental abruption though this finding was based on a low degree of certainty of the evidence. Additionally, expectant management was associated with lower rates of admission to the neonatal intensive care unit, and this finding is based on a moderate level of certainty of the evidence.
Recommended Citation
Njuguna, J. (2021). Planned delivery at 37 weeks gestation versus expectant management for non-severe chronic hypertension, a systematic review. (Unpublished master's dissertation). Aga Khan University, East Africa.