Sectio pada preeclampsia berat

Mode of Delivery

Baha M. Sibai,

MD From the Department of Obstetrics & Gynecology, University of Cincinnati College

of Medicine, Cincinnati, Ohio.
We thank the following individuals who, in addition to members of our Editorial
Board, will serve as referees for this series: Dwight P. Cruikshank, MD, Ronald
S. Gibbs, MD, Gary D. V. Hankins, MD, Philip B. Mead, MD, Kenneth L.
Noller, MD, Catherine Y. Spong, MD, and Edward E. Wallach, MD. VOL. 102, NO. 1, JULY 2003 0029-7844/03/$30.00 181
2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier. doi:10.1016/S0029-7844(03)004757

There are no randomized trials comparing optimal methods

of delivery in women with gestational hypertension
preeclampsia. A plan for vaginal delivery should be
attempted for all women with mild disease and for the
majority of women with severe disease, particularly
those beyond 30 weeks gestation.1 The decision to
perform cesarean delivery should be based on fetal gestational
age, fetal condition, presence of labor, and cervical
Bishop score. In general, the presence of severe
preeclampsia is not an indication for cesarean delivery.
My policy is to recommend elective cesarean delivery for
all women with severe preeclampsia below 30 weeks
gestation who are not in labor and whose Bishop score is
below five. In addition, I recommend elective cesarean
delivery to those with severe preeclampsia plus fetal
growth restriction if the gestational age is below 32 weeks
in the presence of an unfavorable cervical Bishop score.

Route of delivery
Vaginal delivery is usually recommended
with no contraindication in severe pre-eclampsia(56).
Cesarean section should be reserved for the
obstetrical indications. In case of unfavorable cervix,
cervical ripening agents may be used(56). The safety
of labor induction was also demonstrated by one
retrospective study(57). However, the rate of vaginal
delivery after labor induction decreases to about 33
percent at less than 28 to 34 weeks because of the
high frequency of non-reassuring fetal heart rate
tracings and failure of the cervical dilatation(58,59).
Therefore, some institutions recommend scheduled
cesarean delivery for women with severe pre-eclampsia
who are under 30 weeks of gestation and have a low
Bishop score(60).

Severe preeclampsia remote from term: labor induction or elective cesarean delivery?
A H Nassar; A M Adra; N Chakhtoura; O Gmez-Marn; S Beydoun (Profiled Author: Samir
N. Beydoun)
Division of Perinatology, Department of Obstetrics and Gynecology, University of Miami
School of Medicine, Miami, FL 33101, USA.
American journal of obstetrics and gynecology 1998;179(5):1210-3.

Abstract
OBJECTIVES: The study's objectives were as follows: (1) to determine the rate of vaginal
delivery after labor induction in severe preeclampsia remote from term and (2) to determine
potential predictors of success. STUDY DESIGN: Retrospective chart review was conducted
on live-born singleton pregnancies complicated by severe preeclampsia and delivered at 24 to
34 weeks' gestation from January 1, 1992, to December 31, 1996. Exclusion criteria included
eclampsia, presence of labor or spontaneous rupture of membranes on admission, and
complication of pregnancy by an ultrasonographically detected fetal congenital anomaly.
Patients were divided into 3 groups: elective cesarean delivery without labor, cesarean
delivery after labor induction, and vaginal delivery after labor induction. Statistical analyses
included multiple logistic regression, the Student t test, the chi2 test, and the Mann-Whitney
test. P </=.05 was considered significant. RESULTS: A total of 306 charts were reviewed.
Among these, 161 patients (52.6%) underwent elective cesarean delivery without labor; the 2
most common indications were unfavorable cervix (33.5%) and malpresentation (22.4%).
The remaining 145 patients (47.4%) underwent labor induction with a 48. 3% rate of vaginal
delivery after induction, ranging from 31.6% at </=28 weeks' gestation to 62.5% at >32
weeks' gestation. The most common indication for cesarean delivery after induction, in
50.7% of the cases, was nonreassuring fetal heart rate. The median Bishop score was
significantly higher (3 vs 2, P =.004) and the total hospital stay was significantly shorter in
the vaginal delivery after induction group than in the cesarean delivery after induction group.
However, there were no significant differences between the 2 groups in use of cervical
ripening agents, gestational age at delivery, birth weight, 5-minute Apgar score, or
postpartum endometritis. After exclusion of cesarean deliveries performed for
malpresentation, there was no statistically significant difference in classic incision rates
between the elective cesarean delivery without labor and cesarean delivery after induction
groups (13.6% vs 6.8%; P =.137). According to logistic regression analysis, only the Bishop
score was significantly associated with a successful induction (odds ratio 1.38, 95%
confidence interval 1.11-1.71). Gestational age reached marginal significance (odds ratio
1.30, 95% confidence interval 0.89-1.89). CONCLUSIONS: (1) Labor induction should be
considered a reasonable option for patients with severe preeclampsia at </=34 weeks'
gestation because 48% of patients given the chance were successfully delivered vaginally. (2)
The Bishop score on admission is the best predictor of success, although the chance of
successful labor induction increases with advancing gestational age.

Induction or caesarean section for preterm preeclampsia?

Authors: Mashiloane C.D.1; Moodley J.2
Source: Journal of Obstetrics & Gynaecology, Volume 22, Number 4, 1 July 2002 , pp. 353356(4)
Publisher: Informa Healthcare
Abstract:

Controversy continues over the mode of delivery in severe pre-eclampsia remote from term.
The aim of this study was to assess prospectively the mode of delivery in severe preeclampsia remote from term. The clinical data of 108 women who presented consecutively
with severe pre-eclampsia over a 1-year period was used for the study material. Sixty-eight
(63%) patients were delivered by elective caesarean section and 40 (37%) underwent
induction of labour. Twenty-six had a vaginal delivery following induction, the others (n =
14) had emergency caesarean section. No baby with a gestational age of 27 weeks survived
after delivery. Perinatal mortality was highest for the babies delivered following induction of
labour (vaginal delivery vs. caesarean section after induction of labour, P = 00004; vaginal
delivery vs. elective caesarean section, P = 0002). Severe pre-eclampsia remote from term is
associated with a high caesarean section rate. In this study, carried out in a developing
country, elective caesarean section contributed to a better perinatal outcome than vaginal
delivery or emergency caesarean section following induction of labour.

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DOI: 10.2147/IJWH.S8550

Diagnosis and management of pre-eclampsia:

an update Judi A Turner
Department of Anesthesiology,
David Geffen School of Medicine,
University of

Since definitive treatment of pre-eclampsia is delivery of

the fetus and placenta, preferably vaginally, IOL may be warranted.
IOL is considered in cases of $37 weeks gestational
age, fetal lung maturity (3234 weeks gestational age),40 a
favorable cervix, and maternal or fetal deterioration despite
conservative management. Corticosteroids to accelerate fetal
lung maturity should be considered in those with gestational
ages of 2434 weeks, and delivery should commence 48 hours
later in those with gestational ages of 3334 weeks.34,37 Intrauterine
growth restriction is a sign of chronic uteroplacental
insufficiency, and may be another factor recommending
prompt delivery after steroids have been administered, especially
when combined with oligohydramnios.41 There are
numerous maternal and fetal indications for urgent delivery
relating to worsening of the disease state (Table 4).
Women with HELLP should be delivered regardless of
gestational age, but if expectant management is planned,
it should only occur at a tertiary care hospital with close
maternal and fetal monitoring due to the severe nature of the
disease.4 It seems reasonable to recommend prompt delivery
within 48 hours of diagnosis of HELLP, allowing for corticosteroid
therapy for lung maturation, because there is some
evidence that prolongation of pregnancy may not improve
neonatal outcomes.37

Table 4 Urgent indications for delivery in pre-eclampsia 10,37,41

Severe, refractory hypertension .24 hours
Refractory renal failure
Pulmonary edema
Worsening thrombocytopenia, coagulopathy/disseminated
intravascular coagulopathy
Progressive liver dysfunction or hepatic hematoma/rupture
Eclampsia or progression of neurologic symptoms
Placental rupture
E vidence of severe fetal growth restriction or oligohydramnios
(may consider delay for betamethasone therapy)41
Fetal distress