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Medical Article
Expectant management of severe preeclampsia before 34 weeks of pregnancy in rural Indian hospital
 Author : Dr.Shyamala Guruvare MD Associate Professor , Dr.Pralhad Kushtagi MD, DNB, FICOG , Professor Kasturba Medical College, Manipal 576104, Karnataka, India
Traditionally women with severe preeclampsia are delivered immediately regardless of the consequences of extreme fetal prematurity. Delaying this definitive management for severe preeclampsia to at least gain benefit of antenatal steroids and to organize resources for managing the anticipated complications is referred to as expectant management. Such an approach has shown improved perinatal outcome without compromising the maternal wellbeing in developed countries [1, 2, 3, 4]. The experience in an Indian rurally based hospital is reported.

Consenting 52 women between 24 and 34 weeks of pregnancy with severe preeclampsia were recruited for expectant management by avoiding immediate termination of pregnancy. Intensive monitoring for feto-maternal wellbeing and antihypertensive(s) was continued. Institute ethics committee approval was obtained. Cases presenting with any of the complications such as eclampsia, placental abruption, preterm labor, and intrauterine fetal death were not included in the study. Pregnancy was terminated after 34 weeks or earlier in case of any of the following (i) uncontrolled hypertension, (ii) persisting or progressively deteriorating clinical symptoms or the biochemical markers (iii) occurrence of complications such as placental abruption, eclampsia, renal failure or significant retinopathy (v) non-reassuring fetal status.

The median gestational age at hospitalisation with severe preeclampsia was 30 weeks 1 day (SD 2.1; median 31 weeks; range 24 to 34 weeks). Of the 52 cases, thirty-three (63.4%) were aged less than 30 years and 23 were multigravidas (44%). Twenty-six patients had blood pressure beyond 160/110 mm Hg and 20 women (38.4%) had serum uric acid >5mg/dl. Proteinuria of >5grams/24 hours was present in 10 and significantly elevated liver enzymes 6 cases (19.2 and 11.5%, respectively). Two cases had rapidly falling platelet count, and one of them with the platelet count of < 1, 00,000/ cc. Imminent eclampsia was present in 6 cases and oliguria in 5 women (9.6%). There were 29 (55.7%) cases with evidence of fetal growth restriction.
Pregnancies could be prolonged by an average of 9 days (SD 7.1) and the average birth weight was 1231 g (SD 319). Thirty-six women had cesarean delivery (69%), non-reassuring fetal status being the most common indication for termination of pregnancy (34.6%, 18 of 52).