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J Matern Fetal Neonatal Med, Early Online: 17

! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.928689

ORIGINAL ARTICLE

Maternal outcomes according to mode of delivery in women with

severe preeclampsia: a cohort study
Melania M. R. Amorim1,2, Leila Katz1, Amanda S. Barros3, Tainara S. F. Almeida3, Alex Sandro R. Souza1,4, and
Anbal Faundes5
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1
Department of Maternal and Child Health, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil,
2
Department of Obstetrics, Universidade Federal de Campina Grande (UFCG), Campina Grande, Paraba, Brazil, 3Faculdade Pernambucana de
Saude (FPS), Recife, Pernambuco, Brazil, 4Department of Maternal and Child Health, Universidade Federal de Pernambuco (UFPE), Recife,
Pernambuco, Brazil, and 5Department of Obstetrics and Gynecology, Universidade de Campinas (UNICAMP), Campinas, Sao Paulo, Brazil,

Abstract Keywords
Objective: To determine the association between mode of delivery and maternal complications Caesarean, complications, delivery, labour,
in patients with severe preeclampsia. obstetrics, pre-eclampsia, prognosis
Methods: A prospective cohort study was conducted with 500 pregnant women with severe
preeclampsia. The mode of delivery, vaginal or caesarean section, was considered the exposure, History
while the postpartum maternal complications and severe maternal morbidity were the
outcomes. Logistic regression analysis was performed to determine the adjusted risk and 95% Received 27 August 2013
Revised 15 May 2014
For personal use only.

confidence intervals (95% CI) of maternal morbidity.

Results: Labour was spontaneous in 22.0% and induced in 28.2%, while 49.8% had an elective Accepted 23 May 2014
caesarean section. Ninety-five (67.4%) of the patients in whom labour was induced delivered Published online 27 June 2014
vaginally. Total Caesarean rate was 68.2%. The risk of severe maternal morbidity was
significantly greater in patients submitted to Caesarean section (54.0% versus 32.7%)
irrespective of the presence of labour. Factors that remained associated with severe maternal
morbidity following multivariate analysis were a diagnosis of HELLP syndrome after delivery
(OR 3.73; 95% CI: 1.559.88) and having a caesarean (OR 1.91; 95% CI: 1.524.57).
Conclusions: Caesareans are often performed in patients with severe preeclampsia and are
associated with significant postpartum maternal morbidity. Induction of labour should be
considered a feasible option in these patients.

Introduction premature babies, with lower complication rates and a shorter

duration of hospitalization. Furthermore, the rate of cerebral
The ideal mode of delivery in patients with severe
palsy of the newborn remains the same [6,8].
preeclampsia still remains to be established [1].
The therapeutic decision regarding mode of delivery is not
Preeclampsia is one of the most common reasons for the
easy, since obstetricians often have to deal with pregnancies
therapeutic interruption of pregnancy, since delivery consti-
that are still remote from term and with unfavourable cervical
tutes the only definitive treatment for the process [1].
conditions [6]. Additionally, both maternal clinical conditions
As preeclampsia often occurs in preterm pregnancies [2],
and foetal well-being may be compromised [9]. Nonetheless,
interruption is frequently indicated when labour is absent
most medical society guidelines recommend vaginal delivery
[3,4]. The global rate of caesarean sections is estimated to be
due to the benefits to the mother of this mode of delivery, the
high (around 70% or more in preterm pregnancies) because
high likelihood of success and the lower rates of complica-
many obstetricians prefer performing Caesareans in these
tions [1014]. Women with preeclampsia have a low tolerance
patients, even when foetal vitality is good [5,6].
for blood loss and a greater risk of haemorrhagic complica-
Nevertheless, it has yet to be proven that Caesareans
tions; therefore, in these women vaginal delivery may confer
improve neonatal outcome and they may be associated with
significant benefits [15].
poorer maternal outcome [7]. Observational studies suggest
The present study was carried out to evaluate the
that vaginal delivery may be better in the long term for
association between mode of delivery and maternal outcomes
among patients with severe preeclampsia.
Address for correspondence: Melania M. R. Amorim, MD, PhD,
Department of Obstetrics, Universidade Federal de Campina Grande Methods
(UFCG), Rua Neuza Borborema de Souza, 300, 58406-120 Campina
Grande, Paraba, Brazil. Tel: +558333212695. Fax: +558333212695. A prospective, cohort study was conducted in women with
E-mail: melania.amorim@gmail.com severe preeclampsia receiving care at Instituto de Medicina
 2 M. M. R. Amorim et al.
Integral Prof. Fernando Figueira (IMIP), a tertiary referral
center located in the city of Recife in northeastern Brazil,
which is a major referral center for high risk obstetrics care in
the region and the only one that possesses an obstetric ICU.
The caesarean rate of the unit is 40%. The study was
conducted between August 2008 and July 2009 after having
been approved by the institutions Institutional Review Board
under reference # 1199 on 26 June 2008. All the patients
included in the study voluntarily agreed to participate and
gave their signed informed consent. STROBE recommenda-
tions for reporting cohort studies were followed. Data were
extracted by the authors from medical charts and when there
were missing data, charts were again checked and the patient
consulted about disagreement in information.
Sample size was calculated with open source software
(Openepi version 2.3, Atlanta,), assuming a rate of haemor-
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rhagic complications of 8% among patients submitted to
Caesarean sections and 1% among patients who had vaginal
deliveries (data from a previous pilot study carried out in our
institution), with an alpha error of 5% and a power of 90%.
Sample size was thus defined at 420 patients and this number
was increased to 500 patients to cater for possible losses and
exclusions.
All pregnant women with confirmed diagnosis of severe
preeclampsia admitted in our hospital were included in the
study and followed after delivery until hospital discharge.
Cases of haemorrhagic emergencies (placenta praevia and
For personal use only.
placental abruption), eclampsia, coma, inability to provide
informed consent to participate in the study and patients with
a diagnosis of other associated clinical conditions (diabetes,
collagen diseases or thrombophilia) were excluded from the
study. Associated clinical conditions were considered present
when the patient had at admission previous diagnosis of the
condition or when during hospital stay the diagnosis was
made.
The mode of delivery, vaginal or Caesarean section, was
considered the independent variable, while the following
postpartum maternal complications constituted the dependent
variables: haemorrhagic complications, puerperal infection,
blood transfusion, hypertensive crisis, need for antihyperten-
sive drugs, oliguria, acute pulmonary oedema, thrombo-
embolism, eclampsia, HELLP syndrome, severe maternal
morbidity and duration of hospitalization longer than 7 d. The
following control variables (potential confounding factors)
were taken into consideration: maternal age, parity, body
mass index (BMI), clinical form of preeclampsia (pure or
superimposed), blood pressure levels, prepartum complica-
tions, severity of hypertension and HELLP syndrome
diagnosed prior to delivery) and induction of labour.
Criteria defined by the National High Blood Pressure
Education Program Working Group (2000) were taken into
consideration for the diagnosis of severe preeclampsia, i.e.
presence of any one of the following signs or symptoms in
women with hypertension diagnosed after 20 weeks of
pregnancy and proteinuria: blood pressure 160 mmHg
systolic or 110 mmHg diastolic; proteinuria 2.0 g in 24 h
(2+ or 3+ on qualitative examination); increased serum
creatinine level (41.2 mg/dL); platelet count 5100 000 cells/
mm3, evidence of microangiopathic haemolytic anemia
(with increased lactic acid dehydrogenase concentration), or
J Matern Fetal Neonatal Med, Early Online: 17
both; elevated hepatic enzyme activities (either alanine
aminotransferase, aspartate aminotransferase, or both); patient
report of persistent headache or other cerebral or visual
disturbances; patient report of persistent epigastric pain [16].
Preeclampsia was considered to be pure when hypertension
and proteinuria developed after 20 weeks in previously
normotensive patients, whereas preeclampsia was considered
to be superimposed when it was diagnosed following the
appearance of proteinuria (300 mg in 24 h) in patients with a
diagnosis of hypertension prior to 20 weeks or in patients
with hypertension and proteinuria prior to 20 weeks, in
accordance with any of the following findings: sudden
increase in proteinuria; sudden increase in blood pressure in
a woman whose hypertension had previously been well
controlled; thrombocytopenia (platelet count 5100 000 cells/
mm3) or increase in alanine aminotransferase or aspartate
aminotransferase to abnormal levels [16].
All patients were given standard care provided at the
hospital for cases of severe preeclampsia [1] based on the
recommendations outlined in the guidelines of the pertinent
international and national societies [1013,17], including use
of magnesium sulfate for prevention of eclampsia [1012,16].
Investigators did not interfere in any way with the manage-
ment adopted.
Conservative management was indicated for women with
less than 34 weeks of pregnancy and antenatal corticosteroid
therapy with betamethasone (two 12 mg doses with a 24-h
interval) was administered to accelerate foetal lung maturity.
Conservatively managed patients received oral antihyperten-
sive drugs, while foetal well-being was monitored by
ultrasonography, Doppler velocimetry and cardiotocography.
The criteria for interrupting pregnancy were: gestational
age 434 weeks, spontaneous labour, impaired foetal well-
being or maternal complications (HELLP syndrome, uncon-
trolled hypertension). Very high blood pressure occurring
prior to delivery were treated with injectable hydralazine
(5 mg given as an intravenous bolus, up to a maximum dose of
20 mg) and after delivery with captopril (25 mg orally) with
the objective of reducing pressure by approximately 20%. The
decision regarding mode of delivery was made by the
attending team, although the institutions regulation manual
suggests inducing labour if there are no contraindications to
vaginal delivery [1], in agreement with the recommendations
of the international and national societies [12].
Labour induction was defined as the use of any method to
artificially induce labour: either by pharmacological (mis-
oprostol or oxytocin) or mechanical (Foley catheter) means.
Induction was considered to have been successful when the
outcome was vaginal delivery. Elective Caesarean section was
defined as a Caesarean performed in the absence of labour,
whereas an intrapartum Caesarean section was performed in
the presence of uterine contractions, either spontaneous or
induced. The indications for performing a Caesarean section
are described in this study exactly as they were recorded on
the patients chart by the physician on duty responsible for the
procedure. They were later classified into groups for the
purposes of analysis. If more than one indication had been
recorded, the main reason for performing the Caesarean
section was taken into consideration. All patients were
followed during hospitalization until discharge and/or 30 d
 DOI: 10.3109/14767058.2014.928689
postpartum in order to identify postpartum complications.
Duration of hospitalization from delivery to discharge was
determined.
With respect to complications during pregnancy and
postpartum, uncontrolled hypertension or hypertensive crisis
was defined as the 24-h presence of at least one very high
blood pressure urgently requiring administration of antihy-
pertensive drugs (systolic pressure 180 mmHg or diastolic
pressure 120 mmHg). HELLP syndrome was defined in
accordance with the criteria established by Sibai [17]. Acute
pulmonary oedema was diagnosed according to a clinical
finding of severe dyspnea, production of pink frothy sputum
from the airways, excessive sweating and cyanosis, as well as
moist rales present in lung fields [18]. Oliguria was diagnosed
when urinary output was less than 400 ml in 24 h, based on the
criteria of acute kidney failure [19]. Thromboembolism was
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defined as the presence of any thromboembolic event
confirmed by imaging tests and requiring anticoagulant
therapy. The criteria defining postpartum severe maternal
morbidity were modified from World Health Organization
(WHO) in 2009 [20]. As severe preeclampsia per se is defined
like potentially life-threatening conditions and we wanted patients were addressed for inclusion in the study, 525 of
to discriminate the most severe cases, we considered severe
maternal morbidity the presence of other indicators such as
severe hypertension, hypertensive encephalopathy, postpar-
tum HELLP syndrome, endometritis, pulmonary oedema,
respiratory failure, seizures, sepsis, shock, thrombocytopenia
For personal use only.
less than 100 000/ mm3, thyroid crisis and severe management
indicators (blood transfusion, central venous access, hyster-
ectomy, prolonged hospital stay, no anaesthetic intubation,
return to operating room and surgical intervention [20].
Postpartum haemorrhage was defined as blood loss
1000 ml or haemorrhage that justified blood transfusion in
the opinion of the attending physician. Post-surgical haema-
toma was defined as an accumulation of blood in the surgical
wound requiring drainage.
The patient was considered to have an infection when a
clinical and laboratorial diagnosis of infection was made
postpartum (infection at the surgical site, endometritis,
urinary infection, lung infection or any other infection).
Infection of the surgical site was defined in accordance with
the criteria established by the Centers for Disease Control and
Prevention (CDC) and was classified as an incisional
infection (in the surgical wound itself) or related to organs
and spaces (intracavitary or deep infection) [20]. A diagnosis
of postpartum endometritis was based on the patient having a
temperature 438  C in the absence of any other cause other
than in the first 24 h postpartum or a temperature of 38.7  C
in the first 24-h postpartum. Uterine sensitivity, purulent or
foul-smelling lochia and leukocytosis with left shift were
considered adjuvant criteria [21].
Statistical analysis was performed using the public domain
Epi Info software program, version 3.5.3 (Centers for Disease
Control and Prevention, Atlanta, GA). Measures of central
trend and dispersion were calculated for numerical variables,
and frequencies for categorical variables. The statistical tests
used were Pearsons chi-square test and Fishers exact test,
as appropriate, considering only two-tailed values of p.
A significance level of 5% was adopted throughout the
statistical analysis. Risk ratio (RR) was calculated as a measure
Maternal outcomes in severe preeclampsia 3
of the relative risk of maternal complications according to the
type of delivery and a 95% confidence interval was established.
Multivariate analysis with multiple logistic regression was
performed to determine the risk of severe maternal morbidity
according to the mode of delivery, while controlling for
potential confounding factors. A hierarchical model of
analysis was adopted, as recommended by Victora [22],
which included the following variables: maternal age, parity,
BMI, clinical form of preeclampsia (pure or superimposed),
gestational age at delivery, induced labour, spontaneous
labour, type of Caesarean section, (elective or intrapartum),
prepartum complications (HELLP syndrome and uncontrolled
hypertension) and prepartum blood pressure levels. Adjusted
odds ratios (OR) were calculated, together with their 95%
confidence intervals (95% CI) for the variables that continued
to be significantly associated with maternal morbidity.
Results
During the study period, 831 cases of severe preeclampsia and
eclampsia were admitted to this hospital. Of these, 614
whom were considered eligible for the study and 89
ineligible. The reasons for exclusion were: haemorrhagic
emergencies (n 22), eclampsia (n 52), associated clinical
conditions (n 13), coma or inability to provide informed
consent to participate in the study (n 2). Of the eligible
patients, 500 agreed to participate and were evaluated.
The mean age of the patients included in the study was
24.7 years, with 55% being under 25 years of age. Median
parity was zero, with 65% of the participants being prim-
iparas. Around 18% of the patients had had a previous
caesarean section. Preeclampsia was considered pure in 77%
of participants and superimposed in 23%. Mean gestational
age, both at admission and at delivery, was around 36 weeks.
The percentage of premature deliveries was 42.4%. Mean
prepartum blood pressure levels were around 173 mmHg for
systolic pressure and 113 mmHg for diastolic pressure. With
respect to prepartum complications 28% of patients had
uncontrolled hypertension. Mean duration of hospitalization
(from delivery to discharge) was 6.6 4.3 d.
Patients were older, had higher BMI, gestational age was
lower and systolic and diastolic blood pressure was higher in
the caesarean group (Table 1).
Labour was spontaneous in 110 patients (22%) and induced
in 141 (28.2%), 95 of whom went on to have vaginal
deliveries (67.4%). The total caesarean section rate was 68%;
with 249 patients (50%) having elective and 92 (18.4%)
intrapartum caesarean sections. The caesarean section rate
following spontaneous labour was 42% (Table 2).
The methods used to induce labour were vaginal
misoprostol in 64 patients (45.4%), oxytocin alone in 71
patients (50.3%), a Foley catheter alone in 4 patients (2.8%)
and a Foley catheter with oxytocin in 2 patients (1.4%). The
main indications for performing a caesarean section were
severe preeclampsia (57%), chronic foetal distress (15%),
breech presentation (5.6%), dystocias and/or cephalopelvic
disproportion (6%), non-reassuring foetal heart rate (4.4%),
macrosomia (4%) and having had two or more previous
caesarean sections (3.5%).
 4 M. M. R. Amorim et al. J Matern Fetal Neonatal Med, Early Online: 17

An increased risk of various postpartum complications was
found in patients submitted to Caesarean section. There was a
greater incidence of postpartum haemorrhage (4.1% versus
0.6%; p 0.024), post-surgical haematoma (8.2% versus
0.6%; p 0.00009) and any haemorrhagic complication
(12.3% versus 1.3%; p 0.00005). The risk of any haemor-
rhagic complication was almost 10 times higher in patients
submitted to caesarean section (RR 9.8; 95% CI: 2.440.0)
and the need for blood transfusion was significantly higher
following caesarean section (8.2% versus 2.5%; p 0.006)
(Table 3).
Table 1. Patients characteristics.
Vaginal
Caesarean delivery
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Infection of surgical site (2.6%) occurred only in patients
submitted to Caesarean section (p 0.002). The groups were
not significantly different with respect to the risk of
endometritis (p 0.55) or of any kind of puerperal infection
(RR 1.59; 95% CI: 0.604.22; p 0.35) (Table 3).
Thromboembolic complications were rare, with one case
occurring in each group (p 0.54). Oliguria was significantly
more common in women submitted to caesarean section
(9.0% versus 4.0%; p 0.03). Very high blood pressure and
the need for antihypertensive drugs were more common
following caesarean section (47.8% versus 30.2%; p 0.0002
and 80.9% versus 62.3%; p 0.000006, respectively). There
was no significant difference in the rate of acute pulmonary
oedema (p 0.46) or postpartum HELLP syndrome
(p 0.12) as a function of the type of delivery. Duration of
hospitalization was longer after caesarean delivery, with a

Characteristics (n 341) (n 159) p

median of 7 d compared to 5 d for those who had a vaginal
Maternal age (years) 25.1 6.5 23.7 6.6 0.03* delivery. Hospitalization beyond 7 d was more common
(Mean, SD)
Parity (Median, IQR) 1.0 12 1.0 12 0.44y following caesarean section than after vaginal delivery
Gestational age (weeks) 36.1 3.5 36.8 3.4 0.04* (53% versus 23%; p50.0001) (Table 3).
(Mean, SD) The risk of severe maternal morbidity was 1.7 times higher
BMI (kg/m2) (Mean, SD) 31.4 5.4 29.6 5.3 0.003* in patients submitted to caesarean section (54.0% versus
SBP (mmHg) (Mean, SD) 175.2 18.9 169.6 16.2 0.001*
DBP (mmHg) (Mean, SD) 114.2 13.1 111.0 11.7 0.009* 32.7%; RR 1.65; 95% CI: 1.292.11) (Table 3). There was
no difference in the rate of severe maternal morbidity between
SD, standard deviation; IQR, interquartile range; BMI, body mass index; elective and intrapartum caesarean sections (55.0% versus
SBP, systolic blood pressure; DBP, diastolic blood pressure.
*Student t-test.
51.1%, respectively; p 0.52).
yMannWhitney test. When multiple logistic regression analysis was performed,
For personal use only.

the variables that remained significantly associated with

postpartum severe maternal morbidity were caesarean section
Table 2. Characteristics of labour and delivery. (OR 1.91; 95% CI: 1.524.57) and prepartum presence of
HELLP syndrome (OR 3.91; 95% CI: 1.559.88) (Table 4).
Labour N %
Spontaneous labour 110 22.0 Discussion
Induced labour 141 28.2
Elective caesarean 249 49.8 In the present study, a high caesarean section rate of almost
Vaginal delivery 159 31.8 70% was found in patients with severe preeclampsia.
Intrapartum caesarean 92 18.4 Caesarean sections were associated with increased maternal
 Caesarean following induction 46/141 32.6%
 Caesarean following spontaneous labour 46/110 41.8% morbidity, raising the risk of haemorrhagic and infectious
Total number of Caesarean sections 341 68.2 complications and the rate of postpartum hypertensive crises,
and prolonged hospitalization. The risk of severe maternal

Table 3. Postpartum maternal complications according to mode of delivery.

Caesarean (n 341) Vaginal delivery (n 159)

Complication N % N % RR 95% CI p NNH (CI 95%)
Postpartum haemorrhage 14 4.1 1 0.6 6.5 0.8649.2 0.024 29 (10020)
Post-surgical haematoma 28 8.2 1 0.6 13.1 1.7995.1 50.0001 13 (2510)
Any haemorrhagic complication 42 12.3 2 1.3 9.79 2.4039.95 50.0001 9 (147)
Blood transfusion 28 8.2 4 2.5 3.26 1.169.15 0.006 18 (10011)
Surgical site infection 9 2.6 0.002 NE*
Endometritis 12 3.5 4 2.5 1.40 0.464.27 0.55
Any puerperal infection 17 5.0 5 3.1 1.59 0.604.22 0.35
Thromboembolic disease 1 0.3 1 0.6 0.47 0.037.4 0.54
Oliguria 31 9.1 6 3.8 2.41 1.035.66 0.03 19 (10011)
Hypertensive crisis 163 47.8 48 30.2 1.58 1.222.06 0.0002 6 (134)
Need for antihypertensive drugs 276 80.9 99 62.3 1.30 1.141.48 50.0001 5 (104)
Acute pulmonary oedema 2 0.6 0.46
HELLP syndrome 9 2.6 1 0.6 4.20 0.5332.8 0.12
47 d of hospitalizationy 180 52.8 36 22.6 2.33 1.723.16 50.0001 3 (53)
Severe maternal morbidity 184 54.0 52 32.7 1.65 1.292.11 50.0001 5 (83)

RR, relative risk; CI, confidence interval; NNH, number necessary to harm.
*NE, Not estimated.
yDuration of hospitalization (median): Caesarean 8 d; Vaginal delivery 5 d.
 DOI: 10.3109/14767058.2014.928689
Table 4. Risk factors for postpartum severe maternal morbidity
(multivariate analysis).
Standard
Variable Coefficient error p OR 95% CI
Caesarean 1.06 0.33 0.0019 1.91 1.524.57
Prepartum HELLP 1.36 0.47 0.0040 3.91 1.559.88
syndrome
Variables entering the model: maternal age, parity, body mass index,
clinical form of preeclampsia (pure or superimposed), gestational age
at delivery, induced labour, spontaneous labour, type of caesarean
section (elective or intrapartum), uncontrolled hypertension, HELLP
syndrome antepartum blood pressure levels.
OR, odds ratio; CI, confidence interval.
morbidity persisted even after controlling for potential
confounding factors and was 65% higher in patients submitted
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to caesarean sections.
Patients were older and had higher BMI in the caesarean
group, although the difference found is not clinically signifi-
cant. Patients did not differ regarding parity, but gestational
age was lower in the c-section group. This finding can be
explained because of the time from induction to delivery in
the patients that achieve vaginal delivery. Systolic and
diastolic blood pressure was higher in the caesarean group,
and despite the difference not being clinically important, may
be explained by the tendency that care takes usually
demonstrate to be less tolerant and waiting for vaginal
For personal use only.
delivery in patients with uncontrolled blood pressure.
One can argue that these groups are very differents once
women who underwent caesarean section were older, at lower
gestational week, with higher BMI and pre delivery also
systolic and diastolic blood pressure levels. All these differ-
ences together could explain at least in part why clinicians
decided to perform a caesarean section, although none of
these findings are per se true indications for caesarean
section. However, our research question does not adress the
risk factors for caesarean section in these patients, but the
consequences of performing a caesarean section in women
with severe preeclampsia. We intend to evaluate the factors
associated with caesarean section in these women in a later
study.
This high caesarean section rate is compatible with rates
described by other authors [23]; however, it is higher than
rates reported in more recent studies [24]. Differences in the
study population and in the mode of management of these
patients at each institution may explain these findings.
Nevertheless, caesarean rates were high even when patients
went into labour, either spontaneous (41.8%) or induced
(32.6%). The high proportion of cases in which indication for
caesarean section was only severe preeclampsia suggests that
in many cases there was no real obstetric indication. On the
other hand, the 67% success rate of vaginal delivery after
labour induction in patients with severe preeclampsia
achieved in the present study was higher than that described
in the literature, which ranges from 48% to 60% in this
specific clinical situation [6,7,9].
Few studies have specifically analysed the association
between postpartum maternal complications and mode of
delivery in patients with preeclampsia. Caesarean section
constitutes a recognized risk factor for haemorrhagic and
Maternal outcomes in severe preeclampsia 5
infectious complications in the general population [25,26],
although more recent studies have suggested a reduction in
these risks when caesareans are scheduled in low-risk
patients [27].
In the present study, in addition to the risk of haemorrhagic
and infectious complications, an increased risk of oliguria,
very high blood pressure and a need for antihypertensive
drugs were found in women with preeclampsia who were
submitted to a caesarean section, resulting in a significant
increase in the duration of hospitalization.
The present results are unsurprising, since preeclampsia
increases the risk of haemorrhagic complications [28] and
caesarean sections may aggravate this risk further, particu-
larly in patients with thrombocytopenia [25,26]. Our results
support the notion already reported that the best mode of
delivery in cases of preeclampsia and is by the vaginal route,
precisely because of the increased risk of haemorrhagic
complications associated to caesarean delivery [1012].
The risk of infection is increased by both caesarean
sections and haemorrhage [29]. The more frequent finding of
oliguria may reflect the increased amount of blood loss in
caesarean sections [30] and any form of manipulation used to
treat these complications, in addition to the increased infusion
of liquids during the caesarean section, may explain the
increase in very high blood pressure episodes and in the need
for antihypertensive drugs following delivery.
Studies suggest that prognosis is better with elective rather
than intrapartum caesarean sections in the general popula-
tion [26]. Although the proportion of complications was lower
in the case of elective C-section as compared with intra-
partum C-section, we did not find statistically significant
association in the present analysis of women with preeclamp-
sia. The sample size, however, was not calculated aiming to
identify such difference.
This finding strengthens the recommendation to attempt
induction of labour in cases of preeclampsia since it is often
successful and may reduce the risks of complications if
delivery is vaginal. However, if an intrapartum caesarean
section is necessary, the risk appears not to be higher than that
found with an elective caesarean section.
Relatively few studies have been published regarding the
mode of delivery in women with severe preeclampsia and they
generally fail to emphasize postpartum morbidity and to
provide a clear definition of the analysed maternal outcomes
[6,7,9]. To the best of our knowledge, the present study is the
first to compare specific parameters of postpartum morbidity
according to the mode of delivery in patients with severe
preeclampsia. Since this is a prospective study, it has more
strength than retrospective studies, permitting the adoption of
rigid diagnostic criteria both for severe preeclampsia and for
the various morbidities analysed. Furthermore, an expressive
number of cases were included, with sufficient power to
confirm the outcomes evaluated, thus representing a signifi-
cant contribution to obstetric practice and reinforcing the
recommendations of the medical societies and the consensus
on vaginal delivery in cases of severe preeclampsia.
Nevertheless, since this is an observational, cohort study,
the level of evidence presented here is not as strong as that of
a randomized clinical trial. As the selection of patients for
vaginal delivery or caesarean section was not randomized but
 6 M. M. R. Amorim et al.
was the responsibility of the team of attending physicians,
various confounding factors may be involved. For example,
the decision to perform a caesarean section may be associated
with the presence of prepartum maternal complications and
these complications in themselves may be associated with a
greater risk of postpartum maternal morbidity.
Such possible bias was controlled using a multivariate
analysis and caesarean section remained as an independent
risk factor for postpartum complications after controlling for
potentially confounding factors. The only other variable that
persisted in the model was a prepartum diagnosis of HELLP
syndrome, which is a recognized risk factor for maternal
complications in cases of preeclampsia; however, the effect
of the caesarean section in itself continued to be signifi-
cant, resulting in an almost two-fold adjusted risk of
complications.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Columbia University on 12/10/14
The next step would be to perform controlled clinical
trials, which will provide better quality evidence and clarify
any doubts that may persist following observational studies.
Although labour induction may represent a challenge in
patients with severe preeclampsia, particularly in cases that
are remote from term and in whom cervical conditions are
unfavourable, we believe that it would be possible to perform
a randomized clinical trial to compare labour induction with
elective caesarean section in these cases.
Until this clinical trial is carried out and based on the
present findings together with other observational studies
For personal use only.
[6,7,9], we would suggest that, in addition to permitting
labour to progress when spontaneous contractions are present,
labour should be induced in cases of severe preeclampsia with
an indication for interrupting the pregnancy, as long as there
are no contraindications to vaginal delivery. Indicating
caesarean section only on the basis of a diagnosis of
preeclampsia should be avoided in patients with no associated
maternal or foetal risks, thus preventing the increased risk
of complications associated with caesarean sections
among women in whom induction of labour could be
considered.
Acknowledgements
The authors thank National Council for Scientific and
Technological Development (CNPq) for the financial support.
Disclosure of interest
National Counsel of Technological and Scientific
Development (CNPq), Brazil. Melania Amorim conceived
the study, developed the initial protocol, analysed the data,
jointly drafted the article and is guarantor. Leila Katz
reviewed and amended the study protocol, contributed to
enrolment of patients, interpreting data and writing the final
version of the article. Amanda de Souza Barros and Tainara
Sa Freire de Almeida participated in the development of the
initial protocol, enrolled patients and collected data. Alex
Sandro Rolland de Souza reviewed the study protocol and
contributed to statistical analysis and writing the final version
of the article. Anibal Faundes reviewed the study protocol and
the final version of the article. The study was approved by the
institutions Institutional Review Board under reference #
1199 on 26 June 2008.
J Matern Fetal Neonatal Med, Early Online: 17
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For personal use only.