Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
Am J Obstet Gynecol. 2019 Aug;221(2):154.e1-154.e11. doi: 10.1016/j.ajog.2019.03.024. Epub 2019 Mar 30.
Management of preterm hypertensive disorders remains a clinical dilemma. The maternal benefits of delivery need to be weighed against the adverse neonatal consequences of preterm birth. Long-term consequences of obstetric management in offspring of women with hypertensive disorders in preterm pregnancy are largely unknown. We report child neurodevelopmental and behavioral outcomes at 2 years after the Hypertension and Preeclampsia Intervention Trial at near Term (HYPITAT-II) trial, which compared immediate delivery versus expectant monitoring in mild late preterm hypertensive disorders of pregnancy.
To compare effects of immediate delivery vs expectant monitoring on neurodevelopmental and behavioral outcomes at 2 years of age in offspring of women with mild late preterm hypertensive disorders.
We studied children born in the HYPITAT-II trial, a study in which women (n = 704) with hypertensive disorders of pregnancy who were between 34 and 37 weeks' gestation were randomized to immediate delivery or expectant monitoring. Participating women were asked to complete the Ages and Stages Questionnaire for developmental outcome and the Child Behavior Checklist for behavioral problems when their toddlers were 2 years old.
We approached 545 of 704 randomized women (77%); 330 of 545 (61%) returned the questionnaires. In the immediate delivery group, 45 of 162 infants (28%) had an abnormal Ages and Stages Questionnaire score compared to 27 of 148 (18%) in the expectant monitoring group (risk difference, 9.6%; 95% CI, 0.3-18.0%); P = .045. In the pregnancies (n = 94) that delivered before reaching 36 weeks, 27% (n = 25) had an abnormal Ages and Stages Questionnaire score compared to 22% (n = 47) when delivered after 36 weeks (odds ratio, 0.77; confidence interval, 0.44-1.34). An abnormal Child Behavior Checklist outcome was found in 31 of 175 (18%) in the delivery group vs 24 of 166 (15%) in the expectant monitoring group (risk difference, 3.2%; 95% CI, -4.6% to 11.0%). After correction for maternal education, management strategy remained an independent predictor of abnormal Ages and Stages Questionnaire score (odds ratio, 0.48; confidence interval, 0.24 to -0.96, P = .03). In multivariable analyses, low birth weight, low maternal education, and immediate delivery policy were all significantly associated with an abnormal Ages and Stages Questionnaire score.
In this study, we found that early delivery in women with late preterm hypertensive disorders is associated with poorer neurodevelopmental outcomes in their children at 2 years of age. These findings indicate an increased risk of developmental delay after early delivery compared to expectant monitoring. This follow-up study underlines the conclusion of the original HYPITAT-II study that, until the clinical situation deteriorates, expectant monitoring remains the most appropriate management strategy in the light of short- and long-term neonatal outcomes in women with preterm hypertensive disorders.
早产高血压疾病的管理仍然是一个临床难题。需要权衡分娩对母婴的益处与早产儿出生的不良新生儿后果。在患有高血压疾病的孕妇中，分娩管理对早产儿后代的长期影响在很大程度上是未知的。我们报告了在近足月高血压和子痫前期干预试验（HYPITAT-II 试验）后 2 年的儿童神经发育和行为结局，该试验比较了轻度晚期早产高血压疾病孕妇的即刻分娩与期待监测。
比较即刻分娩与期待监测对患有轻度晚期早产高血压疾病的孕妇的后代在 2 岁时神经发育和行为结局的影响。
我们研究了 HYPITAT-II 试验中出生的儿童，这是一项研究，其中患有妊娠高血压疾病的孕妇（n=704）在 34 至 37 周妊娠时被随机分配至即刻分娩或期待监测。当他们的幼儿 2 岁时，参与的女性被要求完成年龄和阶段问卷以评估发育结果，以及儿童行为检查表以评估行为问题。
我们联系了 704 名随机女性中的 545 名（77%）；545 名中有 330 名（61%）返回了问卷。在即刻分娩组中，162 名婴儿中有 45 名（28%）的年龄和阶段问卷评分异常，而在期待监测组中，148 名婴儿中有 27 名（18%）（风险差异，9.6%；95%CI，0.3-18.0%）；P=0.045。在妊娠（n=94）中，有 27%（n=25）在达到 36 周之前分娩的婴儿的年龄和阶段问卷评分异常，而在 36 周后分娩的婴儿中，有 22%（n=47）的婴儿的年龄和阶段问卷评分异常（比值比，0.77；置信区间，0.44-1.34）。分娩组中有 31 名（18%）儿童的儿童行为检查表结果异常，而期待监测组中有 24 名（15%）（风险差异，3.2%；95%CI，-4.6%至 11.0%）。在对母亲教育进行校正后，管理策略仍然是年龄和阶段问卷评分异常的独立预测因素（比值比，0.48；95%CI，0.24 至 -0.96，P=0.03）。在多变量分析中，低出生体重、低母亲教育程度和即刻分娩策略均与年龄和阶段问卷评分异常显著相关。
在这项研究中，我们发现晚期早产高血压疾病女性的早期分娩与她们的孩子在 2 岁时的神经发育结局较差有关。这些发现表明，与期待监测相比，早期分娩与发育迟缓的风险增加有关。这项随访研究强调了原始 HYPITAT-II 研究的结论，即直到临床情况恶化，鉴于患有早产高血压疾病的女性的短期和长期新生儿结局，期待监测仍然是最合适的管理策略。
