Brodowski Lars, Knoth Maria, Zehner Leonie, Pecks Ulrich
Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany.
Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Kiel, Germany.
Geburtshilfe Frauenheilkd. 2024 Aug 6;84(8):760-772. doi: 10.1055/a-2361-0563. eCollection 2024 Aug.
Preeclampsia is a potentially life-threatening hypertensive pregnancy disorder that carries an acute risk of an unfavorable outcome of the pregnancy but also has consequences for the long-term health of the mother. Women who develop the early form of pre-eclampsia before the 32nd week of pregnancy have the highest risk and are also the most difficult to treat. The severity of pre-eclampsia is not characterized uniformly in Germany, so that the indication for delivery is rather individualized. The aim of this study was to reach a consensus on parameters that could serve as criteria for describing the severity of pre-eclampsia based on the urgency of delivery. To this end, a Delphi procedure was used to present a scenario in which a woman was admitted for preeclampsia before 32 gestational weeks and after completion of antenatal steroid therapy.
Clinicians specialized in maternal-fetal medicine from German-speaking countries completed five rounds of a modified Delphi questionnaire. Presented parameters were selected by the section "Hypertensive Pregnancy Diseases and Fetal Growth Restriction" of the German Society of Gynecology and Obstetrics after reviewing the literature. These included objectifiable laboratory or clinical parameters as well as subjective symptoms of the patient. In addition, nine fetal parameters were taken into account. The clinicians were asked to rate presented parameters as an indication for delivery on a Likert scale from 0 to 4 (no indication to absolute indication without delay). For each item, the predefined cut-off for group consensus was ≥ 70% agreement.
A total of 126 experts were approached. Sixty-nine experts (54.8%) took part in the first round; of those 50 completed the entire Delphi procedure. A consensus was reached on 14 parameters to be considered rapid preparation for delivery without delay (4 points on the Likert scale). These were among others hepatic hematoma or liver capsule rupture, acute liver failure with fulminant coagulation disorder or disseminated intravascular coagulation, eclampsia, pathologic findings in imaging (e.g. cMRI) or electrocardiogram arranged for new onset of headache or retrosternal pain, respectively. Twenty-six parameters were rated as factors that should be considered in the decision without being absolute (1 to 3 points), and 13 parameters should have no influence on the decision to deliver (0 points). No consensus on severe hypertension as an indication for delivery could be reached for blood pressure values below 220/140 mmHg.
A consensus was reached on whether to deliver in preeclampsia typic clinical findings and symptoms. The results can serve as guidance for current clinical practice and for the definition of clinical endpoints in intervention studies. Nevertheless, the isolated criteria are a theoretical construction since the combined deterioration or summation of several factors rather than a single factor most likely influences the decision to deliver and reflect the severity of preeclampsia. Moreover, the degree of hypertension as an indication for delivery remains controversial, unless the patient suffers additionally from complaints. Future research should be enforced to incorporate long-term risks for the mother into a decision aid.
子痫前期是一种可能危及生命的妊娠高血压疾病，不仅会使妊娠结局面临急性不良风险，还会对母亲的长期健康产生影响。在妊娠32周前出现早期子痫前期的女性风险最高，治疗难度也最大。在德国，子痫前期的严重程度尚无统一的界定标准，因此分娩指征相当个体化。本研究的目的是就基于分娩紧迫性可作为描述子痫前期严重程度标准的参数达成共识。为此，采用德尔菲法呈现了这样一种情景：一名妊娠32周前因子痫前期入院且已完成产前类固醇治疗的女性。
来自德语国家的母胎医学专家完成了五轮修改后的德尔菲问卷。所呈现的参数由德国妇产科学会“妊娠高血压疾病与胎儿生长受限”分会在查阅文献后选定。这些参数包括可客观化的实验室或临床参数以及患者的主观症状。此外，还考虑了九个胎儿参数。要求临床医生根据李克特量表（0至4分，从无指征到绝对无延迟指征）对所呈现的参数作为分娩指征进行评分。对于每个项目，预先设定的小组共识临界值为≥70%的一致性。
共邀请了126位专家。69位专家（54.8%）参与了第一轮；其中50位完成了整个德尔菲程序。就14个参数达成了共识，这些参数被视为应立即毫不延迟地为分娩做准备（李克特量表4分）。其中包括肝血肿或肝包膜破裂、伴有暴发性凝血障碍或弥散性血管内凝血的急性肝衰竭、子痫、因新发头痛或胸骨后疼痛而安排的影像学检查（如cMRI）或心电图的病理结果等。26个参数被评为在决策时应考虑但非绝对的因素（1至图3分），13个参数被认为对分娩决策不应有影响（0分）。对于血压值低于220/140 mmHg的重度高血压作为分娩指征，未达成共识。
就子痫前期典型临床发现和症状下是否分娩达成了共识。研究结果可为当前临床实践及干预研究中临床终点的定义提供指导。然而，单一标准只是一种理论构建，因为多个因素的综合恶化或累加而非单一因素最有可能影响分娩决策并反映子痫前期的严重程度。此外，除非患者伴有其他不适，高血压程度作为分娩指征仍存在争议。未来应加强研究，将母亲的长期风险纳入决策辅助考量。
