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Timing of Delivery in Women With Chronic Hypertension

Ram, Maya, MD; Berger, Howard, MD; Geary, Michael, MD; McDonald, Sarah D., MD; Murray-Davis, Beth, PhD; Riddell, Catherine, BASc; Hasan, Haroon, MPH; Barrett, Jon, MD; Melamed, Nir, MD for the Diabetes, Obesity and Hypertension in Pregnancy Research Network (DOH-NET) and the Southern Ontario Obstetrical Network (SOON) Investigators

doi: 10.1097/AOG.0000000000002800
Original Research: PDF Only

OBJECTIVE: To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery.

METHODS: We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801).

RESULTS: Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57–0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69–1.17]).

CONCLUSION: Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.

In women with chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; the Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, the Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology, and Health Research Methods, Evidence & Impact, McMaster University, Hamilton,and the Better Outcomes Registry & Network (BORN) Ontario, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada.

Corresponding author: Maya Ram, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, Ontario M4N 3M, Canada; email: maya3000@gmail.com.

Funded by Canadian Institute of Health Research (CIHR) (Grant #146442; Non-communicable Diseases in Obstetrics: Improving Quality of Care and Maternal-infant Outcomes Through an Obstetrical Research Network). Dr. Sarah D. McDonald is supported by a Tier II Canada Research Chair. Dr Beth Murray-Davis is supported by a Hamilton Health Sciences Early Career Award.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as a poster at the annual meeting of the Society for Maternal-Fetal Medicine, January 29–February 3, 2018, Dallas, Texas.

None of the funding agencies had any role in the idea, design, analyses, interpretation of data, writing of the manuscript, or decision to submit the manuscript.

The authors thank Karizma Mawjee for her dedicated contribution as a research coordinator for this project.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received April 13, 2018

Received in revised form May 31, 2018

Accepted June 15, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.