RESUMEN
Resumen Introducción: la preeclampsia severa antes de 34 semanas de gestación tiene alto riesgo de complicaciones maternas y fetales. El manejo expectante, pudiera reducir el riesgo de complicaciones de un parto prematuro. Objetivo: evaluar la efectividad comparativa del manejo expectante en la prevención de desenlaces adversos maternos y perinatales de las pacientes con preeclampsia severa remota del término. Metodología: estudio de cohorte retrospectivo en gestantes con preeclampsia severa entre la 24 a 33,6 semanas, admitidas en un centro de alta complejidad colombiano entre 2011 y 2019. Se compararon medidas descriptivas según el manejo expectante o intervencionistas como grupo de referencia y, de asociación con los desenlaces compuestos maternos y neonatales, además se ajustó por edad gestacional menor a 28 semanas al parto. Resultados: se analizaron 134 pacientes, 110 con manejo expectante y 24 con intervencionista. El manejo expectante tuvo menor probabilidad de cesárea (RR 0,79 IC95% 0,69-0,91) y de resultado compuesto materno (RR 0,67 IC95% 0,57-0,79), que no persistió luego del ajuste. El manejo expectante presentó menor probabilidad de APGAR <7 al minuto (21,6% vs. 40%, RR 0,53 IC95% 0,29-0,97) y de resultado neonatal compuesto (60% vs. 83,3%, RR 0,72 IC95% 0.57-0.90). Al realizar ajuste con edad menor a 28 semanas al parto, el manejo expectante mostró menor probabilidad de APGAR menor a 7 al minuto (RR 0,43 IC95% 0,24-0,75), resultado perinatal adverso compuesto (RR 0,62 IC95% 0,48-0,81), muerte neonatal (RR 0,26 IC95% 0,29-0,71), síndrome de dificultad respiratoria (RR 0,65 IC95% 0,48-0,88), hemorragia intraventricular (RR 0,31 IC95% 0,11-0,89) e ingreso a unidad de cuidados intensivos neonatales (RR 0,80 IC95% 0,70-0,92). Conclusión: la preeclampsia severa remota del término es una patología grave y compleja que enfrenta los intereses maternos y los fetales. Debido al controversial enfoque, su manejo debe realizarse en centros de alta complejidad, con participación interdisciplinaria y anteponiendo la individualidad de cada binomio; nuestros hallazgos sugieren que el manejo expectante es razonable cuando las condiciones maternas y fetales lo permiten, especialmente para gestaciones menores a 28 semanas en favor de mejorar los desenlaces fetales sin detrimento de los desenlaces maternos.
Abstract Introduction: severe preeclampsia before 34 weeks of gestational age has a high risk of maternal and fetal complications. Expectant management could decrease the risk of complications associated with premature birth. Objective: to evaluate the efficacy of expectant management in the prevention of maternal and perinatal adverse events of patients with severe preeclampsia remote from term. Methodology: a retrospective cohort study in pregnant women diagnosed with severe preeclampsia between 24 and 33.6 weeks of gestational age who were admitted in a Colombian high complexity medical center between 2011 and 2019 was carried out. Descriptive measurements of the expectant management and the interventionist management were compared and the association with maternal and neonatal composite outcomes. Results were adjusted by gestational age under 28 weeks of delivery. Results: 134 patients were analyzed; 110 patients with expectant management and 24 interventionist management. Expectant management had a lower probability of cesarean section (RR 0.79 CI95% 0.69-0.91) and maternal composite result (RR 0.67 CI95% 0.57-0.79) that did not persist after the adjustment. Expectant management had a lower probability of APGAR <7 the first minute (21.6% vs. 40%, RR 0.53 CI95% 0.29-0.97) and neonatal composite result (60% vs. 83.3%, RR 0.72 CI95% 0.57-0.90). When adjusting the age under 28 weeks of delivery, the expectant management showed a lower probability of APGAR under 7 at minute one (RR 0.43 CI95% 0.24-0.75), composite outcome of perinatal adverse events (RR 0.62 CI95% 0.48-0.81), neonatal death (RR 0.26 CI95% 0.29-0.71), respiratory distress syndrome (RR 0.65 CI95% 0.48-0.88), intraventricular hemorrhage (RR 0.31 CI95% 0.11-0.89) and admission to the neonatal intensive care unit (RR 0.80 CI95% 0.70-0.92). Conclusion: severe preeclampsia remote from term is a severe and complex disease which faces maternal and neonatal interests. Due to approach controversies, management should be performed in high complexity centers with a multidisciplinary approach individualizing each binomial; our findings suggest expectant management is reasonable when both maternal and fetal conditions allow it, especially in pregnancies under 28 weeks of gestational age to improve fetal outcomes without risking maternal outcomes.
RESUMEN
BACKGROUND: Prediction of neonatal respiratory morbidity may be useful to plan delivery in complicated pregnancies. The limited predictive performance of the current diagnostic tests together with the risks of an invasive procedure restricts the use of fetal lung maturity assessment. OBJECTIVE: The objective of the study was to evaluate the performance of quantitative ultrasound texture analysis of the fetal lung (quantusFLM) to predict neonatal respiratory morbidity in preterm and early-term (<39.0 weeks) deliveries. STUDY DESIGN: This was a prospective multicenter study conducted in 20 centers worldwide. Fetal lung ultrasound images were obtained at 25.0-38.6 weeks of gestation within 48 hours of delivery, stored in Digital Imaging and Communication in Medicine format, and analyzed with quantusFLM. Physicians were blinded to the analysis. At delivery, perinatal outcomes and the occurrence of neonatal respiratory morbidity, defined as either respiratory distress syndrome or transient tachypnea of the newborn, were registered. The performance of the ultrasound texture analysis test to predict neonatal respiratory morbidity was evaluated. RESULTS: A total of 883 images were collected, but 17.3% were discarded because of poor image quality or exclusion criteria, leaving 730 observations for the final analysis. The prevalence of neonatal respiratory morbidity was 13.8% (101 of 730). The quantusFLM predicted neonatal respiratory morbidity with a sensitivity, specificity, positive and negative predictive values of 74.3% (75 of 101), 88.6% (557 of 629), 51.0% (75 of 147), and 95.5% (557 of 583), respectively. Accuracy was 86.5% (632 of 730) and positive and negative likelihood ratios were 6.5 and 0.3, respectively. CONCLUSION: The quantusFLM predicted neonatal respiratory morbidity with an accuracy similar to that previously reported for other tests with the advantage of being a noninvasive technique.
