Management
At admission, all women underwent a physical examination and laboratory work-up according to standard recommendations. Maternal BP was monitored continuously, laboratory tests were assessed at least once a day and fetal assessment was performed by daily cardiotocography and Doppler ultrasound at least twice a week. Magnesium sulfate for seizure prophylaxis was administered to all women and antihypertensive treatment was administered when BP was persistently 160/110 mmHg or higher, with labetalol a first-line drug. Corticosteroid therapy for fetal lung maturity was also administrated.
At admission, the risk for complications was estimated according to the Prediction of complications in Early-onset-Preeclampsia (PREP-L) score (9,26), which includes maternal age, maternal medical conditions, systolic BP, biochemical parameters (urine protein/creatinine ratio, serum urea concentration and platelet count), gestational age and need for antihypertensive treatment or magnesium sulfate. In addition, transabdominal Doppler ultrasound was performed at admission. The fetal ultrasound examination at enrolment included: Estimated Fetal Weight (calculated by the Hadlock formula (27)); UA PI; Middle Cerebral Artery (MCA) PI and Ductus venosus (DV) PI (28). The maternal ultrasound included the Mean Uterine Artery (mUtA) PI, calculated as the average PI of the right and left arteries and was considered abnormal when it was >95th centile (29). All Doppler parameters were adjusted by gestational age.
Indications for immediate delivery were uncontrollable BP (systolic BP> 160 mm Hg or diastolic BP >110 mm Hg not responsive to antihypertensive medication); persistent headaches refractory to treatment; epigastric pain or right upper pain unresponsive to repeat analgesics; visual disturbances, motor deficit or altered sensorium; stroke; myocardial infarction; renal dysfunction; pulmonary edema; eclampsia; suspected placental abruption and/or non-reassuring cardiotocographic reading (30,31). Beyond 26 weeks, indications for delivery also included persistent (>6 hours apart) DV Doppler with reversed diastolic flow; and beyond 30 weeks persistent (>6 hours apart) UA Doppler with reversed end-diastolic flow or DV PI above the 95th centile for gestational age (32). Elective delivery was performed beyond 34 weeks after completion of pulmonary maturation.