CC BY-NC-ND 4.0 · Geburtshilfe Frauenheilkd 2024; 84(08): 760-772
DOI: 10.1055/a-2361-0563
GebFra Science
Original Article

Assessing Severity and Need for Delivery in Early Onset Preeclampsia Before 32 Weeks of Gestation: a Delphi Consensus Procedure

Einschätzung des Schweregrads und der Dringlichkeit einer Entbindung bei Präeklampsie im Frühstadium vor der 32. Schwangerschaftswoche: ein Delphi-Konsensus-Prozess
Lars Brodowski 
1   Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany (Ringgold ID: RIN9177)
,
Maria Knoth
2   Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Kiel, Germany (Ringgold ID: RIN54186)
,
Leonie Zehner
2   Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Kiel, Germany (Ringgold ID: RIN54186)
,
Ulrich Pecks
3   Department of Obstetrics and Gynecology, University Hospital Würzburg, Würzburg, Germany (Ringgold ID: RIN27207)
4   Maternal Health and Midwifery, Julius-Maximilians-University, Würzburg, Germany (Ringgold ID: RIN9190)
› Author Affiliations
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Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Zusammenfassung

Hintergrund

Präeklampsie stellt eine potenziell lebensbedrohende hypertensive Schwangerschaftserkrankung dar, die mit einem akuten Risiko für ein ungünstiges Schwangerschaftsoutcome und mit Konsequenzen für die langfristige Gesundheit der Mutter verbunden ist. Das höchste Risiko haben Frauen, welche die Frühform von Präeklampsie vor der 32. Schwangerschaftswoche entwickeln, und die Behandlung dieser Frauen ist auch am schwierigsten. Der Schweregrad der Präeklampsie wird in Deutschland nicht einheitlich eingestuft. Das bedeutet, dass die Indikation zur Entbindung eher individuell erfolgt. Ziel dieser Studie war es, einen Konsens hinsichtlich der Parameter zu erreichen, die, basierend auf der Dringlichkeit der Entbindung, als Kriterien zur Beschreibung des Schweregrads der Präeklampsie dienen könnten. Es wurde dazu eine Delphi-Studie durchgeführt, die ein Szenario beschreiben sollte, bei der eine Frau wegen Präeklampsie vor der 32. Schwangerschaftswoche und nach Abschluss einer antenatalen Steroidtherapie stationär aufgenommen wird.

Methoden

Fachärzte und -ärztinnen für mütterliche-fetale Medizin aus deutschsprachigen Ländern nahmen an 5 Runden einer modifizierten Delphi-Befragung teil. Die vorgestellten Parameter wurden von der Sektion Hypertensive Schwangerschaftserkrankungen und fetale Wachstumsrestriktion der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe nach Durchsicht der Literatur ausgewählt. Die Liste der Parameter umfasste objektivierbare Laborparameter und klinische Parameter sowie subjektive Symptome von Patientinnen. Es wurden auch 9 fetale Parameter berücksichtigt. Die Fachärzte und -ärztinnen wurden gebeten, die vorgestellten Parameter als Indikation für eine Entbindung auf einer Likert-Skala von 0 bis 4 (keine Indikation bis absolute Indikation ohne Verzug) zu bewerten. Für jeden Punkt war der vorgegebene kritische Wert für ein Gruppenkonsens eine Zustimmung ≥ 70%.

Ergebnisse

Insgesamt wurden 126 Fachärzte und -ärztinnen angeschrieben. Es nahmen 69 Fachärzte und -ärztinnen (54,8%) an der 1. Runde teil; davon haben 50 den gesamten Delphi-Prozess abgeschlossen. Ein Konsens wurde für 14 Parameter erreicht, die als Hinweise für eine schnelle Entbindung eingestuft wurden (4 Punkte auf der Likert-Skala). Dazu zählten u. a. Leberhämatom bzw. Leberkapselruptur, akutes Leberversagen mit fulminanter Gerinnungsstörung oder disseminierter intravasaler Gerinnung, Eklampsie, pathologische Befunde in der Bildgebung (z. B. cMRI) oder beim Elektrokardiogramm, das wegen erneutem Auftreten von Kopfschmerzen bzw. Brustbeinschmerzen durchgeführt wurde. 26 Parameter wurden als Faktoren eingestuft, die bei einer Entscheidung zur Entbindung berücksichtigt werden sollten, ohne dass sie absolut eine Entbindung erfordern (1 bis 3 Punkte); bei 13 Parametern war der Konsens, dass diese keinen Einfluss auf die Entscheidung zur Entbindung haben sollten (0 Punkte). Hinsichtlich des Punktes „schwerer Bluthochdruck als Indikation für eine Entbindung“ konnte kein Konsens erreicht werden, wenn die Blutdruckwerte unter 220/140 mmHg lagen.

Schlussfolgerung

Es wurde ein Konsens hinsichtlich der typischen klinischen Befunde und Symptome für eine dringliche Entbindung erreicht. Die Ergebnisse können als Anleitung für die aktuelle klinische Praxis und bei der Definition von klinischen Endpunkten in Interventionsstudien dienen. Dennoch stellen diese isolierten Kriterien ein theoretisches Konstrukt dar, da in der Praxis die Entscheidung zur Entbindung auf einer kombinierten Verschlechterung bzw. auf der Summierung mehrerer Faktoren anstelle eines einzigen Faktors beruht, da diese Konstellation eher den Schweregrad der Präeklampsie reflektiert. Hinzu kommt noch, dass die Schwere der Hypertonie als Indikation für eine Entbindung immer noch kontrovers diskutiert wird, es sei denn, dass die Patientin auch unter anderen Beschwerden leidet. Die zukünftige Forschung sollte auch mütterliche Langzeitrisiken in die Entscheidungshilfe integrieren.

Keywords

preeclampsia - prematurity - maternal health

Schlüsselwörter

Präeklampsie - Frühgeburt - maternale Gesundheit

Supplementary Material



Publication History

Received: 08 March 2024

Accepted after revision: 29 June 2024

Article published online:
06 August 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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