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Can Planned Early Delivery Between 34+0 And 36+6 Weeks’ Gestation Improve Perinatal Outcomes For Women With Pre-Eclampsia In Low- And Middle-Income

Dr. Alice Beardmore-Gray, Emily Stroud, Prof Lucy Chappell, Prof Andrew Shennan
Institution
King’s College London
Introduction 
99% of deaths due to pre-eclampsia occur in low- and middle-income countries (LMIC). Delivery is the only cure for pre-eclampsia, yet expectant management is still preferred up to 37 weeks’ gestation, unless severe complications develop. This is because of the perceived risk of prematurity and its associated complications to the neonate. We hypothesize that planned early delivery could reduce adverse perinatal outcomes in LMIC.
Methods 
We reviewed data from the CRADLE-2 Trial1 in South Africa, the CLIP Trial in India and our CRADLE-4 Phase 1 study (retrospective case note review of all women with a confirmed diagnosis of pre-eclampsia over a three- month period) in Zambia. We compared stillbirths vs. neonatal deaths by grouped gestational age (GA) at delivery for all three data-sets. CRADLE-4 Phase 1 is part of a multi-centre trial funded by the MRC. Full ethical approval was gained for CRADLE-4 Phase 1 from King’s College London and The University of Zambia.
Results 
A total of 2,402 deliveries complicated by pre-eclampsia were included in our analysis, with 493 occurring between 34 and 36+6 weeks’ gestation. Out of these, there were 42 stillbirths and 6 neonatal deaths (Chi-squared 25.2, P<0.0001) suggesting that stillbirth occurs more commonly than neonatal death in women with pre-eclampsia between 34 and 36+6 weeks.
Despite the perceived risk of prematurity to the neonate, our data shows that between 34 and 36+6 weeks’ gestation there is a significantly higher risk of stillbirth compared to neonatal death due to pre-term delivery, even in settings where neonatal intensive care resources are limited.
Conclusions 
Planned early delivery at this gestation has the potential to prevent these stillbirths. This provides important evidence to support the CRADLE-4 trial and its intervention.
References 
1. Nathan HL, Chappell LC, Shennan AH. Early warning system hypertension thresholds to predict adverse outcomes in pre-eclampsia: A prospective cohort study. Pregnancy Hypertens. 2018 Apr; 12:183-188. 

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