Expectant Versus Interventionist Care in the Management of Severe Preeclampsia Remote from Term: A Systematic Review

Abstract Objective To compare the effects of expectant versus interventionist care in the management of pregnant women with severe preeclampsia remote from term. Data sources An electronic search was conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS, for its Spanish acronym), World Health Organization’s International Clinical Trials Registry Platform (WHO-ICTRP), and Open- Grey databases. The International Federation of Gynecology and Obstetrics (FIGO, for its French acronym), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and Colombian Journal of Obstetrics and Gynecology (CJOG) websites were searched for conference proceedings, without language restrictions, up to March 25, 2020. Selection of studies Randomized clinical trials (RCTs), and non-randomized controlled studies (NRSs) were included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of the evidence. Data collection Studies were independently assessed for inclusion criteria, data extraction, and risk of bias. Disagreements were resolved by consensus. Data synthesis Four RCTs and six NRS were included. Low-quality evidence from the RCTs showed that expectant care may result in a lower incidence of appearance, pulse, grimace, activity, and respiration (Apgar) scores<7 at 5 minutes (risk ratio [RR]: 0.48; 95% confidence interval [95%CI]: 0.23%to 0.99) and a higher average birth weight (mean difference [MD]: 254.7 g; 95%CI: 98.5 g to 410.9 g). Very low quality evidence from the NRSs suggested that expectant care might decrease the rates of neonatal death (RR: 0.42; 95%CI 0.22 to 0.80), hyalinemembrane disease (RR: 0.59; 95%CI: 0.40 to 0.87), and admission to neonatal care (RR: 0.73; 95%CI: 0.54 to 0.99). Nomaternal or fetal differences were found for other perinatal outcomes. Conclusion Compared with interventionist management, expectant care may improve neonatal outcomes without increasing maternal morbidity and mortality.

【摘要】
【研究目的】 对比期待治疗（expectant care）与干预治疗（interventionist care）在足月前重度子痫前期孕妇管理中的临床效果。
【数据来源】 检索了医学文献分析与检索系统在线版（Medical Literature Analysis and Retrieval System Online, MEDLINE）、荷兰医学文摘数据库（Excerpta Medica Database, EMBASE）、考克兰中心对照试验注册库（Cochrane Central Register of Controlled Trials, CENTRAL）、拉丁美洲与加勒比卫生科学文献库（Latin American and Caribbean Health Sciences Literature, LILACS，其西班牙语首字母缩写）、世界卫生组织国际临床试验注册平台（World Health Organization’s International Clinical Trials Registry Platform, WHO-ICTRP）及开放灰色文献数据库（OpenGrey）。同时检索了国际妇产科联合会（International Federation of Gynecology and Obstetrics, FIGO，其法语首字母缩写）、英国皇家妇产科医师学院（Royal College of Obstetricians and Gynaecologists, RCOG）、美国妇产科医师学会（American College of Obstetricians and Gynecologists, ACOG）及《哥伦比亚妇产科杂志》（Colombian Journal of Obstetrics and Gynecology, CJOG）的官网，检索截至2020年3月25日的会议论文，无语言限制。
【研究筛选】 纳入随机对照试验（randomized clinical trials, RCT）及非随机对照研究（non-randomized controlled studies, NRS）。采用推荐分级、评估、制定与评价（Grading of Recommendations, Assessment, Development and Evaluation, GRADE）方法对证据质量进行评价。
【数据收集】 由研究者独立评估研究的纳入标准、提取数据并评价偏倚风险，分歧经协商一致得以解决。
【数据综合】 共纳入4项RCT及6项NRS。来自RCT的低质量证据显示，期待治疗可降低5分钟时阿普加评分（Apgar）<7分的发生率（风险比[RR]=0.48；95%置信区间[95%CI]：0.23~0.99），并提高新生儿平均出生体重（均数差[MD]=254.7g；95%CI：98.5g~410.9g）。来自NRS的极低质量证据表明，期待治疗可能降低新生儿死亡率（RR=0.42；95%CI：0.22~0.80）、肺透明膜病（hyaline membrane disease）发生率（RR=0.59；95%CI：0.40~0.87）及新生儿监护病房入住率（RR=0.73；95%CI：0.54~0.99）。其余围产结局在孕产妇与胎儿层面未发现组间差异。
【结论】 与干预治疗相比，期待治疗可改善新生儿结局，且不会增加孕产妇发病率与死亡率。