Neonatal developmental and behavioral outcomes of immediate delivery versus expectant monitoring in mild hypertensive disorders of pregnancy: 2-year outcomes of the HYPITAT II trial

Abstract Background Management of preterm hypertensive disorders remains a clinical dilemma. The maternal benefits of delivery need to be weighed against the adverse neonatal consequences of preterm birth. Long-term consequences of obstetric management in offspring of women with hypertensive disorders in preterm pregnancy are largely unknown. We report child neurodevelopmental and behavioral outcomes at 2 years after the HYPITAT-II trial, which compared immediate delivery versus expectant monitoring in mild late preterm hypertensive disorders of pregnancy. Objective To compare effects of immediate delivery versus expectant monitoring on neurodevelopmental and behavioral outcomes at two years of age in offspring of women with mild late preterm hypertensive disorders. Study design We studied children born in the HYPITAT-II trial; a study in which women (n= 704) with hypertensive disorders of pregnancy between 34 and 37 weeks of gestation were randomized to immediate delivery or expectant monitoring. Participating women were asked to complete the Ages and Stages Questionnaire (ASQ) for developmental outcome and the Child Behavior Checklist (CBCL) for behavioral problems when their toddlers were two years old. Results We approached 545/704 (77%) randomized women; 330/545 (61%) returned the questionnaires. In the immediate delivery group, 45/162 (28%) infants had an abnormal ASQ-score compared to 27/148 (18%) in the expectant monitoring group (risk difference 9.6%; 95% CI 0.3% to 18.0%); p = 0.045. In the pregnancies (n=94) that delivered before reaching 36 weeks, 27%(n=25) had an abnormal ASQ score compared to 22% (n=47) when delivered after 36 weeks (OR 0.77 CI 0.44 – 1.34). An abnormal CBCL outcome was found in 31/175 (18%) in the delivery group versus 24/166 (15%) in the expectant monitoring group (risk difference 3.2%; 95% CI -4.6% to 11.0%). After correction for maternal education, management strategy remained an independent predictor of abnormal ASQ-score (OR 0.48, CI 0.24 -0.96, p =0.03). In multivariable analyses, low birth weight, low maternal education and immediate delivery policy were all significantly associated with an abnormal ASQ-score. Conclusions In this study we found that early delivery in women with late preterm hypertensive disorders is associated with poorer neurodevelopmental outcome of their children at two years of age. These findings indicate an increased risk of developmental delay after early delivery compared to expectant monitoring. This follow up study underlines the conclusion of the original HYPITAT II study that, until the clinical situation deteriorates, expectant monitoring remains the most appropriate management strategy in the light of short and long term neonatal outcomes for preterm hypertensive disorders.