Labor Induction for the Preterm Severe Pre-Eclamptic Patient: Is it Worth the Effort?

Women who develop severe preeclampsia some time before term quite often undergo preterm cesarean section delivery, although vaginal delivery is viewed as advantageous. It is not clear whether preeclampsia influences the success of labor induction. This study examined the results of induction in women who had severe preeclampsia, defined as a blood pressure of 140/90 mm Hg or higher in addition to one or more of the following: disturbed vision, persistent headache, epigastric pain, low platelets, elevated liver enzymes, pulmonary edema, proteinuria exceeding 5 g/24 h, or oliguria. All parturients delivered at 34 weeks' gestation or earlier. The patients, seen in the years 1991-1998, included 64 not attempting labor, 82 who required cesarean delivery after attempted induction of labor, and 69 having vaginal delivery after successful induction. The overall cesarean delivery rate was 68%. Women who did or did not have attempted induction were similar demographically and clinically, and the severity of maternal disease was comparable in all groups. The major difference was that women requiring cesarean delivery after induction were likelier to have induction because of fetal indications. The chance of successful induction increased as gestational age advanced (Fig. 1). All but 4% of women at less Graph. than 29 weeks' gestational age had cesarean delivery. The association of increasing gestational age with successful induction was confirmed on multivariate logistic regression analysis (P =.001), and induction because of worrisome fetal status correlated with a higher rate of failure. Mode of delivery was not related to parity, cervical dilation, or the presence of intrauterine growth restriction. Questionable fetal status was the major reason for cesarean delivery after attempted induction, accounting for nearly 75% of cases. Major neonatal morbidity became less frequent at longer gestational ages but did not differ significantly in the various groups at any given gestational age grouping. There was no connection between major infant morbidity and the indication for delivery, attempted induction of labor, mode of delivery, steroid therapy, or cesarean delivery on fetal indications. More advanced gestational age was a key factor in good pregnancy outcomes in this series of women with severe preeclampsia who delivered at 34 weeks' gestation or earlier. Induction of labor is safe and effective after 28 weeks' gestation in these patients. Nevertheless, the authors recommend considering cesarean delivery with no attempt at induction once delivery is decided.