Repeated antihypertensive escalation in expectant management may signal progression

Design

Retrospective cohort, single level IV referral centre, 2016 to 2025

Population

396 singleton pregnancies managed expectantly for early-onset pre-eclampsia with severe features (23+0 to 33+5 weeks)

Primary outcome

Composite maternal adverse outcome by number of oral antihypertensive dose escalations

Effect

3 escalations aRR 4.07 (1.41 to 11.78); 4 or more aRR 5.20 (1.81 to 14.90) versus none

A single-centre retrospective cohort at a level IV referral centre followed 396 women with singleton pregnancies managed expectantly for early-onset pre-eclampsia with severe features, between 23 weeks 0 days and 33 weeks 5 days, over ten years. The exposure was the number of oral antihypertensive dose escalations. 157 women (39.6%) had none, and 22 (5.6%) had four or more.

The composite maternal adverse outcome, which included abruption, acute kidney injury, pulmonary oedema, HELLP syndrome, eclampsia, stroke and death, rose across escalation categories. Each extra escalation was associated with a 4.2 percentage point absolute increase in risk (95% CI 2.0 to 6.5). Compared with none, three escalations carried an adjusted relative risk of 4.07 (1.41 to 11.78) and four or more 5.20 (1.81 to 14.90). Repeated intravenous pushes showed a similar pattern, and neonatal outcomes did not differ.

This does not show that escalating treatment causes harm; sicker women need more treatment. The authors suggest the trajectory may act as a marker of progression. It may be worth using as a prompt to reassess, counsel and review delivery timing, without changing the established principle of treating severe hypertension.

• Count and document antihypertensive dose escalations during expectant management.
• Consider a repeat full maternal and fetal reassessment after three or more escalations.
• Use the trajectory in counselling about the risk of maternal complications.
• Keep treating severe-range blood pressure as per protocol; this study does not argue for treating less.
• Discuss borderline cases with maternal-fetal medicine.

Why it matters

It turns a routine nursing observation, how often treatment has been stepped up, into a possible early warning.

Don't overread it

This is confounded by disease severity and from one referral centre; it does not change guidance on when to treat or deliver.

The statistics, in plain English

An adjusted relative risk of 5.2 with a confidence interval of 1.8 to 14.9 shows a strong association but a very uncertain size, because few women had four or more escalations. Retrospective data from one centre cannot separate the effect of disease severity from the effect of the drugs.

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