Cesarean Delivery in Eclampsia May Not Improve Outcomes

In the first trial to evaluate which route of delivery optimizes outcomes in women with eclampsia, researchers in rural India found that labor induction and cesarean section are associated with similar maternal and perinatal outcomes.¹

In women with eclampsia, cesarean section has been the preferred mode of delivery when the cervix is unfavorable and early delivery is unlikely. This practice is based on a recommendation that all women with eclampsia should deliver within 12 hours of admission.² However, there is no evidence showing that cesarean section is optimal in terms of maternal and perinatal outcomes.

In this exploratory trial, researchers randomly assigned 200 women with eclampsia and a gestational age of 34 weeks or greater to either planned cesarean section (n=101) or vaginal delivery via induction (n=99). Of the 99 women in the induction group, 72 delivered vaginally and 27 had a cesarean delivery. Reasons for cesarean section were nonprogress of labor (n=13), fetal heart rate abnormalities (n=8), and patient or family request (n=6). The 101 women in the cesarean group underwent surgery as soon as possible after initial stabilization of seizures; of these women, 3 delivered vaginally (fetal death prior to surgery, 1; request by relatives, 2).

The primary outcomes were predefined composite events for both the mother and the neonate (Table). The rates of composite maternal events were comparable between the groups (10.89% for cesarean delivery vs 7.07% for vaginal delivery). The composite perinatal event rate was slightly higher in the cesarean group compared with the vaginal delivery group (9.9% and 19.9%, respectively), but the difference was insignificant.

Most participants were semiconscious or comatose at admission. In each study group, there were 2 maternal deaths. The mothers who died were comatose at admission and had had more than 5 seizure episodes. Obviously, condition of the woman at admission is important. Perinatal death, defined as stillbirth or death in the first week, occurred in 3 neonates in the cesarean arm and 5 neonates in the vaginal delivery arm.

Because the study was conducted in rural India, the facility was not equipped to provide constant fetal monitoring and epidurals for pain management in vaginal deliveries. Therefore, the results have limited generalizability to developed countries.

Pertinent Points:
- A cesarean section in patients with eclampsia who are not in labor or who are in early labor with cervical dilatation of less than 3 centimeters is associated with maternal and perinatal outcomes that are comparable with those of attempted vaginal delivery.
- A future definitive trial evaluating delivery methods in patients with eclampsia is possible; the study authors hope that their experience will help other researchers in terms of barriers to recruitment, compliance with treatment protocols, and data collection.

References:

1. Seal SL, Ghosh D, Kamilya G, et al. Does route of delivery affect maternal and perinatal outcomes in women with eclampsia? A randomized controlled pilot study. Am J Obstet Gynecol. 2012;206:484.e1-7.
2. Mathai M, Sanghvi H, Guidotti RJ. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. Geneva: Department of Reproductive Health and Research, World Heath Organization; 2000:S43.