Planned early birth versus expectant management for hypertensive disorders from 34 weeks' gestation to term.
Hypertensive disorders in pregnancy are significant contributors to maternal and perinatal morbidity and mortality. They include chronic hypertension, gestational hypertension and pre-eclampsia. Definitive management of these disorders is planned early birth. The alternative is expectant management with close monitoring, if severe complications are not present. There are benefits and risks associated with both policies, so it is important to establish the safest option.
To assess the benefits and risks of planned early birth versus expectant management in pregnant women with hypertensive disorders, from 34 weeks' gestation onwards.
An Information Specialist within the Cochrane Central Executive Team searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov and WHO ICTRP. The searches were run from 1 January 2016 to 16 January 2026 with no language restrictions. Reference lists of retrieved studies were also searched.
We included randomised controlled trials comparing planned early birth (by induction of labour or by caesarean section) with expectant management for women with hypertensive disorders from 34 weeks' gestation. Cluster-randomised trials would have been eligible for inclusion in this review, but we found none. Studies using a quasi-randomised design were not eligible for inclusion in this review. Studies using a cross-over design were not eligible for inclusion, because they are not a suitable study design for investigating hypertensive disorders in pregnancy.
The prespecified critical outcomes (based upon a core outcome set agreed via Delphi consensus) were (1) a composite outcome of maternal mortality and morbidity; (2) a composite outcome of perinatal mortality and morbidity; (3) maternal death; (4) fetal death; (5) neonatal death. The prespecified important maternal outcomes were: caesarean section, maternal admission to a high dependency unit, eclampsia, pulmonary oedema, severe renal impairment, and HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. The prespecified important perinatal outcome was neonatal unit admission. Additional maternal and perinatal outcomes were also analysed in accordance with the review protocol, including maternal quality of life measures and health resource use.
Two review authors independently assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool. The Cochrane trustworthiness screening tool was applied to all eligible studies at full-text review stage.
Two review authors independently assessed eligibility and risk of bias. Two review authors independently extracted data using a prespecified data extraction form. Data were checked for accuracy. Statistical analysis was carried out in RevMan using a random-effects meta-analysis. We assessed the certainty of evidence using GRADE.
We included six studies involving 3491 women. All six studies were randomised controlled trials evaluating planned early birth compared to expectant management. Planned early birth was evaluated at between 34 and 37 weeks in four studies, between 36 and 38 weeks in one study and between 36 and 41 weeks in one study. One study took place in low- and middle-income countries, whilst five took place in high-income countries. Three studies included only women with pre-eclampsia, two studies included women with a mixture of hypertensive disorders in pregnancy and one study included only women with chronic hypertension.
Planned early birth reduces the risk of maternal mortality and morbidity compared to expectant management (RR 0.54, 95% CI 0.37 to 0.77; I² = 0%; 6 studies, 3491 participants; high-certainty evidence). There was no increased risk of caesarean section associated with planned early birth (RR 0.94, 95% CI 0.83 to 1.06; I² = 25%; 6 studies, 3539 participants; high-certainty evidence). Planned early birth likely results in a large reduction in the risk of stillbirth (fetal death) (RR 0.25, 95% CI 0.07 to 0.87; I² not applicable; 5 studies, 3407 participants; moderate-certainty evidence), but probably results in little to no difference in rates of neonatal unit admission (RR 1.11, 95% CI 0.90 to 1.37; I² = 41%; 6 studies, 3560 participants; moderate-certainty evidence). Planned early birth may result in little to no difference in maternal death (RR 0.33, 95% CI 0.05 to 2.10; I² = 0%; 6 studies, 3491 participants; low-certainty evidence) or neonatal death (RR 1.40, 95% CI 0.45 to 4.35; I² not applicable; 5 studies, 3407 participants; low-certainty evidence). The evidence is very uncertain about the effect of planned early birth on composite perinatal mortality and morbidity due to high variation between the trials (RR 1.06, 95% CI 0.75 to 1.51; I² = 83%; 6 studies, 3576 participants; very low-certainty evidence). Five of the six trials included in this analysis were at low risk of bias. We graded the evidence as high, moderate, low, or very low certainty based upon GRADE criteria. Where we downgraded the evidence, it was typically due to higher levels of heterogeneity or due to imprecision, whereby the confidence interval crossed the line of both appreciable benefit and harm or the number of events was low.
For women with hypertensive disorders of pregnancy beyond 34 weeks' gestation, planned early birth is associated with a lower risk of maternal complications, and probably a reduced risk of fetal death (stillbirth), with no increased risk of caesarean section and probably no clear differences in the rate of neonatal unit admission or short-term neonatal morbidity. It is important that the timing of delivery takes into account the woman's preferences, the type of hypertensive disorder and the presence or absence of severe features. Further information is needed to establish the longer-term infant outcomes associated with late preterm birth and longer-term maternal cardiovascular health.
This Cochrane review had no dedicated funding.
The original review and review protocol can be accessed via the following links. Protocol (2011): DOI: 10.1002/14651858.CD009273 Original review (2017): DOI: 10.1002/14651858.CD009273.pub2.
To assess the benefits and risks of planned early birth versus expectant management in pregnant women with hypertensive disorders, from 34 weeks' gestation onwards.
An Information Specialist within the Cochrane Central Executive Team searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov and WHO ICTRP. The searches were run from 1 January 2016 to 16 January 2026 with no language restrictions. Reference lists of retrieved studies were also searched.
We included randomised controlled trials comparing planned early birth (by induction of labour or by caesarean section) with expectant management for women with hypertensive disorders from 34 weeks' gestation. Cluster-randomised trials would have been eligible for inclusion in this review, but we found none. Studies using a quasi-randomised design were not eligible for inclusion in this review. Studies using a cross-over design were not eligible for inclusion, because they are not a suitable study design for investigating hypertensive disorders in pregnancy.
The prespecified critical outcomes (based upon a core outcome set agreed via Delphi consensus) were (1) a composite outcome of maternal mortality and morbidity; (2) a composite outcome of perinatal mortality and morbidity; (3) maternal death; (4) fetal death; (5) neonatal death. The prespecified important maternal outcomes were: caesarean section, maternal admission to a high dependency unit, eclampsia, pulmonary oedema, severe renal impairment, and HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. The prespecified important perinatal outcome was neonatal unit admission. Additional maternal and perinatal outcomes were also analysed in accordance with the review protocol, including maternal quality of life measures and health resource use.
Two review authors independently assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool. The Cochrane trustworthiness screening tool was applied to all eligible studies at full-text review stage.
Two review authors independently assessed eligibility and risk of bias. Two review authors independently extracted data using a prespecified data extraction form. Data were checked for accuracy. Statistical analysis was carried out in RevMan using a random-effects meta-analysis. We assessed the certainty of evidence using GRADE.
We included six studies involving 3491 women. All six studies were randomised controlled trials evaluating planned early birth compared to expectant management. Planned early birth was evaluated at between 34 and 37 weeks in four studies, between 36 and 38 weeks in one study and between 36 and 41 weeks in one study. One study took place in low- and middle-income countries, whilst five took place in high-income countries. Three studies included only women with pre-eclampsia, two studies included women with a mixture of hypertensive disorders in pregnancy and one study included only women with chronic hypertension.
Planned early birth reduces the risk of maternal mortality and morbidity compared to expectant management (RR 0.54, 95% CI 0.37 to 0.77; I² = 0%; 6 studies, 3491 participants; high-certainty evidence). There was no increased risk of caesarean section associated with planned early birth (RR 0.94, 95% CI 0.83 to 1.06; I² = 25%; 6 studies, 3539 participants; high-certainty evidence). Planned early birth likely results in a large reduction in the risk of stillbirth (fetal death) (RR 0.25, 95% CI 0.07 to 0.87; I² not applicable; 5 studies, 3407 participants; moderate-certainty evidence), but probably results in little to no difference in rates of neonatal unit admission (RR 1.11, 95% CI 0.90 to 1.37; I² = 41%; 6 studies, 3560 participants; moderate-certainty evidence). Planned early birth may result in little to no difference in maternal death (RR 0.33, 95% CI 0.05 to 2.10; I² = 0%; 6 studies, 3491 participants; low-certainty evidence) or neonatal death (RR 1.40, 95% CI 0.45 to 4.35; I² not applicable; 5 studies, 3407 participants; low-certainty evidence). The evidence is very uncertain about the effect of planned early birth on composite perinatal mortality and morbidity due to high variation between the trials (RR 1.06, 95% CI 0.75 to 1.51; I² = 83%; 6 studies, 3576 participants; very low-certainty evidence). Five of the six trials included in this analysis were at low risk of bias. We graded the evidence as high, moderate, low, or very low certainty based upon GRADE criteria. Where we downgraded the evidence, it was typically due to higher levels of heterogeneity or due to imprecision, whereby the confidence interval crossed the line of both appreciable benefit and harm or the number of events was low.
For women with hypertensive disorders of pregnancy beyond 34 weeks' gestation, planned early birth is associated with a lower risk of maternal complications, and probably a reduced risk of fetal death (stillbirth), with no increased risk of caesarean section and probably no clear differences in the rate of neonatal unit admission or short-term neonatal morbidity. It is important that the timing of delivery takes into account the woman's preferences, the type of hypertensive disorder and the presence or absence of severe features. Further information is needed to establish the longer-term infant outcomes associated with late preterm birth and longer-term maternal cardiovascular health.
This Cochrane review had no dedicated funding.
The original review and review protocol can be accessed via the following links. Protocol (2011): DOI: 10.1002/14651858.CD009273 Original review (2017): DOI: 10.1002/14651858.CD009273.pub2.
Authors
Beardmore-Gray Beardmore-Gray, Rohwer Rohwer, Fernandez Turienzo Fernandez Turienzo, Cluver Cluver
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