Just Accepted by The Journal of Maternal-Fetal & Neonatal Medicine

Expectant Management of Preterm Preeclampsia in Indonesia and the

Role of Steroids
Ernawati, Erry Gumilar, Kuntoro, Joewono Soeroso, Gus Dekker
doi: 10.3109/14767058.2015.1059815
Abstract
Objective: To present the outcome of expectant management of preterm
preeclampsia in Indonesia, and the effect of ongoing treatment with
methylprednisolone on maternal and perinatal outcome
Material and methods: Prospective RCT on 48 patients with early-onset
preeclampsia. Following the administration of dexamethasone for fetal lung
maturation, patients were randomized to receive 25 mg
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methylprednisolone (MP group) IV for the first week, decreasing to 12.5 mg

during 2nd week and continued till birth, or matching IV placebo treatment
(PL group). Prolongation of entry to delivery interval served as primary
outcome measurement.
Results: The average time gained with expectant management was almost
14 days. However, there was no difference of mean time interval between
entry to delivery between the PL (13,8 days) and MP (13,7 days) groups. Antenatal ongoing treatment with IV
MP also did not improve maternal and/or perinatal outcome and might be associated with a higher risk for
severe maternal infections – in particular tuberculosis.
Conclusion: Expectant management of preterm preeclampsia is a realistic option in a major Indonesian
perinatal referral center. Steroids (outside the use for fetal lung maturation) should not be used in the
For personal use only.

expectant management of preterm preeclampsia in Indonesia.

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 Expectant Management of Preterm Preeclampsia in Indonesia and the Role of Steroids

Ernawati1, Erry Gumilar1, Kuntoro3, Joewono Soeroso4, Gus Dekker1,2

Affiliations:

1. Department of Obstetric Gynecology, Medical Faculty Airlangga University, Indonesia

2. Women’s and Children’s Division, Lyell McEwin Health Service, Medical School North,

University of Adelaide, Australia, Visiting Professor Medical Faculty Airlangga University,

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Indonesia

3. Department of Statistic, Public Health Faculty Airlangga University Indonesia

Department of Internal medicine, Medical Faculty Airlangga University, Indonesia

4. Department of Internal medicine, Medical Faculty Airlangga University, Indonesia

For personal use only.

* Corresponding author:

Dr. Ernawati

Department of Obstetric Gynecology, Medical Faculty Airlangga University, Indonesia

Professor Dr. Moestopo street 6-10 Surabaya, East Java, Indonesia. Tel: +6231-5036609,

+6281232850261, Fax: +6231-5036609.

E-mail address: ernawati.spog @gmail.com.

Abstract
 Objective: To present the outcome of expectant management of preterm preeclampsia in Indonesia,

and the effect of ongoing treatment with methylprednisolone on maternal and perinatal outcome

Material and methods: Prospective RCT on 48 patients with early-onset preeclampsia. Following the

administration of dexamethasone for fetal lung maturation, patients were randomized to receive 25

mg methylprednisolone (MP group) IV for the first week, decreasing to 12.5 mg during 2 nd week and

continued till birth, or matching IV placebo treatment (PL group). Prolongation of entry to delivery
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interval served as primary outcome measurement.

Results: The average time gained with expectant management was almost 14 days. However, there

was no difference of mean time interval between entry to delivery between the PL (13,8 days) and MP

(13,7 days) groups. Antenatal ongoing treatment with IV MP also did not improve maternal and/or

perinatal outcome and might be associated with a higher risk for severe maternal infections – in

particular tuberculosis.
For personal use only.

Conclusion: Expectant management of preterm preeclampsia is a realistic option in a major

Indonesian perinatal referral center. Steroids (outside the use for fetal lung maturation) should not be

used in the expectant management of preterm preeclampsia in Indonesia.

Keywords: Preterm Preeclampsia; Steroids; expectant management

Introduction

1
In Indonesia, a rapidly developing country with a population of 237.6 million in 2010 and

2,4 million birth’s 2

preeclampsia is one of the major obstetrical problems ; 30 % of maternal deaths

in the Dr Soetomo Hospital (largest tertiary perinatal referral hospital in East Java ) were due to
 preeclampsia.3 Unfortunately, there are to our knowledge no publications in the international literature

on the clinical aspects of preeclampsia management in Indonesia. There is also only limited data in

the international literature on conservative management of preeclampsia in developing countries.4

With the recognition of preeclampsia as a state of exaggerated inflammation, the role of

steroids to improve maternal outcome has been one of the ongoing clinical controversies. After

several positive case control studies 5 using mostly dexamethasone or betamethasone in patients with
6
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HELLP syndrome, the study by Fonseca et al concluded that there was no maternal benefit

associated with the use of steroids (except a slightly better platelet recovery in the steroid group). A
7
Dutch trial that did not receive enough attention showed a clear maternal benefit from ongoing

treatment with 50 mg of prednisolone in patients with early onset HELLP syndrome. The 2010
8
Cochrane review concluded that while laboratory parameters (platelets, transaminases, and LDH)

improved with the use of steroids there was only a non-significant trend towards improved maternal
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outcome. To our knowledge no trials have studied the effect of steroids in the expectant management

of preterm preeclampsia.

The current study is the first prospective randomized controlled trial (RCT) on expectant management

of early-onset preeclampsia in Indonesia. The 2 aims of this study were to (1) present outcome of

expectant management of preterm preeclampsia in Indonesia, and (2) to study the effect of ongoing

treatment with methylprednisolone on maternal and perinatal outcome in a double blind RCT.
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Material and Methods

This RCT was completed between August 2013, and January 2015. During this period all

patients with preterm preeclampsia (30-34 weeks gestation) were checked for possible inclusion. The

trial was approved by the Human Research and Ethics Committee for Basic Science and Clinical

Research Dr. Soetomo Hospital, Faculty of Medicine Airlangga University Surabaya.

The following inclusion criteria were used:

- Gestational age 30-34 weeks

 - Prolongation of pregnancy considered to be beneficial to perinatal outcome

- Written informed consent

Exclusion criteria

- Patients in whom maternal and/or fetal condition required immediate delivery

- Presence of major co-existing maternal disorders (severe chronic hypertension, pre-existing

renal disease, pre-existing diabetes mellitus, known infectious diseases – in particular

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tuberculosis)

Definitions used: The revised ISSHP criteria were used to diagnose preeclampsia ; hypertension

(≥140 mmHg systolic blood pressure and/or ≥ 90 mmHg diastolic blood pressure) developing after 20

weeks gestation and the coexistence of one or more of the following new onset conditions: proteinuria

(spot urine protein/creatinine ratio >30 mg/ mmol or >300mg protein/24 hours or at least [‘2 + ’] on

dipstick testing), and/or other maternal organ dysfunction and/or suspected IUGR.
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HELLP syndrome was defines as the presence of the 3 following criteria: platelet count < 100000 x

103/µL, AST/ALT > 50 U/L , Hemolysis , LDH > 600 U/L.10

Suspected IUGR was diagnosed using the biometry femur length/ abdominal circumference

ratio (FL/AC ratio x 100 ) > 23,5 used as cutoff).11,12 Post-partum diagnosis of IUGR was based on

the Lubchenco score measurement (IUGR diagnosed by LS < 10% ).13

During this study period the following criteria were used to stop with expectant management and to

deliver the baby by induction of labor or caesarean section (in line with the existing hospital

protocol):

- Major de novo maternal complications (eclampsia, pulmonary edema, uncontrollable blood

hypertension, placental abruption, development of severe proteinuria [ > 4 gram/24 hours], de

novo HELLP syndrome)

- Gestational age of 34 weeks

- Fetal distress and/or death (fetal distress as based on CTG and/or absent /reversed umbilical

artery Doppler flow patterns)

 After inclusion and obtaining informed consent all patients received the standard 4 x 6 mg of

dexamethasone I.M. every 12 hours for fetal lung maturation. After the first 48 hours patients were

computer randomized to receive 25 mg methylprednisolone (MP) iv for 7 days (or matching iv

placebo treatment). Randomization was done by central hospital pharmacy using SPSS based

computer randomization; subsequently the hospital pharmacist provided the intravenous trial

medication being Methylprednisolone or identical placebo. During the 2nd week this dose was

decreased to 12.5 mg till birth. Postpartum the antenatal IV dose of MP or placebo (PL) was
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continued for 48 hours, following this, patients received a 4-day oral tapering protocol of 25, 10 and 5

mg of trial medication respectively, with identical appearance and taste of the tablets for the MP and

PL group. Patients delivering during the tapering period or after discontinuation of protocol

medication, all received a stress dose of prednisolone or placebo during and after delivery, consisting

of 25 mg of prednisolone or placebo twice a day during 48 hr.

For personal use only.

Antihypertensive treatment consisted of oral nifedipine as first line medication, additional

methyldopa if required, and intravenous nicardipine for severe hypertension (systolic > 180 mmHg,

diastolic > 110 mmHg). All patients were initially treated with IV MgSO4; following an IV bolus of 4

g MgSO4, patients continued to receive 2 g/hr for the first 24 hours or longer at the discretion of the

obstetrical team. Pulmonary edema is a relatively common complication of preeclampsia in Indonesia;

regular albumin measurements and albumin infusions are considered standard practice in most

Indonesian centers. A serum albumin level < 2,5 g/L is typically treated with albumin transfusion. 14

Since prematurity in the 30-34 week’s gestation period is still associated with a high perinatal

mortality in Indonesia (28% perinatal mortality), length of expectant management was used as the

primary endpoint. A sample size of 24 versus 24 was required in order to be able to demonstrate a

doubling of the % of patients (expected 33%) in the MP group where expectant management would

gain > 7 days (α < 0.05%; power 80%).

 Results

During the study period 48 patients with preterm preeclampsia were initially included. Four

patients dropped out of the study; these 4 patients decided to stop their participation because of socio-

economic or family reasons. All these patients left before research medication was started (these
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patients were excluded from further analysis). Ultimately 44 women received trial medication after

randomization: 22 women in the MP group and 22 women in the PL group ; 1 patient in the MP group

had 6 days of trial medication, self-discharged for unknown reasons but came back 3 weeks later to

give birth (patient included in analysis).

Baseline demographics of study participants and the main maternal clinical outcomes are
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presented in table 1. A significant difference in maternal age between the PL and MP group was

identified (table 1; mean age PL group 32.6 yr vs 28.7 yr in the MP group) after completion of the

trial and disclosure of the trial medication. On reviewing the details of the patients it turned out that 8

patients with a maternal age > 35 yr ended up in the PL group versus only 3 patients in the MP group

with a maternal age > 35 yr.

Table 1

In this study, there was no difference of mean time interval between entry to delivery between

the PL and MP groups. The number of patients delivered within 7 days was the same in both groups, 4

versus 4 patients had to be delivered < 7 days. Also post-hoc analysis for expectant management per

every 48 hours gained did not show any significant differences. Antihypertensive drugs used in both

groups were similar: most patients required a combination of nifedipine and methyldopa. Mode of

delivery was comparable.

 No maternal death occurred in the overall group of 44 patients; 4 patients in the PL group

versus 5 in the MP group developed complications (including complete and incomplete HELLP

syndrome); overall rate of maternal complications 20% (9/44).

One case in the MP group developed acute pulmonary edema after 6 days of MP. This patient

required an emergency C-section and was delivered of a baby at 31+4 weeks gestation (baby died on

day 3 because of respiratory distress syndrome and sepsis). After initial improvement the patient
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developed pleural effusion on day 5 post-partum. Pleural fluid aspiration was performed, culture

demonstrated active tuberculosis. Unfortunately iatrogenic haemato-thorax occurred. After a

prolonged ICU period (including an episode with gram negative sepsis), she did make a full recovery

after 30 days treatment. In the PL group, 2 cases developed pulmonary edema. First case (twin

pregnancy) had pulmonary edema after 15 days of treatment. Her serum albumin level was always

low, (range 2,2-2,7 g/dL) notwithstanding albumin transfusions. She required an emergency C-section
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at 32+2 weeks, and was delivered of 2 babies in a good condition (birth weight’s 1200 and 1600g). The

2nd case developed pulmonary edema after 7 days of treatment, a C-section was performed at 34

weeks, and she was delivered of a neonate in good condition (serum albumin 2,7-3,2 g/dL).

Two case of acute renal failure (ARF) developed in the MP group. The first case of ARF was

diagnosed in the postpartum period. She required a C-section for (incomplete) HELLP syndrome, and

suspected sepsis (CRP 116). She was delivered of a healthy baby at 34 weeks and required ICU for 7

days. Her creatinine peaked at 1,7 mg/dL, no hemodialysis was required because she responded well

to diuretics. The 2nd case also was diagnosed with (incomplete) HELLP syndrome, she developed

ARF (peak serum creatinine 5,6 mg/dL), and pulmonary edema but fortunately made a full recovery

after 10 days without hemodialysis.

The changes in laboratory findings (admission, pre-delivery and post-partum) for both the MP and PL

group are detailed in table 2.

Table 2
 All patients had a normal platelet count ( > 150.000/uL ) on admission, 3 PL patients (platelet

count 89, 56, 50 (x103 /uL)) versus 3 MP patients (platelet count 41, 51, 61 (x103/uL)) developed

severe thrombocytopenia . As expected patients in the MP group demonstrated a significant

leukocytosis. Interestingly patients in MP group also showed an increase in CRP. A drop in serum

albumin occurred in both groups, with no difference between PL and MP patients. Serum creatinine

pre- and post-delivery was high in both groups; the non-significant differences were primarily due to

the patient with renal failure associated with suspected sepsis in the MP group.
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Mean time length of post-partum hospitalization differed between PL (3.96 ± 2.1 days) and

MP (6.38 ± 6.03 days) groups but this difference was not statistically different (p 0,083). Most of the

difference was caused by the patient who developed pulmonary edema and post-partum active

pulmonary tuberculosis (30 days). In both groups a minor improvement was noticed in umbilical

Doppler flow waveforms following admission, with no differences between the 2 groups.
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The overall perinatal outcome is presented in table 3.

Table 3

Overall we found no significant differences in the MP and PL groups in neonatal outcomes.

Perinatal mortality was comparable; 3 cases in PL group versus 5 cases in MP group. Of the perinatal

deaths in the MP group, one involved a fetal demise (asphyxia intra-partum in patient with HELLP

syndrome). Four neonates in MP group versus 3 neonates in the PL group died in first week of life

due to severe RDS plus or minus sepsis.

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Discussion

The results of this RCT represent the first data ever on expectant management in a large

Indonesian perinatal referral center. The overall perinatal and maternal outcomes are similar to data
 published by an Egypt group.4 Abdel Hady et al (2010) reported on patients in the 32-34 weeks range

and found a perinatal mortality rate of 17 out of 84 (20%) versus 9 out of 44 (20%) in the current

study. In the current study no maternal death occurred, while major maternal complications occurred

in 20% of patients (9 out 44) compared with 16.7 % in the Egyptian study. Average length of

expectant management was almost 2 weeks which is associated with a much better perinatal outcome

in the typical perinatal setting in Indonesia (expected perinatal mortality at 32-34 weeks 28%). 3 It is

important to note that not having access to surfactant to treat/prevent RDS due to lack of funding is a
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major issue in Indonesia and clearly one of the causes for the relatively high institutional preterm

perinatal mortality rate.

In contrast to the Dutch trial7, our data on steroids clearly indicate the absence of any

maternal and/or perinatal outcome associated with the IV administration of MP. Although all patients

were explicitly asked for a history of tuberculosis, the patient with a major tuberculosis complication,
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demonstrated the potential risk of powerful steroids in an Indonesian setting. One other patient in the

MP group developed a suspected sepsis associated with ARF (no positive cultures). The significant

increase in CRP levels in the MP group is hard to explain but could represent a flare up of underlying

infectious disorders due to the effect of steroids.

The difference with the Dutch study is the lower dose of MP used in the current study (25 mg IV

versus 50 mg in the Dutch trial). In theory the dose difference could be one of the reasons for the

difference in results. However, if anything such a higher dose would have the potential to cause a

further suppression of the maternal immune system 15.

In summary, expectant management of preterm (30-34 weeks) preeclampsia allows for a

prolongation of pregnancy of up to 14 days (± 7 days) in a large tertiary center in Indonesia. This trial

did not randomize between expectant management versus immediate delivery, however it is

reasonable to assume that a prolongation of this magnitude represent a clinically relevant neonatal

benefit. Antenatal ongoing treatment with IV MP (after initial dexamethasone for fetal lung

maturation) does not improve maternal and/or perinatal outcome and might be associated with a
 higher risk for severe maternal infections – in particular tuberculosis. Steroids (outside the use of

steroids for fetal lung maturation) should not be used in the expectant management of preterm

preeclampsia in Indonesia.
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Declaration of interest

The authors report no declarations of interest.

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References

(1) Statistics Indonesia : Officially Census 2010. (Cited 2 Mei 2013). Available from

http://www.bps.go.id/eng/tab_sub/view.php?kat=1&tabel=1&daftar=
 (2) Indonesian TFR . Officially census 2010. (Cited 2 Mei 2013). Available from

http://www.bkkbn.go.id/kependudukan/Pages/DataSensus/Sensus_Penduduk/Fertilitas/TFR/Nasional.

aspx

(3) Dr. Soetomo Hospital Yearly Report 2013.

(4) Abdel-Hady E, Fawzy M, El-Negeri M, Nezar M, Ragab A, Helal AS. Is expectant management

of early onset severe preeclampsia in low-resource setting? Arch Gynecol Obstet 2010; 282:23-27.
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(5) Martin JN Jr, Owens MY, Keiser SD, Parrish MR, Tam Tam KB, Brewer JM, Cushman JL, May

WL. Standardized Mississippi Protocol treatment of 190 patients with HELLP syndrome: slowing

disease progression and preventing new major maternal morbidity. Hypertens Pregnancy

2012;31(1):79-90

(6) E Javier , Fonseca, Mendez F, Catano C, Arias F. Dexamethasone treatment does not improve the
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outcome of women with HELLP syndrome: A double-blind, Placebo-controlled, randomized clinical

trial. American Journal of Obstetric & Gynecology 2005;193:1991-1998.

(7) Heimel PJR, Huisjes AJM, Franx Arie, Koopman C, Bots ML, Bruinse HW. A randomized

placebo-contolled trial of prolonged prednisolone administration to patiens with HELLP syndrome

remote from term. European Journal of Obstetric & Gynaecology and Reproductive Biology 2006;

128:187-193

(8) Woundstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP (hemolysis,

levated liver enzymes, low platelets) syndrome in pregnancy (Review). The Cohcrane Lybrary 2010,

issue 9.

(9) Lowe SA1, Brown MA, Dekker GA, Gatt S, McLintock CK, McMahon LP, Mangos G, Moore

MP, Muller P, Paech M, Walters B; Society of Obstetric Medicine of Australia. Guidelines for the

management of hypertensive disorder of pregnancy. Aust N Z J Obstet Gynaecol 2009 Jun;49(3):242-

6.
 (10) Sibai BM. Diagnosis, Controversies, and Management of the Syndrome of Hemolysis, Elevated

Liver Enzymes, and Low Platelet Count. The American College of Obstetricians and Gynecologists.

Published by Lippincott Williams & Wilkins 2004; vol 103:5 part 1

(11) Hadlock FP, Deter RL, Harrist RB, Roecker E, Park SK. A date-independent predictor of

intrauterine growth retardation: femur length/abdominal circumference ratio. Am J Roentgenol

1983;141(5):979
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(12) Shalev E, Romano S, Weiner E, Ben-Ami M. Predictive value of the femur length to abdominal

circumference ratio in the diagnosis of intrauterine growth retardation. J Med Sci 1991;27(3):131

(13) Lubchenco LO, Hansman C, Dressler M, Boyd E. Intrauterine growth as estimated from liveborn

birth-weigh data at 24 to 42 weeks of gestation. Pediatrics 1963;32:793– 800

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(14) Aditiawarman. Effect of amino acid profile changes on increasing endoplasmic reticulum stress

proteins (GRP7) and decreased levels of VEGF placenta in preeclampsia with hypoalbuminemia

(dissertation). Airlangga University,2008. Available from: ADLN digital collections, Airlangga

digital repository.

(15) Bennett, P.N & Brown, M.J. Endocrine system, metabolic conditions : Adrenal corticosteroids,

antagonists, corticotropin. Clinical pharmacology, 2003. Ed 9th Churchill Livingstone, Spain: 663-678
 Table 1 . Baseline demographics and maternal outcomes PL and MP group

Baseline demographics PL (n=22) MP (n=22) p-Value

Maternal age (years) 32.64 ± 5.69 28.73 ± 5.25 0.026

GA at start study (days) 224.90 ± 8.20 224.14 ± 8.44 0.492

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Systole BP (mmHg) 165.36 ± 11.57 166.95 ± 12.92 0.613

Diastole BP (mmHg) 109.41 ± 13.42 103.86 ± 11.12 0.131

BMI > 30 (n) 8 9

Maternal Outcomes PL (n=22) MP (n=22) P-Value

Admission delivery interval

(days) 13.86 ± 7.7 13.76 ± 7.9 0.848
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Gestational age at delivery (days) 238.77 ± 8.94 237.54 ± 12.97 0.43

Vaginal birth 4 5

Cesarean delivery overall (n)

- For fetal reason 6 2

- For maternal reason 12 14

Systolic BP at birth 164.4 166.95 0.714

Diastolic BP at birth 102.35 103.409 0.945

Antihypertensive drugs (n)

- Oral Nifedipine 11 5

- Oral Nifedipine + Methyl Dopa 11 17

Nicardipine IV 1 2

Albumin transfusion (n) 6 9

Complications during study (n) 4 5

 - HELLP 2 2

- Eclampsia 0 0

- Placental abruption 0 0

- DIC 0 0

- Sepsis 0 0

- Lung edema 1 0

- Acute kidney injury 0 0

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- Multiple complications 1 3

Maternal death 0 0

Post-partum stay (days) 3.96 ± 2.1 6.38 ± 6.03 0.083

All values are mean ± S.D. unless stated otherwise. GA, gestational age; BP, Blood Pressure; BMI, Body Mass Index; FL, Femur Length;
*
AC, Abdominal Circumference; DIC, Disseminated Intravascular Coagulation; t-test (p < 0.05); PL = placebo; MP = methylprednisolone
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 Table 2

Table 2. Laboratory findings (admission, pre-delivery and post-partum)

Laboratory Admission Pre- delivery Post partum

findings
PL MP PL MP PL MP

Hemoglobin (g/dL) 12.2 ± 1.4 12.4 ± 1.1 12.3 ± 1.9 12.6 ± 2.5 11.9 ± 2.3 10.03 ± 2.7

PLT (x103/uL) 256.0 ± 77.1 247.3 ± 100.9 224.8 ± 94.6 210.3 ± 91.7 247.9 ± 109.4 237.8 ± 76.2
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Leukocytes 10.5 ± 2.0 11.3 ± 2.1 12.7 ± 5.7 18.7 ± 7.1* 14.6 ± 5.4 19.5 ± 7.9
(x103/uL)

LDH (U/L) 421.0 ± 163.9 428.4 ± 125.8 515.9 ± 250.9 644.8 ± 475.3 594.4 ± 234.9 597.5 ± 289.2

CRP (mg/L) 5.3 ± 14.4 6.9 ± 8.1 18.3 ± 27.9 35.2 ± 51.4 43.8 ± 60.7 30.1 ± 10.1

AST (U/L) 26.7 ± 17.9 20.3 ± 8.8 26.3 ± 13.9 32.8 ± 18.9 32.6 ± 16.5 32.4 ± 20.7

ALT (U/L) 15.9 ± 8.1 16.3 ± 12.1 18.3 ± 12.3 29.1 ± 24.1 25.6 ±15.3 37.3 ± 26.3

Albumin (g/dL) 2.9 ± 0.4 3.04 ± 0.6 2.8 ± 0.5 2.9 ± 0.5 2.5 ± 0.4 2.7 ± 0.4
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All values are mean ± S.D unless stated otherwise , * t-test (p = 0,008); PL = placebo; MP = methylprednisolone;
 Table 3 Neonatal outcomes

Neonatal Outcomes PL (n=22) MP (n=22) p-Value

GA at delivery (weeks) 249.82 ± 16.65 249.18 ± 17 0.485

1 min Apgar score < 7 9 10

5 min Apgar score < 7 5 8

Birth weight (g) 1954.17 ± 617.84 1924.09 ± 558.45 0.592*

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IUGR (n) 4 4

Perinatal death / infant death (n) 3/0 5/0

RDS gr I-II (n) 3 3

RDS gr III-IV (n) 3 2

IVH gr I-II (n) 0 0

IVH gr III-IV (n) 0 0

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Sepsis (n) 0 1

Mechanical ventilation (n) 4 4

Duration of NICU admission (days) 6.53 6.71

Congenital anomaly (n) 1 0

Long term neonatal follow up at 6th

month

Head Circumference < -2 SD (n) 3 3

Abnormal DDST (n) 2 0

All values are mean ± S.D. unless stated otherwise. GA, gestational age; IUGR, Intra Uterine Growth Restriction; RDS, respiratory distress
syndrome; IVH, intraventricular hemorrhage; NICU, neonatal intensive care unit; S.D., standard deviation; DDST, Denver Development
*
Screening Test; t-test (p < 0,05)
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