We thank Dr Paulino Vigil-De Gracia for his interest, comments, and thoughtful questions and agree that the topic of this article is of great clinical importance.

In our study, all of the patients had inpatient management of preeclampsia. It was not standard practice, during the study period, to manage preeclampsia as an outpatient at the participating institutions. Therefore, our findings may not be generalizable to patients who are managed at home, which may represent an inherently lower risk group with better outcomes.

The participating study institutions all practice expectant management of severe preeclampsia when an indication for immediate delivery is not present. However, we cannot comment on latency of patients expectantly managed for severe preeclampsia because those women were not included in this study. For those who were candidates for expectant management <34 weeks’ gestation, it was standard practice to administer 1 course of antenatal corticosteroids with mild or superimposed preeclampsia. Magnesium sulfate was utilized for seizure prophylaxis among women who developed severe features of the disease and was administered throughout the intrapartum course and for 24 hours postpartum, per institutional protocols. For fetal neuroprotection, individual study site protocols for the administration of magnesium sulfate were implemented proximate to the time of delivery for pregnancies delivered at <33 weeks.

With respect to the US prospective study with expectant management of severe preeclampsia, an approximate 15-day latency was demonstrated. However, the study was performed >20 years ago and the population demographics as well as practice patterns have changed over the past 2 decades, limiting its comparability to our study. Study participants were on average 4-8 years younger than our study population and the study only focused on severe preeclampsia. More recent studies have shown a similar latency period to ours, which may be more representative of the current pregnant population.

Our study did not address the influence of antihypertensive therapy, as not all patients in either exposure group received these medications. And as such, we are unable to infer a cause and effect of antihypertensive treatment with small for gestational age, low birthweight, or other adverse outcomes in women with chronic hypertension. Our study demonstrated a high rate of antihypertensive treatment among women with chronic hypertension, which may be indicative of ongoing chronic treatment of their underlying vascular and endothelial disorder, longer disease duration, poorer overall health, or other unmeasured confounding influences. Antihypertensive therapy is recommended to reduce the risk of severe hypertension, worsening or development of end-organ damage, and maternal complications including cerebral hemorrhage and infarction. Therefore, we do believe it is justifiable to use antihypertensive medications for pregnant women who meet recommended criteria for treatment.

It is clear from Dr Vigil-De Gracia’s thoughtful comments and questions that there are many unanswered questions on this topic, and we hope to stimulate future studies to address these important clinical quandaries.