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Morris RK, Johnstone E, Lees C, Morton V, Smith G. Investigation and Care of a Small-for-Gestational-Age Fetus and a Growth Restricted Fetus (Green-top Guideline No. 31). BJOG 2024; 131:e31-e80. [PMID: 38740546 DOI: 10.1111/1471-0528.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Key recommendations
All women should be assessed at booking (by 14 weeks) for risk factors for fetal growth restriction (FGR) to identify those who require increased surveillance using an agreed pathway [Grade GPP]. Findings at the midtrimester anomaly scan should be incorporated into the fetal growth risk assessment and the risk assessment updated throughout pregnancy. [Grade GPP]
Reduce smoking in pregnancy by identifying women who smoke with the assistance of carbon monoxide (CO) testing and ensuring in‐house treatment from a trained tobacco dependence advisor is offered to all pregnant women who smoke, using an opt‐out referral process. [Grade GPP]
Women at risk of pre‐eclampsia and/or placental dysfunction should take aspirin 150 mg once daily at night from 12+0–36+0 weeks of pregnancy to reduce their chance of small‐for‐gestational‐age (SGA) and FGR. [Grade A]
Uterine artery Dopplers should be carried out between 18+0 and 23+6 weeks for women at high risk of fetal growth disorders [Grade B]. In a woman with normal uterine artery Doppler and normal fetal biometry at the midtrimester scan, serial ultrasound scans for fetal biometry can commence at 32 weeks. Women with an abnormal uterine artery Doppler (mean pulsatility index > 95th centile) should commence ultrasound scans at 24+0–28+6 weeks based on individual history. [Grade B]
Women who are at low risk of FGR should have serial measurement of symphysis fundal height (SFH) at each antenatal appointment after 24+0 weeks of pregnancy (no more frequently than every 2 weeks). The first measurement should be carried out by 28+6 weeks. [Grade C]
Women in the moderate risk category are at risk of late onset FGR so require serial ultrasound scan assessment of fetal growth commencing at 32+0 weeks. For the majority of women, a scan interval of four weeks until birth is appropriate. [Grade B]
Maternity providers should ensure that they clearly identify the reference charts to plot SFH, individual biometry and estimated fetal weight (EFW) measurements to calculate centiles. For individual biometry measurements the method used for measurement should be the same as those used in the development of the individual biometry and fetal growth chart [Grade GPP]. For EFW the Hadlock three parameter model should be used. [Grade C]
Maternity providers should ensure that they have guidance that promotes the use of standard planes of acquisition and calliper placement when performing ultrasound scanning for fetal growth assessment. Quality control of images and measurements should be undertaken. [Grade C]
Ultrasound biometry should be carried out every 2 weeks in fetuses identified to be SGA [Grade C]. Umbilical artery Doppler is the primary surveillance tool and should be carried out at the point of diagnosis of SGA and during follow‐up as a minimum every 2 weeks. [Grade B]
In fetuses with an EFW between the 3rd and 10th centile, other features must be present for birth to be recommended prior to 39+0 weeks, either maternal (maternal medical conditions or concerns regarding fetal movements) or fetal compromise (a diagnosis of FGR based on Doppler assessment, fetal growth velocity or a concern on cardiotocography [CTG]) [Grade C]. For fetuses with an EFW or abdominal circumference less than the 10th centile where FGR has been excluded, birth or the initiation of induction of labour should be considered at 39+0 weeks after discussion with the woman and her partner/family/support network. Birth should occur by 39+6 weeks. [Grade B]
Pregnancies with early FGR (prior to 32+0 weeks) should be monitored and managed with input from tertiary level units with the highest level neonatal care. Care should be multidisciplinary by neonatology and obstetricians with fetal medicine expertise, particularly when extremely preterm (before 28 weeks) [Grade GPP]. Fetal biometry in FGR should be repeated every 2 weeks [Grade B]. Assessment of fetal wellbeing can include multiple modalities but must include computerised CTG and/or ductus venous. [Grade B]
In pregnancies with late FGR, birth should be initiated from 37+0 weeks to be completed by 37+6 weeks [Grade A]. Decisions for birth should be based on fetal wellbeing assessments or maternal indication. [Grade GPP]
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Li T, Wang Y, Miao Z, Lin Y, Yu X, Xie K, Ding H. Neonatal Adverse Outcomes of Induction and Expectant Management in Fetal Growth Restriction: A Systematic Review and Meta-Analysis. Front Pediatr 2020; 8:558000. [PMID: 33251165 PMCID: PMC7673389 DOI: 10.3389/fped.2020.558000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: Fetal growth restriction (FGR) is a pathological condition in which the fetus cannot reach its expected growth potential. When it is diagnosed as a suspected FGR, it remains an unsolved problem whether to direct induction or continue expectant management. To effectively reduce the incidence of neonatal adverse outcomes, we aimed to evaluate whether either method was associated with a lower incidence of neonatal adverse outcomes. Methods: We searched the relevant literature through the PubMed, Web of Science, and Cochrane Library from inception to January 10, 2020. We defined induction as the experimental group and expectant management as the control group. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models owing to heterogeneity. Furthermore, we conducted a sensitivity analysis to explore the robustness of the included literature. We used the Newcastle-Ottawa scale (NOS) to evaluate the quality of the available studies. We applied the funnel plot to describe the publication bias. Additionally, subgroup analysis based on the study method, sample size, area, NOS score, Apgar score <7 at 5 min, definition of suspected FGR, severity, and neonatal adverse outcomes were performed to further evaluate the differences between the induction and expectant management. Results: Our study included a total of eight articles with 6,706 patients, which consisted of four randomized controlled trials (RCTs), three retrospective cohort studies, and one prospective cohort study. The total pooled OR and 95% CI between the induction group and the expected management group was 1.38 (95% CI, 0.84-2.28) in the random model. The heterogeneity was I 2 = 84%, P < 0.01. The sensitivity analysis showed that the neonatal adverse outcomes of induction vs. expectant management still presented similar outcomes after omitting of any one of these studies. The funnel plot and linear regression equation showed that there was no publication bias in our study (P = 0.75). Subgroup analysis showed that induction increased the neonatal adverse outcome risks of hypoglycemia and respiratory insufficiency (ORneonatal hypoglycaemia = 8.76, 95% CI: 2.57-29.90; ORrespiratory insufficiency = 1.74, 95% CI: 1.35-2.24, respectively). However, no significant differences were observed based on the other subgroups (all P > 0.05). Conclusion: Regardless of induction or expectant management of a suspected FGR, the neonatal adverse outcomes showed no obvious differences. More studies should be conducted and confounding factors should be taken into consideration to elucidate the differential outcomes of the two approaches for suspected FGR.
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Affiliation(s)
| | | | | | | | | | - Kaipeng Xie
- Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing, China
| | - Hongjuan Ding
- Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing, China
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Fonseca MJ, Santos F, Afreixo V, Silva IS, Almeida MDC. Does induction of labor at term increase the risk of cesarean section in advanced maternal age? A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 253:213-219. [PMID: 32889327 DOI: 10.1016/j.ejogrb.2020.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Women of advanced maternal age, defined as ≥ 35 years at delivery, are at increased risk of multiple complications during pregnancy, with perinatal death being one of the most feared. For instance, the risk of stillbirth at term in this subgroup of women is higher than in younger women, and particularly high beyond 39 weeks of gestation. Induction of labor at 39-40 weeks might help prevent some cases of perinatal death, however, the fact that induction of labor has been historically associated with an increased risk of cesarean delivery and the knowledge that advanced maternal age is an independent risk factor for cesarean delivery are some of the major reasons why clinicians are reluctant to offer elective induction of labor in this particular group. OBJECTIVE The aim of the study was to assess if induction of labor in advanced maternal age was associated with increased rates of cesarean delivery when compared to expectant management. MATERIAL AND METHODS We performed an electronic search limited to published articles available between January 2000 and March 2020. Randomized clinical trials and retrospective studies with large cohorts comparing induction of labor with expectant management in singleton pregnancies at term, of women aged ≥ 35 years were included. The primary outcome was the rate of cesarean delivery in induction of labor versus expectant management, and secondary outcomes were the occurrence of assisted vaginal delivery and postpartum hemorrhage. RESULTS Eight studies, including 81151 pregnancies (26,631 in the induction group and 54,520 expectantly managed), were included in the analysis. Six of the included studies were randomized clinical trials with the remaining two being observational and retrospective cohort studies. Induction of labor was not associated with a significant increased risk of cesarean delivery (OR 0.97, 95 % CI 0.86-1.1), assisted vaginal delivery (OR 1.12, 95 % CI 0.96-1.32) or postpartum hemorrhage (OR 1.11, 95 % CI 0.88-1.41). DISCUSSION The belief that induction of labor is associated with an increased risk of cesarean delivery is based on the results of retrospective studies comparing induction with spontaneous labor at the same gestational age. However, at any point in a pregnancy, the comparison should be between induction of labor and expectant management, with the latter contributing to a pregnancy of greater gestation age and not always leading to spontaneous labor. When comparing induction to expectant management, our study shows no significant increase of cesarean section, assisted vaginal delivery or postpartum hemorrhage. Our study was not powered to assess neonatal outcomes, and additional research is needed to confirm whether induction of labor might have a positive effect in preventing stillbirth. CONCLUSION Induction of labor at term in advanced maternal age has no significant impact on cesarean delivery rates, assisted vaginal delivery or postpartum hemorrhage, giving additional reassurance to obstetricians who would consider this intervention in this particular subgroup.
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Affiliation(s)
- Maria João Fonseca
- Department of Obstetrics, Maternidade Bissaya Barreto- Centro Hospitalar e Universitário de Coimbra, Portugal.
| | - Fernanda Santos
- Department of Obstetrics, Maternidade Bissaya Barreto- Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Vera Afreixo
- CIDMA/IBIMED/Department of Mathematics, University of Aveiro, Portugal
| | - Isabel Santos Silva
- Department of Obstetrics, Maternidade Bissaya Barreto- Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Maria do Céu Almeida
- Department of Obstetrics, Maternidade Bissaya Barreto- Centro Hospitalar e Universitário de Coimbra, Portugal
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Coates D, Makris A, Catling C, Henry A, Scarf V, Watts N, Fox D, Thirukumar P, Wong V, Russell H, Homer C. A systematic scoping review of clinical indications for induction of labour. PLoS One 2020; 15:e0228196. [PMID: 31995603 PMCID: PMC6988952 DOI: 10.1371/journal.pone.0228196] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist. METHODS A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool. RESULTS 68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence. CONCLUSIONS While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.
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Affiliation(s)
- Dominiek Coates
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Angela Makris
- Department of Medicine, Western Sydney University, Sydney, Australia
- Women’s Health Initiative Translational Unit (WHITU), Liverpool Hospital, Liverpool, Australia
| | - Christine Catling
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Amanda Henry
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
- Department of Women’s and Children’s Health, St George Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW Medicine, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Deborah Fox
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Purshaiyna Thirukumar
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Vincent Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Research Science, University of New South Wales, Liverpool, Australia
| | - Hamish Russell
- South Western Sydney Local Health District, Sydney, Australia
| | - Caroline Homer
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
- Maternal and Child Health Program, Burnet Institute, Victoria, Australia
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Townsend R, Sileo F, Stocker L, Kumbay H, Healy P, Gordijn S, Ganzevoort W, Beune I, Baschat A, Kenny L, Bloomfield F, Daly M, Devane D, Papageorghiou A, Khalil A. Variation in outcome reporting in randomized controlled trials of interventions for prevention and treatment of fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:598-608. [PMID: 30523658 DOI: 10.1002/uog.20189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Although fetal growth restriction (FGR) is well known to be associated with adverse outcomes for the mother and offspring, effective interventions for the management of FGR are yet to be established. Trials reporting interventions for the prevention and treatment of FGR may be limited by heterogeneity in the underlying pathophysiology. The aim of this study was to conduct a systematic review of outcomes reported in randomized controlled trials (RCTs) assessing interventions for the prevention or treatment of FGR, in order to identify and categorize the variation in outcome reporting. METHODS MEDLINE, EMBASE and The Cochrane Library were searched from inception until August 2018 for RCTs investigating therapies for the prevention and treatment of FGR. Studies were assessed systematically and data on outcomes that were reported in the included studies were extracted and categorized. The methodological quality of the included studies was assessed using the Jadad score. RESULTS The search identified 2609 citations, of which 153 were selected for full-text review and 72 studies (68 trials) were included in the final analysis. There were 44 trials relating to the prevention of FGR and 24 trials investigating interventions for the treatment of FGR. The mean Jadad score of all studies was 3.07, and only nine of them received a score of 5. We identified 238 outcomes across the included studies. The most commonly reported were birth weight (88.2%), gestational age at birth (72.1%) and small-for-gestational age (67.6%). Few studies reported on any measure of neonatal morbidity (27.9%), while adverse effects of the interventions were reported in only 17.6% of trials. CONCLUSIONS There is significant variation in outcome reporting across RCTs of therapies for the prevention and treatment of FGR. The clinical applicability of future research would be enhanced by the development of a core outcome set for use in future trials. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - L Stocker
- Women and Children Division, University Hospital Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - H Kumbay
- GKT School of Medicine, King's College, London, UK
| | - P Healy
- Health Research Board - Trials Methodology Research Network, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
| | - S Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Beune
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Baschat
- Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - L Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - F Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - M Daly
- Advocacy and Policymaking, Irish Neonatal Health Alliance, Wicklow, Ireland
| | - D Devane
- Health Research Board - Trials Methodology Research Network, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
| | - A Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital Women's Centre, Oxford, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Saccone G, Della Corte L, Maruotti GM, Quist-Nelson J, Raffone A, De Vivo V, Esposito G, Zullo F, Berghella V. Induction of labor at full-term in pregnant women with uncomplicated singleton pregnancy: A systematic review and meta-analysis of randomized trials. Acta Obstet Gynecol Scand 2019; 98:958-966. [PMID: 30723915 DOI: 10.1111/aogs.13561] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/29/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The lowest incidence of perinatal morbidity and mortality occurs around 39-40 weeks. Therefore, some have advocated induction of uncomplicated singleton gestations once they reach full-term. The aim of the study was to evaluate the risk of cesarean delivery, and any maternal and perinatal effects of a policy of induction of labor in women with full-term uncomplicated singleton gestations. MATERIAL AND METHODS We performed an electronic search from inception of each database to August 2018. All results were then limited to randomized trial. No restrictions for language or geographic location were applied. Inclusion criteria were randomized clinical trials of asymptomatic women with uncomplicated, singleton gestations at full-term (ie, between 39+0 and 40+6 weeks) who were randomized to either planned induction of labor or control (ie, expectant management). Only trials on asymptomatic singleton gestations without premature rupture of membranes or any other indications for induction evaluating the effectiveness of planned induction of labor in full-term singleton gestations were included. The primary outcome was the incidence of cesarean delivery. RESULTS Seven randomized clinical trials, including 7598 participants were analyzed. Three studies enrolled only women with favorable cervix, defined as a Bishop score of ≥5 in nulliparous women or ≥4 in multiparous women. One trial included only women aged 35 years or older. Women randomized to the planned induction of labor, received scheduled induction usually at 39+0 to 39+6 weeks of gestation, whereas women in the control group received expectant management usually until 41-42 weeks of gestation, or earlier if medically indicated. Methods of induction usually included cervical ripening, with either misoprostol or Foley catheter, in conjunction with or followed by oxytocin for women with unfavorable cervix, and oxytocin and artificial rupture of membranes for those with favorable cervix. Five trials also used artificial rupture of membranes as a method for induction. Uncomplicated full-term singleton gestations that were randomized to receive induction of labor had similar incidence of cesarean delivery compared with controls (18.6% vs 21.4%; relative risk 0.96, 95% CI 0.78-1.19). Regarding neonatal outcomes, induction of labor at full-term was associated with a significantly lower rate of meconium-stained amniotic fluid (4.0% vs 13.5%; relative risk 0.32, 95% CI 0.18-0.57), and lower mean birthweight (mean difference -98.96 g, 95% CI -126.29 to -71.63) compared with the control group. There were no between-group differences in other adverse neonatal outcomes. CONCLUSIONS Induction of labor at about 39 weeks is not associated with increased risk of cesarean delivery.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppe M Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Antonio Raffone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Valentino De Vivo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gennaro Esposito
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Walker KF, Malin G, Wilson P, Thornton JG. Induction of labour versus expectant management at term by subgroups of maternal age: an individual patient data meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016; 197:1-5. [DOI: 10.1016/j.ejogrb.2015.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/10/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
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Bond DM, Gordon A, Hyett J, de Vries B, Carberry AE, Morris J. Planned early delivery versus expectant management of the term suspected compromised baby for improving outcomes. Cochrane Database Syst Rev 2015; 2015:CD009433. [PMID: 26599471 PMCID: PMC8935540 DOI: 10.1002/14651858.cd009433.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fetal compromise in the term pregnancy is suspected when the following clinical indicators are present: intrauterine growth restriction (IUGR), decreased fetal movement (DFM), or when investigations such as cardiotocography (CTG) and ultrasound reveal results inconsistent with standard measurements. Pathological results would necessitate the need for immediate delivery, but the management for 'suspicious' results remains unclear and varies widely across clinical centres. There is clinical uncertainty as to how to best manage women presenting with a suspected term compromised baby in an otherwise healthy pregnancy. OBJECTIVES To assess, using the best available evidence, the effects of immediate delivery versus expectant management of the term suspected compromised baby on neonatal, maternal and long-term outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing expectant management versus planned early delivery for women with a suspected compromised fetus from 37 weeks' gestation or more. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Of the 20 reports identified by the search strategy, we included three trials (546 participants: 269 to early delivery and 277 to expectant management), which met our inclusion criteria. Two of the trials compared outcomes in 492 pregnancies with IUGR of the fetus, and one in 54 pregnancies with oligohydramnios. All three trials were of reasonable quality and at low risk of bias. The level of evidence was graded moderate, low or very low, downgrading mostly for imprecision and for some indirectness. Overall, there was no difference in the primary neonatal outcomes of perinatal mortality (no deaths in either group, one trial, 459 women, evidence graded moderate), major neonatal morbidity (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.01 to 2.81, one trial, 459 women, evidence graded low), or neurodevelopmental disability/impairment at two years of age (RR 2.04, 95% CI 0.62 to 6.69,one trial, 459 women, evidence graded low). There was no difference in the risk of necrotising enterocolitis (one trial, 333 infants) or meconium aspiration (one trial, 459 infants), There was also no difference in the reported primary maternal outcomes: maternal mortality (RR 3.07, 95% CI 0.13 to 74.87, one trial, 459 women, evidence graded low), and significant maternal morbidity (RR 0.92, 95% CI 0.38 to 2.22, one trial, 459 women, evidence graded low).The gestational age at birth was on average 10 days earlier in women randomised to early delivery (mean difference (MD) -9.50, 95% CI -10.82 to -8.18, one trial, 459 women) and women in the early delivery group were significantly less likely to have a baby beyond 40 weeks' gestation (RR 0.10, 95% CI 0.01 to 0.67, one trial, 33 women). Significantly more infants in the planned early delivery group were admitted to intermediate care nursery (RR 1.28, 95% CI 1.02 to 1.61, two trials, 491 infants). There was no difference in the risk of respiratory distress syndrome, (one trial, 333 infants), Apgar score less than seven at five minutes (three trials, 546 infants), resuscitation required (one trial, 459 infants), mechanical ventilation (one trial, 337 infants), admission to neonatal intensive care unit (NICU) (RR 0.88, 95% CI 0.35 to 2.23, three trials, 545 infants, evidence graded very low), length of stay in NICU/SCN (one trial, 459 infants), and sepsis (two trials, 366 infants).Babies in the expectant management group were more likely to be < 2.3rd centile for birthweight (RR 0.51, 95% CI 0.36 to 0.73, two trials, 491 infants), however there was no difference in the proportion of babies with birthweight < 10th centile (RR 0.98, 95% CI 0.88 to 1.10). There was no difference in any of the reported maternal secondary outcomes including: caesarean section rates (RR 1.02, 95% CI 0.65 to 1.59, three trials, 546 women, evidence graded low), placental abruption (one trial, 459 women), pre-eclampsia (one trial, 459 women), vaginal birth (three trials 546 women), assisted vaginal birth (three trials 546 women), breastfeeding rates (one trial, 218 women), and number of weeks of breastfeeding after delivery one trial, 124 women). There was an expected increase in induction in the early delivery group (RR 2.05, 95% CI 1.78 to 2.37, one trial, 459 women).No data were reported for the pre-specified secondary neonatal outcomes of the number of days of mechanical ventilation, moderate-severe hypoxic ischaemic encephalopathy or need for therapeutic hypothermia. Likewise, no data were reported for secondary maternal outcomes of postnatal infection, maternal satisfaction or views of care. AUTHORS' CONCLUSIONS A policy for planned early delivery versus expectant management for a suspected compromised fetus at term does not demonstrate any differences in major outcomes of perinatal mortality, significant neonatal or maternal morbidity or neurodevelopmental disability. In women randomised to planned early delivery, the gestational age at birth was on average 10 days earlier, women were less likely to have a baby beyond 40 weeks' gestation, they were more likely to be induced and infants were more likely to be admitted to intermediate care nursery. There was also a significant difference in the proportion of babies with a birthweight centile < 2.3rd, however this did not translate into a reduction in morbidity. The review is informed by only one large trial and two smaller trials assessing fetuses with IUGR or oligohydramnios and therefore cannot be generalised to all term pregnancies with suspected fetal compromise. There are other indications for suspecting compromise in a fetus at or near term such as maternal perception of DFM, and ultrasound and/or CTG abnormalities. Future randomised trials need to assess effectiveness of timing of delivery for these indications.
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Affiliation(s)
- Diana M Bond
- Royal Prince Alfred Hospital; The Kolling Institute of Medicine, University of Sydney at the Royal North Shore HospitalRPA Newborn CareSydneyAustralia
| | - Adrienne Gordon
- Royal Prince Alfred HospitalNeonatologyMissenden RoadCamperdownSydneyNSWAustralia2050
| | - Jon Hyett
- Royal Prince Alfred HospitalDepartment of High Risk Obstetrics, RPA Women and BabiesMissenden RoadCamperdownSydneyAustraliaNSW 2050
| | - Bradley de Vries
- Royal Prince Alfred HospitalDepartment of High Risk Obstetrics, RPA Women and BabiesMissenden RoadCamperdownSydneyAustraliaNSW 2050
| | - Angela E Carberry
- University of SydneySydney School of Public HealthCamperdownSydneyNSWAustralia2050
| | - Jonathan Morris
- University of SydneyThe Kolling Institute of MedicineSt LeonardsNSWAustralia2060
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Saccone G, Berghella V. Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2015; 213:629-36. [PMID: 25882916 DOI: 10.1016/j.ajog.2015.04.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 03/17/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
Abstract
The aim of this study was to evaluate the risk of cesarean and any maternal and perinatal effects of a policy induction of labor in uncomplicated full-term singleton gestations. Searches were performed in an electronic database with the use of a combination of text words related to "induction" and "cesarean section" from inception of each database through December 2014. We included all randomized controlled trials of uncomplicated singleton gestations at full term (ie, between 39 weeks 0/7 days and 40 weeks 6/7 days) with intact membranes randomized to induction of labor or control (ie, expectant management). The primary outcome was the incidence of cesarean delivery. The summary measures were reported as risk ratio (RR) with 95% confidence interval (CI). Five randomized controlled trials, including 844 women, were analyzed. Full-term vertex singleton gestations receiving induction of labor had similar incidence of cesarean delivery compared to controls (9.7% vs 7.5%; RR, 1.25; 95% CI, 0.75-2.08). Rates of spontaneous (75.9% vs 80.2%; RR, 0.95; 95% CI, 0.87-1.02) and operative (13.1% vs 10.6%; RR, 1.22; 95% CI, 0.83-1.81) vaginal delivery were also similar. Induction was associated with similar rates of chorioamnionitis (9.6% vs 8.0%; RR, 1.17; 95% CI, 0.38-3.39), but statistically significantly less blood loss (mean difference -57.59 mL; 95% CI, -83.96 to -31.21) compared to controls. Regarding neonatal outcomes, induction was associated with a significantly lower rate of meconium-stained amniotic fluid (4.0% vs 13.5%; RR, 0.32; 95% CI, 0.18-0.57) and significantly lower mean birthweight (mean difference -135.51 g; 95% CI, -205.24 to -65.77) compared to control group. Induction of labor at full term in uncomplicated singleton gestations is not associated with increased risk of cesarean delivery and has overall similar outcomes compared to expectant management.
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Saccone G, Berghella V. Planned delivery at 37 weeks in twins: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2015; 29:685-9. [PMID: 25716078 DOI: 10.3109/14767058.2015.1016423] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the effects of planned delivery at 37 weeks in women with twin gestations compared to expectant management. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Searches were performed in electronic databases. We included all RCTs of uncomplicated early term twin gestations with intact membranes who were randomized to planned delivery at 37 weeks or control (i.e. expectant management until at least 38(0) weeks). The primary outcome was the rate of cesarean delivery. RESULTS Two trials (271 women) were analyzed. Women with twin gestations who had planned delivery at 37 weeks had similar rates of cesarean delivery compared to controls [51.9 versus 49.3%; relative risk (RR): 1.05, 95% confidence interval (CI): 0.83-1.32]. Furthermore, no differences in all secondary outcomes were detected, except for a significantly lower rate of serious adverse infant outcomes in the women who had planned delivery at 37 weeks compared to controls (4.7 versus 12.2%; RR: 0.39, 95% CI: 0.20-0.76). CONCLUSIONS Planned delivery at 37 weeks in twins is associated with a similar risk of cesarean delivery and lower risk of serious adverse infant outcomes, compared to expectant management until at least 38 weeks.
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Affiliation(s)
- Gabriele Saccone
- a Department of Neuroscience , Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II , Naples , Italy and
| | - Vincenzo Berghella
- b Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
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Mishanina E, Rogozinska E, Thatthi T, Uddin-Khan R, Khan KS, Meads C. Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis. CMAJ 2014; 186:665-73. [PMID: 24778358 DOI: 10.1503/cmaj.130925] [Citation(s) in RCA: 173] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Induction of labour is common, and cesarean delivery is regarded as its major complication. We conducted a systematic review and meta-analysis to investigate whether the risk of cesarean delivery is higher or lower following labour induction compared with expectant management. METHODS We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery. RESULTS We identified 157 eligible RCTs (n = 31,085). Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management (pooled relative risk [RR] 0.88, 95% confidence interval [CI] 0.84-0.93; I(2) = 0%). The effect was significant in term and post-term gestations but not in preterm gestations. Meta-regression analysis showed that initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25-0.99; I(2) = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79-0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10-9.57; I(2) = 0%) with labour induction. INTERPRETATION The risk of cesarean delivery was lower among women whose labour was induced than among those managed expectantly in term and post-term gestations. There were benefits for the fetus and no increased risk of maternal death.
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Affiliation(s)
- Ekaterina Mishanina
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Ewelina Rogozinska
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Tej Thatthi
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Rehan Uddin-Khan
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Khalid S Khan
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Catherine Meads
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
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12
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Wood S, Cooper S, Ross S. Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes. BJOG 2013; 121:674-85; discussion 685. [PMID: 23834460 DOI: 10.1111/1471-0528.12328] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent literature on the effect of induction of labour (compared with expectant management) has provided conflicting results. Reviews of observational studies generally report an increase in the rate of caesarean section, whereas reviews of post-dates and term prelabour rupture of membrane (PROM trials suggest either no difference or a reduction in risk. OBJECTIVE To evaluate with a systematic review and meta-analysis of randomised controlled trials (RCTs) whether or not the induction of labour increases the risk of caesarean section in women with intact membranes. SEARCH STRATEGY Literature search using electronic databases: MEDLINE, EMBASE, and the Cochrane Database of Clinical Trials. SELECTION CRITERIA RCTs comparing a policy of induction of labour with expectant management in women with intact membranes. DATA COLLECTION AND ANALYSIS A total of 37 trials were identified and reviewed. Quantitative analyses with fixed- and random-effects models were performed with revman 5.1. MAIN RESULTS Of the 37 RCTs, 27 were trials of uncomplicated pregnancies at 37-42 weeks of gestation. The remaining ten evaluated induction versus expectant management in pregnancies with suspected macrosomia (two), diabetes in pregnancy (one), oligohydramnios (one), twins (two), intrauterine growth restriction (IUGR) (two), mild pregnancy-induced hypertension (PIH) (one), and women with a high-risk score for caesarean section (one). Meta-analysis of 31 trials determined that a policy of induction was associated with a reduction in the risk of caesarean section compared with expectant management (OR 0.83, 95% CI 0.76-0.92). AUTHOR'S CONCLUSIONS Induction of labour in women with intact membranes reduces the risk of caesarean section. Review of the trials suggests that this effect may arise from non-treatment effects, and that additional trials are needed.
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Affiliation(s)
- S Wood
- Departments of Obstetrics and Gynaecology, University of Calgary, Calgary, AB, Canada; Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Bijlenga D, Birnie E, Mol BW, Bonsel GJ. Obstetrical outcome valuations by patients, professionals, and laypersons: differences within and between groups using three valuation methods. BMC Pregnancy Childbirth 2011; 11:93. [PMID: 22078302 PMCID: PMC3226638 DOI: 10.1186/1471-2393-11-93] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 11/12/2011] [Indexed: 12/02/2022] Open
Abstract
Background Decision-making can be based on treatment preferences of the patient, the doctor, or by guidelines based on lay people's preferences. We compared valuations assigned by three groups: patients, obstetrical care professionals, and laypersons, for health states involving both mother and (unborn) child. Our aim was to compare the valuations of different groups using different valuation methods and complex obstetric health outcome vignettes that involve both maternal and neonatal outcomes. Methods Patients (n = 24), professionals (n = 30), and laypersons (n = 27) valued the vignettes using three valuation methods: visual analogue scale (VAS), time trade-off (TTO), and discrete choice experimentation (DCE). Each vignette covered five health attributes: maternal health ante partum, time between diagnosis and delivery, process of delivery, maternal outcome, and neonatal outcome. We used feasibility questionnaires, Generalization theory, test-retest reliability and within-group reliability to compare the valuation patterns between groups and methods. We assessed relative weights from each valuation method to test for consistency across groups. Results Test-retest reliability was equal across groups, but different across methods: highest for VAS (ICC = 0.61-0.73), intermediate for TTO (ICC = 0.24-0.74) and lowest for DCE (kappa = 0.15-0.37). Within-group reliability was highest in all groups with VAS (ICC = 0.70-0.73), intermediate with DCE (kappa = 0.56-0.76) and lowest with TTO (ICC = 0.20-0.66). Effects of groups were smaller than effects of methods. Differences between groups were largest for severe health states. Conclusion Based on our results, decision making among laypersons should use TTO or DCE; patients should use VAS or TTO.
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Affiliation(s)
- Denise Bijlenga
- Dept, of Social Medicine, Academic Medical Centre - University of Amsterdam, The Netherlands.
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Bijlenga D, Boers KE, Birnie E, Mol BWJ, Vijgen SCM, Van der Post JAM, De Groot CJ, Rijnders RJP, Pernet PJ, Roumen FJ, Stigter RH, Delemarre FMC, Bremer HA, Porath M, Scherjon SA, Bonsel GJ. Maternal health-related quality of life after induction of labor or expectant monitoring in pregnancy complicated by intrauterine growth retardation beyond 36 weeks. Qual Life Res 2011; 20:1427-36. [PMID: 21468753 PMCID: PMC3195683 DOI: 10.1007/s11136-011-9891-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pregnancies complicated by intrauterine growth retardation (IUGR) beyond 36 weeks of gestation are at increased risk of neonatal morbidity and mortality. Optimal treatment in IUGR at term is highly debated. Results from the multicenter DIGITAT (Disproportionate Intrauterine Growth Intervention Trial At Term) trial show that induction of labor and expectant monitoring result in equal neonatal and maternal outcomes for comparable cesarean section rates. We report the maternal health-related quality of life (HR-QoL) that was measured alongside the trial at several points in time. METHODS Both randomized and non-randomized women were asked to participate in the HR-QoL study. Women were asked to fill out written validated questionnaires, covering background characteristics, condition-specific issues and the Short Form (SF-36), European Quality of Life (EuroQoL 6D3L), Hospital Anxiety and Depression scale (HADS), and Symptom Check List (SCL-90) at baseline, 6 weeks postpartum and 6 months postpartum. We compared the difference scores of all summary measures between the two management strategies by ANOVA. A repeated measures multivariate mixed model was defined to assess the effect of the management strategies on the physical (PCS) and mental (MCS) components of the SF-36. Analysis was by intention to treat. RESULTS We analyzed data of 361 randomized and 198 non-randomized patients. There were no clinically relevant differences between the treatments at 6 weeks or 6 months postpartum on any summary measures; e.g., on the SF-36 (PCS: P = .09; MCS: P = .48). The PCS and the MCS were below norm values at inclusion. The PCS improved over time but stayed below norm values at 6 months, while the MCS did not improve. CONCLUSION In pregnancies complicated by IUGR beyond 36 weeks, induction of labor does not affect the long-term maternal quality of life.
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Affiliation(s)
- Denise Bijlenga
- Department of Social Medicine, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
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15
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Boers KE, Vijgen SMC, Bijlenga D, van der Post JAM, Bekedam DJ, Kwee A, van der Salm PCM, van Pampus MG, Spaanderman MEA, de Boer K, Duvekot JJ, Bremer HA, Hasaart THM, Delemarre FMC, Bloemenkamp KWM, van Meir CA, Willekes C, Wijnen EJ, Rijken M, le Cessie S, Roumen FJME, Thornton JG, van Lith JMM, Mol BWJ, Scherjon SA. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). BMJ 2010; 341:c7087. [PMID: 21177352 PMCID: PMC3005565 DOI: 10.1136/bmj.c7087] [Citation(s) in RCA: 247] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the effect of induction of labour with a policy of expectant monitoring for intrauterine growth restriction near term. DESIGN Multicentre randomised equivalence trial (the Disproportionate Intrauterine Growth Intervention Trial At Term (DIGITAT)). SETTING Eight academic and 44 non-academic hospitals in the Netherlands between November 2004 and November 2008. PARTICIPANTS Pregnant women who had a singleton pregnancy beyond 36+0 weeks' gestation with suspected intrauterine growth restriction. INTERVENTIONS Induction of labour or expectant monitoring. MAIN OUTCOME MEASURES The primary outcome was a composite measure of adverse neonatal outcome, defined as death before hospital discharge, five minute Apgar score of less than 7, umbilical artery pH of less than 7.05, or admission to the intensive care unit. Operative delivery (vaginal instrumental delivery or caesarean section) was a secondary outcome. Analysis was by intention to treat, with confidence intervals calculated for the differences in percentages or means. RESULTS 321 pregnant women were randomly allocated to induction and 329 to expectant monitoring. Induction group infants were delivered 10 days earlier (mean difference -9.9 days, 95% CI -11.3 to -8.6) and weighed 130 g less (mean difference -130 g, 95% CI -188 g to -71 g) than babies in the expectant monitoring group. A total of 17 (5.3%) infants in the induction group experienced the composite adverse neonatal outcome, compared with 20 (6.1%) in the expectant monitoring group (difference -0.8%, 95% CI -4.3% to 3.2%). Caesarean sections were performed on 45 (14.0%) mothers in the induction group and 45 (13.7%) in the expectant monitoring group (difference 0.3%, 95% CI -5.0% to 5.6%). CONCLUSIONS In women with suspected intrauterine growth restriction at term, we found no important differences in adverse outcomes between induction of labour and expectant monitoring. Patients who are keen on non-intervention can safely choose expectant management with intensive maternal and fetal monitoring; however, it is rational to choose induction to prevent possible neonatal morbidity and stillbirth. TRIAL REGISTRATION International Standard Randomised Controlled Trial number ISRCTN10363217.
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Affiliation(s)
- K E Boers
- Leiden University Medical Centre, Leiden, Netherlands.
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16
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Boers KE, van der Post JAM, Mol BWJ, van Lith JMM, Scherjon SA. Labour and neonatal outcome in small for gestational age babies delivered beyond 36+0 weeks: a retrospective cohort study. J Pregnancy 2010; 2011:293516. [PMID: 21490789 PMCID: PMC3066629 DOI: 10.1155/2011/293516] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 10/24/2010] [Accepted: 11/08/2010] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Small for gestational age (SGA) is associated with increased neonatal morbidity and mortality. At present, evidence on whether these pregnancies should be managed expectantly or by induction is lacking. To get insight in current policy we analysed data of the National Dutch Perinatal Registry (PRN). METHODS We used data of all nulliparae between 2000 and 2005 with a singleton in cephalic presentation beyond 36+0 weeks, with a birth weight below the 10th percentile. We analysed two groups of pregnancies: (I) with isolated SGA and (II) with both SGA and hypertensive disorders. Onset of labour was related to route of delivery and neonatal outcome. RESULTS Induction was associated with a higher risk of emergency caesarean section (CS), without improvement in neonatal outcome. For women with isolated SGA the relative risk of emergency CS after induction was 2.3 (95% Confidence Interval [CI] 2.1 to 2.5) and for women with both SGA and hypertensive disorders the relative risk was 2.7 (95% CI 2.3 to 3.1). CONCLUSION Induction in pregnancies complicated by SGA at term is associated with a higher risk of instrumental deliveries without improvement of neonatal outcome. Prospective studies are needed to determine the best strategy in suspected IUGR at term.
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Affiliation(s)
- K E Boers
- Department of Gynaecology and Obstetrics, Bronovo Hospital, Bronovolaan 5, 2597 AX The Hague, The Netherlands.
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17
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Bijlenga D, Birnie E, Bonsel GJ. Feasibility, reliability, and validity of three health-state valuation methods using multiple-outcome vignettes on moderate-risk pregnancy at term. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:821-7. [PMID: 19508667 DOI: 10.1111/j.1524-4733.2009.00503.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVES Preference-based health-state valuation methods such as discrete choice experiment (DCE) are claimed to be superior than attitude-based valuation methods like visual analogue scale (VAS) and time trade-off (TTO). We compared VAS, TTO, and DCE in terms of feasibility, reliability, and validity using vignettes depicting moderate-risk pregnancy at term. METHODS People from the community (n = 97) participated in both a panel session and an individual home assignment. Each participant valuated 46 vignettes with VAS, TTO, and DCE. Each vignette consisted of five attributes: maternal health antepartum, time between diagnosis and delivery, process of delivery, maternal outcome, and neonatal outcome. The questionnaire included Feasibility, which we evaluated by questionnaire. Test–retest reliability and interobserver consistency were assessed by intraclass correlation (ICC), and variance consistency by generalization theory. Convergent validity was determined with ICC and Cohen's kappa; construct validity was determined with linear regression, multinomial logit modeling, and Kendall's Tau-b correlation (τ). RESULTS The DCE was reported as most feasible (DCE: 87% vs. VAS: 69% vs. TTO: 42%). Test–retest reliability was high overall and equal (VAS: ICC = 0.77; TTO: ICC = 0.79; DCE: κ = 0.78). The VAS had the highest interobserver reliability (ICC = 0.73). Convergent validity between VAS and DCE was high (κ = 0.79) and there was sufficient construct validity between VAS and DCE (τ = 0.68). The TTO yielded less optimal results. Generally, neonatal and maternal outcomes weighed most, whereas process outcomes weighed least in moderate-risk pregnancy at term. CONCLUSIONS In our context of multidimensional health states with complex trade-offs, DCE was superior to TTO and performed equal to VAS, with DCE displaying slightly higher user feasibility.
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Affiliation(s)
- Denise Bijlenga
- Academic Medical Centre—University of Amsterdam, Amsterdam,The Netherlands.
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Illa M, Coloma JL, Eixarch E, Meler E, Iraola A, Gardosi J, Gratacós E, Figueras F. Growth deficit in term small-for-gestational fetuses with normal umbilical artery Doppler is associated with adverse outcome. J Perinat Med 2009; 37:48-52. [PMID: 18956962 DOI: 10.1515/jpm.2009.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM The association between the growth deficit and the occurrence of adverse outcome was analyzed in a cohort of small-for-gestational age fetuses delivered at term. METHODS A cohort of consecutive singleton fetuses suspected of being SGA during the late third trimester and delivered beyond 37 weeks was selected. Growth deficit area was calculated as that between the individual 10(th) centile curve of the customized optimal fetal weight and the individual fetal growth curve. RESULTS A total of 55 women were included. Of these, 16 had 28 adverse events: eight cases of umbilical artery pH<7.15, 9 cases of caesarean section for fetal distress and 11 cases of admission to neonatal intensive care unit. Whereas the mean area of growth deficit was 8.8 kg x week units (SD 7.6) for cases with normal outcomes, it was 13.9 (SD 8.04) for cases with adverse outcomes (P=0.03). A growth area deficit >10 units, predicted the occurrence of adverse outcome with a sensitivity and specificity of 62% and 68%, respectively. CONCLUSION In term growth restricted fetuses the degree of growth deficit from the optimal customized growth may be used to identify a subgroup of fetuses at high-risk for adverse outcomes.
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Affiliation(s)
- Miriam Illa
- Department of Obstetrics, Hospital Clinic, Barcelona, Spain
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Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: a best-evidence review. BJOG 2009; 116:626-36. [PMID: 19191776 DOI: 10.1111/j.1471-0528.2008.02065.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Rates of labour induction are increasing. OBJECTIVES To review the evidence supporting indications for induction. SEARCH STRATEGY We listed indications for labour induction and then reviewed the evidence. We searched MEDLINE and the Cochrane Library between 1980 and April 2008 using several terms and combinations, including induction of labour, premature rupture of membranes, post-term pregnancy, preterm prelabour rupture of membranes (PROM), multiple gestation, suspected macrosomia, diabetes, gestational diabetes mellitus, cardiac disease, fetal anomalies, systemic lupus erythematosis, oligohydramnios, alloimmunization, rhesus disease, intrahepatic cholestasis of pregnancy (IHCP), and intrauterine growth restriction (IUGR). We performed a review of the literature supporting each indication. SELECTION CRITERIA We identified 1387 abstracts and reviewed 418 full text articles. We preferentially included high-quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised trials and observational studies. MAIN RESULTS We included 34 full text articles. For each indication, we assigned levels of evidence and grades of recommendation based upon the GRADE system. Recommendations for induction of labour for post-term gestation, PROM at term, and premature rupture of membranes near term with pulmonary maturity are supported by the evidence. Induction for IUGR before term reduces intrauterine fetal death, but increases caesarean deliveries and neonatal deaths. Evidence is insufficient to support induction for women with insulin-requiring diabetes, twin gestation, fetal macrosomia, oligohydramnios, cholestasis of pregnancy, maternal cardiac disease and fetal gastroschisis. AUTHORS' CONCLUSIONS Research is needed to determine risks and benefits of induction for many commonly advocated clinical indications.
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Affiliation(s)
- E Mozurkewich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
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Outcome of induced deliveries in growth-restricted fetuses: second thoughts about the vaginal option. Arch Gynecol Obstet 2008; 279:139-43. [PMID: 18506461 DOI: 10.1007/s00404-008-0685-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 05/05/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the outcome of induced deliveries with IUGR. STUDY DESIGN We reviewed the computerized files of parturients who underwent inducted labor because of IUGR (<5th percentile). Outcome assessment included mode of delivery, indication for CS, NICU admissions and 5 min Apgar score. We compared these parameters to a control group of women whose deliveries were induced for other indications. RESULTS A total of 836 women with IUGR were included. Mean gestational age and birth weight were 38.2 weeks and 2,114 g, respectively. Overall, 43% of women delivered by non-elective C/S. The rate of non-elective CS for other indications was 12.3% (P < 0.0001) for all deliveries and 23.6% (P < 0.001) for induced deliveries. CS was performed due to non-reassuring FHR in 63% of IUGR fetuses, compared with 27% of all induced deliveries. There were 160 women with IUGR who preferred elective CS. Their newborns' NICU admission and 5 min Apgar score <7 rates were lower than those for induced deliveries (NICU 43.1 and 29.4%, P < 0.05, 5 min Apgar <7 5 and 1%, P < 0.05). CONCLUSION Growth-restricted neonates born after labor induction had higher rates of low Apgar scores and NICU admissions compared to growth restricted neonates delivered by elective C/S. Inductions of labor for IUGR were associated with higher rates of non-elective C/S due to non-reassuring fetal heart rate compared with inductions performed for other indications.
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Boers KE, Bijlenga D, Mol BWJ, LeCessie S, Birnie E, van Pampus MG, Stigter RH, Bloemenkamp KWM, van Meir CA, van der Post JAM, Bekedam DJ, Ribbert LSM, Drogtrop AP, van der Salm PCM, Huisjes AJM, Willekes C, Roumen FJME, Scheepers HCJ, de Boer K, Duvekot JJ, Thornton JG, Scherjon SA. Disproportionate Intrauterine Growth Intervention Trial At Term: DIGITAT. BMC Pregnancy Childbirth 2007; 7:12. [PMID: 17623077 PMCID: PMC1933438 DOI: 10.1186/1471-2393-7-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 07/10/2007] [Indexed: 11/10/2022] Open
Abstract
Background Around 80% of intrauterine growth restricted (IUGR) infants are born at term. They have an increase in perinatal mortality and morbidity including behavioral problems, minor developmental delay and spastic cerebral palsy. Management is controversial, in particular the decision whether to induce labour or await spontaneous delivery with strict fetal and maternal surveillance. We propose a randomised trial to compare effectiveness, costs and maternal quality of life for induction of labour versus expectant management in women with a suspected IUGR fetus at term. Methods/design The proposed trial is a multi-centre randomised study in pregnant women who are suspected on clinical grounds of having an IUGR child at a gestational age between 36+0 and 41+0 weeks. After informed consent women will be randomly allocated to either induction of labour or expectant management with maternal and fetal monitoring. Randomisation will be web-based. The primary outcome measure will be a composite neonatal morbidity and mortality. Secondary outcomes will be severe maternal morbidity, maternal quality of life and costs. Moreover, we aim to assess neurodevelopmental and neurobehavioral outcome at two years as assessed by a postal enquiry (Child Behavioral Check List-CBCL and Ages and Stages Questionnaire-ASQ). Analysis will be by intention to treat. Quality of life analysis and a preference study will also be performed in the same study population. Health technology assessment with an economic analysis is part of this so called Digitat trial (Disproportionate Intrauterine Growth Intervention Trial At Term). The study aims to include 325 patients per arm. Discussion This trial will provide evidence for which strategy is superior in terms of neonatal and maternal morbidity and mortality, costs and maternal quality of life aspects. This will be the first randomised trial for IUGR at term. Trial registration Dutch Trial Register and ISRCTN-Register: ISRCTN10363217.
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Affiliation(s)
- Kim E Boers
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, The Netherlands
| | - Denise Bijlenga
- Department of Social Medicine, Academic Medical Center Amsterdam, The Netherlands
| | - Ben WJ Mol
- Department of Obstetrics and Gynaecology, Máxima Medical Center Veldhoven, The Netherlands
| | - Saskia LeCessie
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Center, Tthe Netherlands
| | - Erwin Birnie
- Department of Public Health Economy, Erasmus Medical Center Rotterdam, The Netherlands
| | - Marielle G van Pampus
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, The Netherlands
| | - Rob H Stigter
- Department of Obstetrics and Gynaecology, Deventer Hospital, The Netherlands
| | - Kitty WM Bloemenkamp
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, The Netherlands
| | - Claudia A van Meir
- Department of Obstetrics and Gynaecology, Groene Hart Hospital Gouda, The Netherlands
| | - Joris AM van der Post
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, The Netherlands
| | - Dick J Bekedam
- Department of Obstetrics and Gynaecology, OLVG Amsterdam, The Netherlands
| | - Lucy SM Ribbert
- Department of Obstetrics and Gynaecology, St. Antonius Hospital Nieuwegein, The Netherlands
| | - Addie P Drogtrop
- Department of Obstetrics and Gynaecology, TweeSteden Hospital Tilburg, The Netherlands
| | - Paulien CM van der Salm
- Department of Obstetrics and Gynaecology, Meander Medical Center Amersfoort, The Netherlands
| | - Anjoke JM Huisjes
- Department of Obstetrics and Gynaecology, Gelre Hospital Apeldoorn, The Netherlands
| | - Christine Willekes
- Department of Obstetrics and Gynaecology, University Hospital Maastricht, The Netherlands
| | - Frans JME Roumen
- Department of Obstetrics and Gynaecology, Atrium Medical Center Heerlen, The Netherlands
| | | | | | - Johannes J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus Medical Center Rotterdam, The Netherlands
| | - Jim G Thornton
- Department of Obstetrics and Gynaecology and Child Health, University of Nottingham, Nottingham City Hospital, UK
| | - Sicco A Scherjon
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, The Netherlands
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Figueras F, Eixarch E, Meler E, Iraola A, Figueras J, Puerto B, Gratacos E. Small-for-gestational-age fetuses with normal umbilical artery Doppler have suboptimal perinatal and neurodevelopmental outcome. Eur J Obstet Gynecol Reprod Biol 2007; 136:34-8. [PMID: 17434250 DOI: 10.1016/j.ejogrb.2007.02.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 01/08/2007] [Accepted: 02/15/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the perinatal and neurodevelopmental outcome of small-for-gestational-age fetuses with normal umbilical artery Doppler managed expectantly during pregnancy and delivery. STUDY DESIGN Perinatal and neurodevelopmental outcome was assessed from a cohort of singleton small-for-gestational-age fetuses with normal umbilical artery Doppler and normally grown controls matched by gestational age at delivery, parity and parental socio-economic level. Neurodevelopmental outcome was prospectively evaluated by means of the 24-month Age&Stage Questionnaire (ASQ). RESULTS A total of 129 small-for-gestational-age fetuses and 259 controls were included. Small-for-gestational-age fetuses had a higher risk for neonatal intensive care unit admission (15.5% versus 3.9%; p<0.001) and significant neonatal morbidity (2.3% versus 0%; p=0.04) than controls. At 24-months, these fetuses showed significantly lower neurodevelopmental centile in the problem solving (42.8 versus 52.1; p=0.001) and personal-social (44.4 versus 54.6; p<0.001) areas than controls. CONCLUSION Perinatal and neurodevelopmental outcome in small-for-gestational-age fetuses with normal umbilical artery Doppler is suboptimal, which may challenge the role of umbilical artery Doppler to discriminate between normal-SGA and growth-restricted fetuses.
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Affiliation(s)
- Francesc Figueras
- Obstetrics and Neonatal Department, IDIBAPS, Hospital Clinic, Barcelona, Spain.
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