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Sigdel M, Burd J, Walker KF, Wennerholm UB, Berghella V. Severe perineal lacerations in induction of labor versus expectant management: A systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol MFM 2024; 6:101407. [PMID: 38880238 DOI: 10.1016/j.ajogmf.2024.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/22/2024] [Accepted: 05/12/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE This study aimed to evaluate if induction of labor (IOL) is associated with an increased risk of severe perineal laceration. DATA SOURCES A systematic search was conducted in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and CINHAL using a combination of keywords and text words related to "induction of labor," "severe perineal laceration," "third-degree laceration," "fourth-degree laceration," and "OASIS" from inception of each database until January 2023. STUDY ELIGIBILITY CRITERIA We included all randomized controlled trials (RCTs) comparing IOL to expectant management of a singleton, cephalic pregnancy at term gestation that reported rates of severe perineal laceration. STUDY APPRAISAL AND SYNTHESIS AND METHODS The primary outcome of interest was severe perineal laceration, defined as 3rd- or 4th-degree perineal lacerations. We conducted meta-analyses using the random effects model of DerSimonian and Laird to determine the relative risks (RR) or mean differences with 95% confidence intervals (CIs). Bias was assessed using guidelines established by Cochrane Handbook for Systematic Reviews of Interventions. RESULTS A total of 11,187 unique records were screened and ultimately eight RCTs were included, involving 13,297 patients. There was no statistically significant difference in the incidence of severe perineal lacerations between the IOL and expectant management groups (209/6655 [3.1%] vs 202/6641 [3.0%]; RR 1.03, 95% CI 0.85, 1.26). There was a statistically significant decrease in the rate of cesarean birth (1090/6655 [16.4%] vs 1230/6641 [18.5%], RR 0.89, 95% CI 0.82, 0.95) and fetal macrosomia (734/2696 [27.2%] vs 964/2703 [35.7%]; RR 0.67: 95% CI 0.50, 0.90) in the IOL group. CONCLUSION There is no significant difference in the risk of severe perineal lacerations between IOL and expectant management in this meta-analysis of RCTs. Furthermore, there is a lower rate of cesarean births in the IOL group, indicating more successful vaginal deliveries with similar rates of severe perineal lacerations. Patients should be counseled that in addition to the known benefits of induction, there is no increased risk of severe perineal lacerations.
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Affiliation(s)
- Manisha Sigdel
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Pittsburg Medical Center, Harrisburg, PA (Sigdel)
| | - Julia Burd
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis, St Louis, MO (Burd)
| | - Kate F Walker
- Centre for Perinatal Research, University of Nottingham, Nottingham, UK (Walker)
| | - Ulla-Britt Wennerholm
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sahlgrenska University Hospital, Stockholm, Sweden (Wennerholm)
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA (Berghella).
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Ukoha EP, Wen T, Reddy UM. Induction of labor vs expectant management among low-risk patients with 1 prior cesarean delivery. Am J Obstet Gynecol 2024:S0002-9378(24)00661-6. [PMID: 38852849 DOI: 10.1016/j.ajog.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Studies that have compared induction of labor in individuals with 1 prior cesarean delivery to expectant management have shown conflicting results. OBJECTIVE To determine the association between clinical outcomes and induction of labor at 39 weeks in a national sample of otherwise low-risk patients with 1 prior cesarean delivery. STUDY DESIGN This cross-sectional study analyzed 2016 to 2021 US Vital Statistics birth certificate data. Individuals with vertex, singleton pregnancies, and 1 prior cesarean delivery were included. Patients with prior vaginal deliveries, delivery before 39 weeks 0 days or after 42 weeks 6 days of gestation, and medical comorbidities were excluded. The primary exposure of interest was induction of labor at 39 weeks 0 days to 39 weeks 6 days compared to expectant management with delivery from 40 weeks 0 days to 42 weeks 6 days. The primary outcome was vaginal delivery. The main secondary outcomes were separate maternal and neonatal morbidity composites. The maternal morbidity composite included uterine rupture, operative vaginal delivery, peripartum hysterectomy, intensive care unit admission, and transfusion. The neonatal morbidity composite included neonatal intensive care unit admission, Apgar score less than 5 at 5 minutes, immediate ventilation, prolonged ventilation, and seizure or serious neurological dysfunction. Unadjusted and adjusted log binomial regression models accounting for demographic variables and the exposure of interest (induction vs expectant management) were performed. Results are presented as unadjusted and adjusted risk ratios with 95% confidence intervals. RESULTS From 2016 to 2021, a total of 198,797 individuals with vertex, singleton pregnancies, and 1 prior cesarean were included in the primary analysis. Of these individuals, 25,915 (13.0%) underwent induction of labor from 39 weeks 0 days to 39 weeks 6 days and 172,882 (87.0%) were expectantly managed with deliveries between 40 weeks 0 days and 42 weeks 6 days. In adjusted analyses, patients induced at 39 weeks were more likely to have a vaginal delivery when compared to those expectantly managed (38.0% vs 31.8%; adjusted risk ratio 1.32, 95% confidence interval 1.28, 1.36). Among those who had vaginal deliveries, induction of labor was associated with increased likelihood of operative vaginal delivery (11.1% vs 10.0; adjusted risk ratio 1.15, 95% confidence interval 1.07, 1.24). The maternal morbidity composite occurred in 0.9% of individuals in both the induction and expectant management groups (adjusted risk ratio 0.92, 95% confidence interval 0.79, 1.06). The rates of uterine rupture (0.3%), peripartum hysterectomy (0.04% vs 0.05%), and intensive care unit admission (0.1% vs 0.2%) were all relatively low and did not differ significantly between groups. There was also no significant difference in the neonatal morbidity composite between the induction and expectant management groups (7.3% vs 6.7%; adjusted risk ratio 1.04, 95% confidence interval 0.98, 1.09). CONCLUSION When compared to expectant management, elective induction of labor at 39 weeks in low-risk patients with 1 prior cesarean delivery was associated with a significantly higher likelihood of vaginal delivery with no difference in composite maternal and neonatal morbidity outcomes. Prospective studies are needed to better elucidate the risks and benefits of induction of labor in this patient population.
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Affiliation(s)
- Erinma P Ukoha
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY.
| | - Timothy Wen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA
| | - Uma M Reddy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
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Grobman WA. The ARRIVE Trial. Clin Obstet Gynecol 2024; 67:374-380. [PMID: 38032824 DOI: 10.1097/grf.0000000000000844] [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: 12/02/2023]
Abstract
Timing of delivery such that maternal and perinatal outcomes are optimized is among the most important and commonplace decisions in obstetric care. Given the importance of this determination, it is somewhat surprising that there has been, until relatively recently, little in the way of high-quality evidence to guide obstetric clinicians in this decision. This chapter describes the evolution of studies examining the effects of labor induction and the importance of the ARRIVE trial in that context.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
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Kawakita T, Saeed H, Huang JC. An Externally Validated Model to Predict Prolonged Induction of Labor with an Unfavorable Cervix. Am J Perinatol 2024; 41:e3140-e3146. [PMID: 37863073 DOI: 10.1055/a-2195-6063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
OBJECTIVE To develop and externally validate a prediction model to calculate the likelihood of prolonged induction of labor (induction start to delivery time > 36 hours). STUDY DESIGN This was a retrospective cohort study of all nulliparous women with singleton pregnancies and vertex presentation at term who underwent induction of labor and had a vaginal delivery at a single academic center. Women with contraindications for vaginal delivery were excluded. Analyses were limited to women with unfavorable cervix (both simplified Bishop score [dilation, station, and effacement: range 0-9] <6 and cervical dilation <3 cm). Prolonged induction of labor was defined as the duration of induction (induction start time to delivery) longer than 36 hours. A backward stepwise logistic regression analysis was used to identify the factors associated with prolonged induction of labor by considering maternal characteristics and comorbidities as well as fetal conditions. The final model was validated using an external dataset of the Consortium on Safe Labor after applying the same inclusion and exclusion criteria. We developed a receiver observer characteristic curve with area under the curve (AUC) in validation cohorts. RESULTS Of 2,118 women, 364 (17%) had prolonged induction of labor. Factors associated with prolonged induction of labor included body mass index at admission, hypertension, fetal conditions, and epidural. Factors including younger maternal age, prelabor rupture of membranes, and a more favorable simplified Bishop score were associated with a decreased likelihood of prolonged induction of labor. In the external validation cohort, 4,418 women were analyzed, of whom 188 (4%) had prolonged induction of labor. The AUC of the final model was 0.76 (95% confidence interval: 0.73-0.80) for the external validation cohort. The online calculator was created and is available at: https://medstarapps.org/obstetricriskcalculator. CONCLUSION Our externally validated model was efficient in predicting prolonged induction of labor with an unfavorable cervix. KEY POINTS · The number of inductions of labor at 39 weeks' gestation and beyond has been increasing.. · Our model had a good prediction of prolonged induction of labor.. · An online calculator has been created and available..
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Affiliation(s)
- Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Haleema Saeed
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Jim C Huang
- Department of Business Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
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Grobman WA. The role of labor induction in modern obstetrics. Am J Obstet Gynecol 2024; 230:S662-S668. [PMID: 38299461 DOI: 10.1016/j.ajog.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 11/01/2022]
Abstract
A primary goal of obstetrical practice is the optimization of maternal and perinatal health. This goal translates into a seemingly simple assessment with regard to considerations of the timing of delivery: delivery should occur when the benefits are greater than those of continued pregnancy. In the absence of an indication for cesarean delivery, planned delivery is initiated with induction of labor. When medical or obstetrical complications exist, they may guide recommendations regarding the timing of delivery. In the absence of these complications, gestational age also has been used to guide delivery timing, given its association with both maternal and perinatal adverse outcomes. If there is no medical indication, delivery before 39 weeks has been discouraged, given its association with greater chances of adverse perinatal outcomes. Conversely, it has been recommended that delivery occur by 42 weeks of gestation, given the perinatal risks that accrue in the post-term period. Historically, a 39-week induction of labor, particularly for individuals with no previous birth, has not been routinely offered in the absence of medical or obstetrical indications. That approach was based on numerous observational studies that demonstrated an increased risk of cesarean delivery and other adverse outcomes among individuals who underwent labor induction compared to those in spontaneous labor. However, from a management and person-centered-choice perspective, the relevant comparison is between those undergoing planned labor induction at a given time vs those planning to continue pregnancy beyond that time. When individuals have been compared using that rubric-either in observational studies or randomized trials that have been performed in a wide variety of locations and populations- there has not been evidence that induction increases adverse perinatal or maternal outcomes. Conversely, even when the only indication for delivery is the achievement of a full-term gestational age, evidence suggests that multiple different outcomes, including cesarean delivery, hypertensive disorders of pregnancy, neonatal respiratory impairment, and perinatal mortality, are less likely when induction is performed. This information underscores the importance of making the preferences of pregnant individuals for different birth processes and outcomes central to the approach to delivery timing.
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Taylor B, Cross-Sudworth F, Rimmer M, Quinn L, Morris RK, Johnston T, Morad S, Davidson L, Kenyon S. Induction of labour care in the UK: A cross-sectional survey of maternity units. PLoS One 2024; 19:e0297857. [PMID: 38416750 PMCID: PMC10901341 DOI: 10.1371/journal.pone.0297857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/10/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES To explore local induction of labour pathways in the UK National Health Service to provide insight into current practice. DESIGN National survey. SETTING Hospital maternity services in all four nations of the UK. SAMPLE Convenience sample of 71 UK maternity units. METHODS An online cross-sectional survey was disseminated and completed via a national network of obstetrics and gynaecology specialist trainees (October 2021-March 2022). Results were analysed descriptively, with associations explored using Fisher's Exact and ANOVA. MAIN OUTCOME MEASURES Induction rates, criteria, processes, delays, incidents, safety concerns. RESULTS 54/71 units responded (76%, 35% of UK units). Induction rate range 19.2%-53.4%, median 36.3%. 72% (39/54) had agreed induction criteria: these varied widely and were not all in national guidance. Multidisciplinary booking decision-making was not reported by 38/54 (70%). Delays reported 'often/always' in hospital admission for induction (19%, 10/54) and Delivery Suite transfer once induction in progress (63%, 34/54). Staffing was frequently reported cause of delay (76%, 41/54 'often/always'). Delays triggered incident reports in 36/54 (67%) and resulted in harm in 3/54 (6%). Induction was an area of concern (44%, 24/54); 61% (33/54) reported induction-focused quality improvement work. CONCLUSIONS There is substantial variation in induction rates, processes and policies across UK maternity services. Delays appear to be common and are a cause of safety concerns. With induction rates likely to increase, improved guidance and pathways are critically needed to improve safety and experience of care.
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Affiliation(s)
- Beck Taylor
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Fiona Cross-Sudworth
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Michael Rimmer
- Medical Research Council Centre for Reproductive Health, The Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Laura Quinn
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - R. Katie Morris
- Professor of Obstetrics and Maternal Fetal Medicine, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Tracey Johnston
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Sharon Morad
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Louisa Davidson
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Sara Kenyon
- Professor of Evidence Based Maternity Care, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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Aedla NR, Mahmood T, Ahmed B, Konje JC. Challenges in timing and mode of delivery in morbidly obese women. Best Pract Res Clin Obstet Gynaecol 2024; 92:102425. [PMID: 38150814 DOI: 10.1016/j.bpobgyn.2023.102425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/31/2023] [Accepted: 11/13/2023] [Indexed: 12/29/2023]
Abstract
Globally obesity is increasing especially in the reproductive age group. Pregnant women with obesity have higher complication and intervention rates. They are also at increased risk of stillbirth and intrapartum complications. Although organisations like NICE, RCOG, ACOG and WHO have published guidelines and recommendations on care of pregnant women with obesity the evidence from which Grade A recommendations can be made on timing and how to deliver is limited. The current advice is therefore to have discussions with the woman on risks to help her make an informed decision about timing, place, and mode of delivery. Obesity is an independent risk factor for pregnancy complications including diabetes, hypertension and macrosomia. In those with these complications, the timing of delivery is often influenced by the severity of the complication. As an independent factor, population based observational studies in obese women have shown an increase in the risk of stillbirth. This risk increases linearly with weight from overweight through to class II obesity, but then rises sharply in those with class III obesity by at least 10-fold beyond 42 weeks when compared to normal weight women. This risk of stillbirth is notably higher in obese women from 34 weeks onwards compared to normal weight women. One modifiable risk factor for stillbirth as shown from various cohorts of pregnant women is prolonged pregnancy. Research has linked obesity to prolonged pregnancy. Although the exact mechanism is yet unknown some have linked this to maternal dysregulation of the hypothalamic pituitary adrenal axis leading to hormonal imbalance delaying parturition. For these women the two dilemmas are when and how best to deliver. In this review, we examine the evidence and make recommendations on the timing and mode of delivery in women with obesity. For class I obese women there are no differences in outcome with regards to timing and mode of delivery when compared to lean weight women. However, for class II and III obesity, planned induction or caesarean sections may be associated with a lower perinatal morbidity and mortality although this may be associated with an increased in maternal morbidity especially in class III obesity. Studies have shown that delivery by 39 weeks is associated with lower perinatal mortality compared to delivering after in these women. On balance the evidence would favour planned delivery (induction or caesarean section) before 40 weeks of gestation. In the morbidly obese, apart from the standard lower transverse skin incision for CS, there is evidence that a supraumbilical transverse incision may reduce morbidity but is less cosmetic. Irrespective of the option adopted, it is important to discuss the pros and cons of each.
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Affiliation(s)
- Nivedita R Aedla
- Simpsons Centre for Reproductive Medicine Royal Infirmary of Edinburgh, Edinburgh, UK.
| | | | - Badreldeen Ahmed
- Fetal Maternal Centre, Doha, Qatar; Weill Cornell Medicine Qatar. Qatar; University of Qatar, Qatar
| | - Justin C Konje
- Fetal Maternal Centre, Doha, Qatar; Weill Cornell Medicine Qatar. Qatar; Department of Health Sciences, University of Leicester, UK; University of Ho, Ghana
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Butler SE, Wallace EM, Bisits A, Selvaratnam RJ, Davey MA. Induction of labor and cesarean birth in lower-risk nulliparous women at term: A retrospective cohort study. Birth 2024. [PMID: 38173333 DOI: 10.1111/birt.12806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/13/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To evaluate whether induction of labor (IOL) is associated with cesarean birth (CB) and perinatal mortality in uncomplicated first births at term compared with expectant management outside the confines of a randomized controlled trial. METHODS Population-based retrospective cohort study of all births in Victoria, Australia, from 2010 to 2018 (n = 640,191). Preliminary analysis compared IOL at 37 weeks with expectant management at that gestational age and beyond for uncomplicated pregnancies. Similar comparisons were made for IOL at 38, 39, 40, and 41 weeks of gestation and expectant management. The primary analysis repeated these comparisons, limiting the population to nulliparous women with uncomplicated pregnancies and excluding those with a medical indication for IOL. We compared perinatal mortality between groups using Chi-square tests and multivariable logistic regression for all other comparisons. Adjusted odds ratios and 99% confidence intervals were reported. p < 0.01 denoted statistical significance. RESULTS Among nulliparous, uncomplicated pregnancies at ≥37 weeks of gestation in Victoria, IOL increased from 24.6% in 2010 to 30.0% in 2018 (p < 0.001). In contrast to the preliminary analysis, the primary analysis showed that IOL in lower-risk nulliparous women was associated with increased odds of CB when performed at 38 (aOR 1.23(1.13-1.32)), 39 (aOR 1.31(1.23-1.40)), 40 (aOR 1.42(1.35-1.50)), and 41 weeks of gestation (aOR 1.43(1.35-1.51)). Perinatal mortality was rare in both groups and non-significantly lower in the induced group at most gestations. DISCUSSION For lower-risk nulliparous women, the odds of CB increased with IOL from 38 weeks of gestation, along with decreased odds of perinatal mortality at 41 weeks only.
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Affiliation(s)
- Sarah E Butler
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- Department of Health, Melbourne, Victoria, Australia
| | - Andrew Bisits
- Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Roshan J Selvaratnam
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Mary-Ann Davey
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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Schoen CN, Backley S, Orr L, Roy A, Corlin T, Knee AB. Induction of labor versus expectant management in patients with idiopathic polyhydramnios. Eur J Obstet Gynecol Reprod Biol 2024; 292:182-186. [PMID: 38039900 DOI: 10.1016/j.ejogrb.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To evaluate whether induction of labor is associated with lower risk of cesarean section compared to expectant management in patients with isolated polyhydramnios. STUDY DESIGN This is a single-center, retrospective cohort study of patients with pregnancies complicated by idiopathic polyhydramnios, documented between 34 and 38 weeks gestation, who were delivered between July 2012 and February 2020. The primary outcome was cesarean delivery. Secondary outcomes included chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, and composite neonatal morbidity. RESULTS There were 194 patients included with idiopathic polyhydramnios - 115 underwent induction and 79 patients were expectantly managed. Planned induction was associated with a lower rate of CD compared with expectant management but did not meet statistical significance (19.1 % vs 30.4 %, aOR 0.51, 95 % CI 0.24, 1.05). A similar effect was seen when stratifying for parity: both nulliparous (9.1 % vs 16.3 %, aOR 0.59, 95 % CI 0.17, 1.98) and multiparous (32.7 % vs 47.2 %, aOR 0.45, 95 % CI 0.18, 1.15) patients had a lower CD rate when there was a planned induction, though neither group met statistical significance. No differences in maternal or fetal secondary outcomes were identified (chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, composite neonatal morbidity). CONCLUSION Lower rates of cesarean section were associated with labor induction for patients with isolated polyhydramnios, but confidence intervals did not reach statistical significance.
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Affiliation(s)
- Corina N Schoen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, UMASS Chan Medical School -Baystate, Springfield, MA 01199, USA.
| | - Sami Backley
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX 077030, USA
| | - Lauren Orr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, WellSpan Health System, York, PA 17403, USA
| | - Amrita Roy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Tiffany Corlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Alexander B Knee
- Department of Medicine, UMASS Chan Medical School -Baystate, Springfield, MA, USA; Office of Research, Epidemiology/Biostatistics Research Core, Baystate Medical Center, Springfield, MA 01199, USA
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Shajan A, Menon B, Gilvaz S, Biju N, Abraham SV. Maternal and Perinatal Outcomes Amongst Nulliparous Singleton Pregnancies Electively Induced at 39 Weeks: A Prospective Observational Study. J Obstet Gynaecol India 2023; 73:199-205. [PMID: 38143962 PMCID: PMC10746687 DOI: 10.1007/s13224-023-01833-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/16/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Given the uncertainty of inducing beyond 39 weeks, we intended to study the maternal and neonatal mortality and morbidity associated with planned elective induction of labour (eIOL) at 390/7 to 396/7 weeks. Objectives To study the maternal and perinatal outcomes, after eIOL, at 390/7 to 396/7 weeks, amongst nulliparous singleton pregnancies, followed up for the duration of their hospital stay. Methods All consecutive nulliparous, singleton gestations, undergoing eIOL, at 390/7 to 396/7 weeks, with no plan for caesarean section (CS) or contraindication for vaginal delivery were prospectively recruited. The primary outcome studied was the incidence of CS and neonatal intensive care requirement, and the secondary outcomes studied were induction-delivery interval, incidence of chorioamnionitis, postpartum haemorrhage, meconium aspiration syndrome (MAS), APGAR ≤ 7 at 1 min and neonatal mortality. Results Amongst the total 304 mothers electively induced at 390/7 to 396/7 weeks, 80 (26.3%) mothers underwent CS and 48 (15.8%) neonates required intensive care. Fifteen (4.9%) babies required respiratory support at birth. The mean induction-delivery interval was 19 h 42 min ± 10 h. There were 9(3%) cases of PPH and no reported cases of chorioamnionitis. Eleven (3.6%) babies had an APGAR < / = 7 at 1 min and 9 (2.9%) had MAS, but there was no maternal or neonatal mortality. Conclusion Induction of labour at 39 weeks in low-risk nulliparous women did not result in a lower frequency of CS or adverse perinatal outcomes.
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Affiliation(s)
- Athulya Shajan
- Department of Obstetrics and Gynaecology, Institute of Kidney Diseases and Research Centre (IKDRC), Ahmedabad, India
- Institute of Kidney Diseases and Research Centre (IKDRC), Ahmedabad, India
- Department of Reproductive Medicine and Surgery at CIMAR-The Women’s hospital, Thrissur, Kerala India
| | - Bindu Menon
- Department of Obstetrics and Gynaecology, Institute of Kidney Diseases and Research Centre (IKDRC), Ahmedabad, India
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
| | - Sareena Gilvaz
- Department of Obstetrics and Gynaecology, Institute of Kidney Diseases and Research Centre (IKDRC), Ahmedabad, India
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
| | - Nirmal Biju
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
| | - Siju V. Abraham
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
- Department of Obstetrics and Gynaecology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala India
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Bachar G, Abu-Rass H, Farago N, Justman N, Buchnik G, Chen YS, David CB, Goldfarb N, Khatib N, Ginsberg Y, Zipori Y, Weiner Z, Vitner D. Continuous vs intermittent induction of labor with oxytocin in nulliparous patients: a randomized controlled trial. Am J Obstet Gynecol MFM 2023; 5:101176. [PMID: 37813304 DOI: 10.1016/j.ajogmf.2023.101176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/13/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Oxytocin is considered the drug of choice for the induction of labor, although the optimal protocol and infusion duration remain to be determined. OBJECTIVE This study aimed to assess whether the duration of oxytocin infusion increases 24-hour delivery rates and affects the length of time-to-delivery and patient's experience. STUDY DESIGN A randomized controlled trial was performed at a single tertiary medical center, between January 1, 2020 and June 30, 2022. Nulliparous patients with a singleton pregnancy at a vertex presentation and a Bishop score ≥6 were randomly assigned to receive either continuous (16 hours, with a 4 hours pause in between infusions) or intermittent (8 hours, with a 4 hours pause in between infusions) oxytocin infusion, until delivery. In both groups, infusion was halted when signs of maternal or fetal compromise were observed. Randomization was conducted with a computer randomization sequence generation program. The primary outcome was delivery within 24 hours from the first oxytocin infusion and the secondary outcome included time-to-delivery, mode of delivery, and additional maternal and neonatal outcomes. Seventy-two patients per group were randomized to reach 80% statistical power with a 20% difference in the primary outcome according to previous studies. RESULTS A total of 153 patients were randomized, 72 to the continuous oxytocin infusion group and 81 to the intermittent infusion group. The total oxytocin infusion time was similar between the groups. Patients in the continuous arm were more likely to deliver within 24 hours from oxytocin initiation (79.73% vs 62.96%, P<.05), and had a shorter oxytocin-to-delivery time interval, compared with patients receiving intermittent treatment (9.3±3.7 hours vs 21±11.7 hours, P<.001). Furthermore, time from ruptured membranes to delivery was shorter (9.3±3.7 hours vs 21±11.7 hours; P<.0001) and chorioamnionitis was less frequent (9.46% vs 21%; P<.05) in the continuous compared with the intermittent arm. Cesarean delivery rate was 20% in both groups (P=.226). There was no difference in postpartum hemorrhage, or adverse neonatal outcomes between the groups. Patients receiving continuous oxytocin infusion were more satisfied with the birthing experience. CONCLUSION Continuous infusion of oxytocin for labor induction in nulliparous patients with a favorable cervix may be superior to intermittent oxytocin infusion, because it shortens time-to-delivery, decreases chorioamnionitis rate, and improves maternal satisfaction, without affecting adverse maternal or neonatal outcomes.
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Affiliation(s)
- Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana).
| | - Hiba Abu-Rass
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Naama Farago
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Gili Buchnik
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Yoav Siegler Chen
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Chen Ben David
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Nirit Goldfarb
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gal, Hiba, Naama, Naphtali, Gili, Yoav, Chen, Mr Nirit, Drs Nizar, Yuval, Yaniv, Zeev, and Dana); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Nizar, Yuval, Yaniv, Zeev, and Dana)
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Jeer B, Haberfeld E, Khalil A, Thangaratinam S, Allotey J. Perinatal and maternal outcomes according to timing of induction of labour: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 288:175-182. [PMID: 37549509 DOI: 10.1016/j.ejogrb.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023]
Abstract
The risk of adverse perinatal and maternal outcomes increases with gestational age, and although induction of labour may reduce these risks, the optimal timing of induction remains unknown. We carried out a systematic review and meta-analysis, to determine the gestational age at which induction should be offered. We searched Cochrane Central Register of Controlled Trials, Medline, and Embase databases from inception to July 2022, to identify randomised trials comparing induction of labour at or beyond 37' weeks gestation with expectant management or delayed induction, and according to the gestational age at planned induction. We undertook random effects meta-analysis and pooled estimates as odds ratios with 95% confidence intervals. We assessed risk of bias of studies using the Cochrane Risk of Bias tool 2.0. We included 44 trials (23,960 women and 22,191 offspring) from 1,839 citations in our meta-analysis. The odds of perinatal death (odds ratio 0.42, 95% confidence interval 0.22 to 0.81; 26 studies, 20,154 offspring), stillbirth (0.40, 0.16 to 0.98; 25 studies, 19,412 offspring), admission to neonatal intensive care unit (0.86, 0.78 to 0.96; 23 studies, 18,846 offspring), and caesarean section (0.90, 0.83 to 0.98; 40 studies, 23,616 women) were reduced in the induction of labour group compared to expectant management or delayed induction. The odds of admission to neonatal intensive care unit (0.82, 0.70 to 0.96; 6 studies, 9,316 offspring) were lower with induction of labour at 41 weeks compared to induction at or after 42 weeks' gestation, and the odds of caesarean section were reduced with labour induction at 39 weeks' compared to induction at or after 40 weeks' (0.83, 0.74 to 0.93; 8 studies, 7,677 women). There were no significant differences in pregnancy outcomes by method of induction of labour. Induction of labour compared to expectant management or delayed induction reduces the risk of adverse pregnancy outcomes, and the optimal timing may depend on the specific outcome of interest.
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Affiliation(s)
- Bavita Jeer
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, Northern Ireland, United Kingdom
| | - Emily Haberfeld
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, Northern Ireland, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular and Clinical Sciences Research Institute, St George's University of London, London, Northern Ireland, United Kingdom
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, Northern Ireland, United Kingdom; Birmingham Women's and Children's NHS Foundation Trust, Birmingham, Northern Ireland, United Kingdom; NIHR Biomedical Research Centre, University of Birmingham, Birmingham, Northern Ireland, United Kingdom
| | - John Allotey
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, Northern Ireland, United Kingdom; NIHR Biomedical Research Centre, University of Birmingham, Birmingham, Northern Ireland, United Kingdom.
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Nethery E, Levy B, McLean K, Sitcov K, Souter VL. Effects of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial on Elective Induction and Obstetric Outcomes in Term Nulliparous Patients. Obstet Gynecol 2023; 142:242-250. [PMID: 37411030 DOI: 10.1097/aog.0000000000005217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/02/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To evaluate the effect of publication of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial on perinatal outcomes in singleton, term, nulliparous patients. METHODS An interrupted time series analysis was performed using clinical data for nulliparous singleton births at 39 weeks of gestation or later at 13 hospitals in the Northwest region of the United States (January 2016-December 2020). A modified Poisson regression was used to model time trends and changes after the ARRIVE trial (August 9, 2018). Outcomes of interest were elective induction, unplanned cesarean births, hypertensive disorders of pregnancy, a composite of perinatal adverse outcomes, and neonatal intensive care unit admissions. RESULTS The analysis included 28,256 births (15,208 pre-ARRIVE and 13,048 post-ARRIVE). The rate of elective labor induction was 3.6% during the pre-ARRIVE period (January 2016-July 2018) and 10.8% post-ARRIVE (August 2018-December 2020). In the interrupted time series analysis, elective induction increased by 42% (relative risk [RR] 1.42; 95% CI 1.18-1.71) immediately after the ARRIVE trial publication. Thereafter, the trend was unchanged compared with the pre-ARRIVE period. There was no statistically significant change in cesarean birth (RR 0.96; 95% CI 0.89-1.04) or hypertensive disorders of pregnancy (RR 0.91; 95% CI 0.79-1.06) immediately after the trial, and no change in trend. After the ARRIVE trial, there was no immediate change in adverse perinatal outcomes, but a statistically significant increase in trend of adverse perinatal events (1.03; 95% CI 1.01-1.05) when compared with a declining trend observed in the pre-ARRIVE period. CONCLUSION Publication of the ARRIVE trial was associated with an increase in elective induction, and no change in cesarean birth or hypertensive disorders of pregnancy in singleton nulliparous patients giving birth at 39 weeks or later. There was a flattening of the pre-ARRIVE decreasing trend in perinatal adverse events.
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Affiliation(s)
- Elizabeth Nethery
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; and the Foundation for Health Care Quality, Quilted Health, and the School of Public Health, University of Washington, Seattle, Washington
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Mann ES, Berkowitz D. The Biomedical Subjectification of Women of Advanced Maternal Age: Reproductive Risk, Privilege, and the Illusion of Control. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2023; 64:192-208. [PMID: 36440586 DOI: 10.1177/00221465221136252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The United States is experiencing a demographic transition toward older motherhood. Biomedicine classifies pregnancies among all women of advanced maternal age (AMA) as high-risk; paradoxically, women having first births at AMA are typically economically and racially privileged, which can reduce the risk of risks. This article examines the implications of the biomedicalization of AMA for first-time mothers, age 35 and older, using qualitative interviews. We find participants had substantial cultural health capital, which informed their critiques of AMA and the medical model of birth. When they found themselves subjected to biomedical protocols and concerned about reproductive risk as their pregnancies progressed, their subsequent biomedical subjectification compelled most to accept biomedical interventions. Consequently, some participants had traumatic birth experiences. Our findings illustrate that while first-time mothers of AMA anticipated that they would have more control over the birth process because of their advantages, ultimately, most did not.
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Zeevi G, Zlatkin R, Hochberg A, Danieli-Gruber S, Houri O, Hadar E, Walfisch A, Wertheimer A. Is There an Age Limit for a Trial of Vaginal Delivery in Nulliparous Women? J Clin Med 2023; 12:jcm12113620. [PMID: 37297815 DOI: 10.3390/jcm12113620] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The number of nulliparous women over the age of 35 is consistently increasing, and the optimal delivery strategy is a subject of ongoing discussion. This study compares perinatal outcomes in nulliparous women aged ≥35 years undergoing a trial of labor (TOL) versus a planned cesarean delivery (CD). METHODS A retrospective cohort study including all nulliparous women ≥ 35 years who delivered a single term fetus at a single center between 2007-2019. We compared obstetric and perinatal outcomes according to mode of delivery-TOL versus a planned CD, in three different age groups: (1) 35-37 years, (2) 38-40 years, and (3) >40 years. RESULTS Out of 103,920 deliveries during the study period, 3034 women met the inclusion criteria. Of them, 1626 (53.59%) were 35-37 years old (group 1), 848 (27.95%) were 38-40 (group 2), and 560 (18.46%) were >40 years (group 3). TOL rates decreased as age increased: 87.7% in group 1, 79.3% in group 2, and 50.1% in group 3, p < 0.001. Rates of successful vaginal delivery were 83.4% in group 1, 79.0% in group 2, and 69.4% in group 3, p < 0.001). Neonatal outcomes were comparable between a TOL and a planned CD. Using multivariate logistic regression, maternal age was found to be independently associated with slightly increased odds for a failed TOL (aOR = 1.13, CI 95% 1.067-1.202). CONCLUSIONS A TOL at advanced maternal age appears to be safe, with considerable success rates. As maternal age advances, there is a small additive risk of intrapartum CD.
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Affiliation(s)
- Gil Zeevi
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Rita Zlatkin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Alyssa Hochberg
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Shir Danieli-Gruber
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997505, Israel
| | - Ohad Houri
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Asnat Walfisch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Avital Wertheimer
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva 4941492, Israel
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Gantt A, Metz TD, Kuller JA, Louis JM, Cahill AG, Turrentine MA. Obstetric Care Consensus #11, Pregnancy at age 35 years or older. Am J Obstet Gynecol 2023; 228:B25-B40. [PMID: 35850202 DOI: 10.1016/j.ajog.2022.07.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.
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Evidence-Based Approaches to Labor Induction. Obstet Gynecol Surv 2023; 78:171-183. [PMID: 36893337 DOI: 10.1097/ogx.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Importance The induction rate continues to increase in the United States placing pressure on the health care system with increasing cost and time spent on labor and delivery. Most labor induction regimens have evaluated uncomplicated singleton-term gestations. Unfortunately, the optimal labor regimens of medically complicated pregnancies have not been well described. Objective The aim of this study was to review the current available evidence regarding the various labor induction regimens and understand the evidence that exists for induction regimens in complicated pregnancies. Evidence Acquisition Data were acquired by a literature search on PubMed, ClinicalTrials.gov, the Cochrane Review database, the most recent American College of Obstetricians and Gynecologists practice bulletin on labor induction, and a review of the most recent edition on widely used obstetric texts for key words related to labor induction. Results Many heterogeneous clinical trials exist examining various labor induction regimens such as prostaglandin only, oxytocin only, or a combination of mechanical dilation with prostaglandins or oxytocin. Several Cochrane systematic reviews have been performed, which suggest a combination of prostaglandins and mechanical dilation results in an improved time to delivery when compared with single-use methods. Evaluating pregnancies complicated by maternal or fetal conditions, there exist retrospective cohorts describing significantly different labor outcomes. Although a few of these populations have planned or active clinical trials, most do not have an optimal labor induction regimen described. Conclusions and Relevance Most induction trials are significantly heterogeneous and limited to uncomplicated pregnancies. A combination of prostaglandins and mechanical dilation may result in improved outcomes. Complicated pregnancies have significantly different labor outcomes; however, almost none have well-described labor induction regimens.
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Krogh LQ, Glavind J, Henriksen TB, Thornton J, Fuglsang J, Boie S. Full-term induction of labor vs expectant management and cesarean delivery in women with obesity; systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100909. [PMID: 36842468 DOI: 10.1016/j.ajogmf.2023.100909] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE This study aimed to review the literature comparing full-term induction of labor with expectant management in women with obesity on the risk of cesarean delivery and other adverse outcomes. DATA SOURCES A literature search was performed on PubMed, EMBASE, Scopus, ClinicalTrials.gov, and the Cochrane Library. This study had no time, language, or geographic restriction. STUDY ELIGIBILITY CRITERIA Studies were eligible if (1) they were cohort or randomized controlled trials, (2) they compared induction of labor at early or late term with expectant management, and (3) they included women with a body mass index of ≥30 kg/m2. Studies restricted to women with multiple pregnancy, premature rupture of membranes, or noncephalic presentation were excluded. The primary outcome was cesarean delivery. The secondary outcomes included maternal and neonatal mortality and morbidities and were evaluated. METHODS The risk of bias was assessed by 2 authors using the Risk of Bias In Non-Randomized Studies of Interventions tool. Only studies assessed with low or moderate risk of bias contributed to the meta-analysis. Data were combined to pooled relative risks and 95% confidence intervals using random effects models. The quality of evidence was assessed for selected outcomes. RESULTS Of the 232 studies identified, 13 were aligned with the inclusion criteria, and 4 cohort studies, including 216,318 women with induction of labor and 1,122,769 women managed expectantly, were included in the meta-analysis for the primary outcome. In women with obesity, full-term induction of labor was associated with a lower risk of cesarean delivery than expectant management (19.7% vs 24.5%; relative risk, 0.71; 95% confidence interval, 0.63-0.81). Moreover, this study found the same direction of the association for other selected outcomes: severe perineal lacerations (relative risk, 0.65; 95% confidence interval, 0.48-0.89), maternal infection (relative risk, 0.42; 95% confidence interval, 0.21-0.84), perinatal mortality (relative risk, 0.41; 95% confidence interval, 0.18-0.90), low Apgar score (relative risk, 0.48; 95% confidence interval, 0.26-0.91), meconium aspiration syndrome (relative risk, 0.40; 95% confidence interval, 0.28-0.56), and macrosomia (relative risk, 0.57; 95% confidence interval, 0.43-0.75). Conversely, induction of labor was associated with an increased risk of instrumental vaginal delivery (relative risk, 1.12; 95% confidence interval, 1.02-1.22). The quality of evidence ranged from low to very low. CONCLUSION Full-term induction of labor in women with obesity may reduce the risk of cesarean delivery compared with expectant management, but the quality of the evidence is low.
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Affiliation(s)
- Lise Qvirin Krogh
- Departments of Obstetrics and Gynecology (Drs Krogh, Glavind, Fuglsang, and Boie), Aarhus University Hospital, Aarhus, Denmark.
| | - Julie Glavind
- Departments of Obstetrics and Gynecology (Drs Krogh, Glavind, Fuglsang, and Boie), Aarhus University Hospital, Aarhus, Denmark; Departments of Clinical Medicine (Drs Glavind, Henriksen, and Fuglsang), Aarhus University Hospital, Aarhus, Denmark
| | - Tine Brink Henriksen
- Departments of Clinical Medicine (Drs Glavind, Henriksen, and Fuglsang), Aarhus University Hospital, Aarhus, Denmark; Departments of Pediatrics (Dr Henriksen), Aarhus University Hospital, Aarhus, Denmark
| | - Jim Thornton
- Department of Obstetrics and Gynecology, Nottingham University, Nottingham, United Kingdom (Dr Thornton)
| | - Jens Fuglsang
- Departments of Obstetrics and Gynecology (Drs Krogh, Glavind, Fuglsang, and Boie), Aarhus University Hospital, Aarhus, Denmark; Departments of Clinical Medicine (Drs Glavind, Henriksen, and Fuglsang), Aarhus University Hospital, Aarhus, Denmark; Steno Diabetes Centre, Aarhus University Hospital, Aarhus, Denmark (Dr Fuglsang)
| | - Sidsel Boie
- Departments of Obstetrics and Gynecology (Drs Krogh, Glavind, Fuglsang, and Boie), Aarhus University Hospital, Aarhus, Denmark; Department of Obstetrics and Gynecology, Aalborg University Hospital, Aarhus, Denmark (Dr Boie)
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Is gestational age at term a risk factor for ongoing pregnancies in nulliparous women: A prospective cohort study. Am J Obstet Gynecol MFM 2023; 5:100808. [PMID: 36371036 DOI: 10.1016/j.ajogmf.2022.100808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The results of American observational studies and 1 large, randomized trial show that elective induction of labor among nulliparous women can reduce cesarean delivery rates and suggest that gestational age at delivery may be a risk factor for cesarean delivery in pregnancies managed expectantly. However, data on the risk of cesarean delivery at term in ongoing pregnancies are sparse, especially in high-income countries, and further information is needed to explore the external validity of these previous studies. OBJECTIVE This study aimed to evaluate the risk of cesarean delivery for each gestational week of ongoing pregnancy in nulliparous women with a singleton fetus in the cephalic presentation at term in a French population. STUDY DESIGN This retrospective study was conducted in a perinatal network of 10 maternity units from January 1, 2016, to December 31, 2017, and included all nulliparous women with a singleton fetus in the cephalic presentation who gave birth at term (≥37 0/7 weeks of gestation). From the start of term (37 completed weeks) and at the start of each subsequent week of completed gestation (each week + 0 days), ongoing pregnancy was defined as that of a woman who was still pregnant and who gave birth at any time after that date. For each week of gestation for these ongoing pregnancies, the cesarean delivery rate was defined as the number of cesarean deliveries performed in each ongoing pregnancy group divided by the number of women in this group. Separate models for each week of gestation, adjusted by maternal characteristics and hospital status, were used to compare the cesarean delivery risk between ongoing pregnancies and those delivered the preceding week. The same methods were applied to subgroups defined according to the mode of labor onset. Odds ratios were calculated after adjusting for maternal age and educational level, presence of severe preeclampsia, and maternity unit status. RESULTS The study included 11,308 nulliparous women, 2544 (22.5%) of whom had a cesarean delivery. These rates remained stable for ongoing pregnancies at 37 0/7, 38 0/7, and 39 0/7 weeks of gestation; the rates were 22.5% (95% confidence interval, 21.7-23.2), 22.6% (95% confidence interval, 21.8-23.3); and 22.7% (95% confidence interval, 21.9-23.6), respectively. The risk of cesarean delivery started to increase in ongoing pregnancies at 40 0/7 weeks of gestation (24.3%; 95% confidence interval, 23.1-25.4) and especially at 41 0/7 weeks of gestation (30.7%; 95% confidence interval, 28.9-32.5). Similar trends were also shown for all modes of labor onset and in every maternity unit. In univariate and multivariate analyses, ongoing pregnancy at or beyond 40 0/7 weeks of gestation was associated with a higher risk of cesarean delivery than pregnancy delivered the previous week: 24.3% of ongoing pregnancies at 40 0/7 weeks of gestation vs 19.9% of deliveries between 39 0/7 weeks of gestation and 39 6/7 weeks of gestation. The odds ratios were 1.28 (95% confidence interval, 1.15-1.44) or 30.4% of ongoing pregnancies at 41 0/7 weeks of gestation vs 1.73 (95% confidence interval, 1.51-1.96) or 19.6% of deliveries between 40 0/7 weeks of gestation and 40 6/7 weeks of gestation. CONCLUSION Cesarean delivery rates increased starting at 40 0/7 weeks of gestation in ongoing pregnancies regardless of the mode of labor onset.
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The Role of Melatonin in Pregnancy and the Health Benefits for the Newborn. Biomedicines 2022; 10:biomedicines10123252. [PMID: 36552008 PMCID: PMC9775355 DOI: 10.3390/biomedicines10123252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/08/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
In the last few years, there have been significant evolutions in the understanding of the hormone melatonin in terms of its physiology, regulatory role, and potential utility in various domains of clinical medicine. Melatonin's properties include, among others, the regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As it is also bioavailable and has little or no toxicity, it has been proposed as safe and effective for the treatment of numerous diseases and to preserve human health. In this manuscript, we tried to evaluate the role of melatonin at the beginning of human life, in pregnancy, in the fetus and in newborns through newly published literature studies.
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von Dadelszen P, Tohill S, Wade J, Hutcheon JA, Scott J, Green M, Thornton JG, Magee LA. Labor induction information leaflets—Do women receive evidence-based information about the benefits and harms of labor induction? Front Glob Womens Health 2022; 3:936770. [DOI: 10.3389/fgwh.2022.936770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/16/2022] [Indexed: 11/22/2022] Open
Abstract
ObjectivesTo determine the extent to which a sample of NHS labor induction leaflets reflects evidence on labor induction.SettingAudit of labor induction patient information leaflets—local from WILL trial (When to Induce Labor to Limit risk in pregnancy hypertension) internal pilot sites or national-level available online.MethodsDescriptive analysis [n = 21 leaflets, 19 (one shared) in 20 WILL internal pilot sites and 2 NHS online] according to NHS “Protocol on the Production of Patient Information” criteria: general information (including indications), why and how induction is offered (including success and alternatives), and potential benefits and harms.ResultsAll leaflets described an induction indication. Most leaflets (n = 18) mentioned induction location and 16 the potential for delays due to delivery suite workloads and competing clinical priorities. While 19 leaflets discussed membrane sweeping (17 as an induction alternative), only 4 leaflets mentioned balloon catheter as another mechanical method. Induction success (onset of active labor) was presented by a minority of leaflets (n = 7, 33%), as “frequent” or in the “majority”, with “rare” or “occasional” failures. Benefits, harms and outcomes following induction were not compared with expectant care, but rather with spontaneous labor, such as for pain (n = 14, with nine stating more pain with induction). Potential benefits of induction were seldom described [n = 7; including avoiding stillbirth (n = 4)], but deemed to be likely. No leaflet stated vaginal birth was more likely following induction, but most stated Cesarean was not increased (n = 12); one leaflet stated that Cesarean risks were increased following induction. Women's satisfaction was rarely presented (n = 2).ConclusionInformation provided to pregnant women regarding labor induction could be improved to better reflect women's choice between induction and expectant care, and the evidence upon which treatment recommendations are based. A multiple stakeholder-involved and evidence-informed process to update guidance is required.
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Affiliation(s)
- Andrew D Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool L8 7SS, UK.
| | - Zarko Alfirevic
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool L8 7SS, UK
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Elective Induction of Labour at 39 Weeks Compared With Expectant Management in Nulliparous Persons Delivering in a Community Hospital. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1159-1166. [PMID: 36108896 DOI: 10.1016/j.jogc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies. METHODS The charts of all pregnant people who delivered at Brockville General Hospital between September 2018 and December 2021 were retrospectively reviewed. Perinatal and maternal outcomes of low-risk nulliparous pregnant people who underwent elective induction at 39 weeks and over were extracted and compared with those of low-risk nulliparous pregnant people who underwent expectant management. Exclusion criteria included multiparous people, high-risk pregnancies, multiple gestations, deliveries at less than 39 weeks gestation, and elective cesarean deliveries. Univariate and multivariate analysis was performed. RESULTS A total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 390 and 396 weeks gestation over the period of June 2020 to December 2021, whereas 118 (67.8%) were expectantly managed from 390 weeks gestation over the period of September 2018 to March 2020. Compared with expectant management, those in the 39+ weeks induction group had a significantly lower risk of cesarean delivery (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15-0.99), composite adverse maternal outcomes (OR 0.34; 95% CI 0.12-0.97), and composite adverse perinatal outcomes (OR 0.26; 95% CI 0.074-0.92). CONCLUSION Our results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant management.
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Bruinsma A, Keulen JKJ, Kortekaas JC, van Dillen J, Duijnhoven RG, Bossuyt PMM, van Kaam AH, van der Post JAM, Mol BW, de Miranda E. Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial. Eur J Obstet Gynecol Reprod Biol X 2022; 16:100165. [PMID: 36262791 PMCID: PMC9574420 DOI: 10.1016/j.eurox.2022.100165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/21/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy. Design Multicentre prospective cohort study alongside RCT. Setting 90 midwifery practices and 12 hospitals in the Netherlands. Population 3642 low-risk women with uncomplicated singleton late-term pregnancy. Main outcome measures Composite adverse outcome (perinatal death, Apgar score 5′ < 7, NICU admission, meconium aspiration syndrome), composite severe adverse perinatal outcome (all above with Apgar score 5′ < 4 instead of < 7) and caesarean section. Results From 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096). Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84). A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (11/1039) (adjRR 0.54; 95 % CI 0.07–24.19). One maternal death due to amniotic fluid embolism occurred after elective induction at 41 weeks + 6 days. Conclusion In this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable. No stillbirths in late-term pregnancy (IOL or EM) of 3642 women in INDEX-cohort. Less adverse perinatal outcomes in INDEX-cohort than in trial with comparable risk difference. More women approaching late-term pregnancy prefer EM, not elective induction.
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Affiliation(s)
- Aafke Bruinsma
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands,Rotterdam University of Applied Sciences, School of Midwifery, Rochussenstraat 198, Rotterdam, the Netherlands,Corresponding author at: Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Judit KJ Keulen
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands,Zuyd University, Research Center for Midwifery Science, Faculty Midwifery Education & Studies Maastricht, Universiteitssingel 60, Maastricht, the Netherlands
| | - Joep C Kortekaas
- Elkerliek Medical Center, Department of Obstetrics & Gynaecology, Wesselmanlaan 25, Helmond, the Netherlands
| | - Jeroen van Dillen
- Radboud University Medical Center, Department of Obstetrics & Gynaecology, Geert Grooteplein Zuid 10, Nijmegen, the Netherlands
| | - Ruben G Duijnhoven
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands
| | - Patrick MM Bossuyt
- Amsterdam UMC, University of Amsterdam, Department of Epidemiology & Data Science, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anton H van Kaam
- Amsterdam UMC, University of Amsterdam, Emma, Children’s hospital, Department of Neonatology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Joris AM van der Post
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands
| | - Ben W Mol
- Monash University, Department of Obstetrics and Gynaecology, 246 Clayton Road, Clayton, Victoria, Australia,University of Aberdeen, Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, AB24 3FX Aberdeen, UK
| | - Esteriek de Miranda
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands
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Zhang C, Yan L, Qiao J. Effect of advanced parental age on pregnancy outcome and offspring health. J Assist Reprod Genet 2022; 39:1969-1986. [PMID: 35925538 PMCID: PMC9474958 DOI: 10.1007/s10815-022-02533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/24/2021] [Indexed: 10/16/2022] Open
Abstract
PURPOSE Fertility at advanced age has become increasingly common, but the aging of parents may adversely affect the maturation of gametes and the development of embryos, and therefore the effects of aging are likely to be transmitted to the next generation. This article reviewed the studies in this field in recent years. METHODS We searched the relevant literature in recent years with the keywords of "advanced maternal/paternal age" combined with "adverse pregnancy outcome" or "birth defect" in the PubMed database and classified the effects of parental advanced age on pregnancy outcomes and birth defects. Related studies on the effect of advanced age on birth defects were classified as chromosomal abnormalities, neurological and psychiatric disorders, and other systemic diseases. The effect of assisted reproduction technology (ART) on fertility in advanced age was also discussed. RESULTS Differences in the definition of the range of advanced age and other confounding factors among studies were excluded, most studies believed that advanced parental age would affect pregnancy outcomes and birth defects in offspring. CONCLUSION To some extent, advanced parental age caused adverse pregnancy outcomes and birth defects. The occurrence of these results was related to the molecular genetic changes caused by aging, such as gene mutations, epigenetic variations, etc. Any etiology of adverse pregnancy outcomes and birth defects related to aging might be more than one. The detrimental effect of advanced age can be corrected to some extent by ART.
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Affiliation(s)
- Cong Zhang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49, North garden road, Haidian district, Beijing, 100191, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191, China
- Research Units of Comprehensive Diagnosis and Treatment of Oocyte Maturation Arrest (Chinese Academy of Medical Sciences), Beijing, 100191, China
- Savid Medical College (University of Chinese Academy of Sciences), Beijing, 100049, China
| | - Liying Yan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49, North garden road, Haidian district, Beijing, 100191, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191, China
- Research Units of Comprehensive Diagnosis and Treatment of Oocyte Maturation Arrest (Chinese Academy of Medical Sciences), Beijing, 100191, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49, North garden road, Haidian district, Beijing, 100191, People's Republic of China.
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital), Beijing, 100191, China.
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191, China.
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191, China.
- Research Units of Comprehensive Diagnosis and Treatment of Oocyte Maturation Arrest (Chinese Academy of Medical Sciences), Beijing, 100191, China.
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Wu LC, Peng FS, Leung C, Lu HF, Lin HH, Hsiao SM. Comparison of cesarean section rates between obstetricians preferring labor induction at early versus late gestational age. Taiwan J Obstet Gynecol 2022; 61:847-853. [PMID: 36088054 DOI: 10.1016/j.tjog.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare the cesarean section (CS) rates of obstetricians with a preference of labor induction at early versus late gestational age. MATERIAL AND METHODS Medical records of women who were low risk, nulliparous, singleton pregnancy, and >37 weeks and delivered their babies, were reviewed. Obstetricians, who preferred labor induction at<41 weeks, were allocated to the early induction group; and the other obstetricians were allocated to the late induction group. RESULTS The late induction group had a higher percentage of labor induction at ≥41 weeks, compared with the early induction group (21% vs. 8%, p = 0.007). The late induction group had a lower CS rate (11.0% vs. 19.1%, p < 0.001). Multivariable Cox proportional hazard model revealed that the early induction group (hazard ratio [HR] = 2.14, p < 0.001), maternal age (HR = 1.04, p = 0.001), premature rupture of membranes (HR = 1.59, p = 0.006), and birth body weight (kg, HR = 2.13, p < 0.001) were independent predictors of CS. In women receiving labor induction (n = 312), birth body weight (kg, HR = 1.72, p = 0.04) was the sole predictor of CS; and there is a trend that the early induction group (HR = 1.54, p = 0.051) has a higher CS rate, compared with the late induction group. However, gestational age at labor induction was not a predictor of CS. CONCLUSION In low-risk pregnancies, obstetricians preferring labor induction at early gestational age seem to be associated with a higher CS rate, compared with obstetricians preferring labor induction at late gestational age. Nonetheless, the above finding seems to be associated with physician's factor, instead of gestational age at labor induction.
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Affiliation(s)
- Liu-Ching Wu
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Fu-Shaing Peng
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Cheung Leung
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Hsin-Fen Lu
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Ho-Hsiung Lin
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, New Taipei, Taiwan; Department of Obstetrics and Gynecology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Mou Hsiao
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, New Taipei, Taiwan; Department of Obstetrics and Gynecology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan; Graduate School of Biotechnology and Bioengineering, Yuan Ze University, Taoyuan, Taiwan.
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Abstract
SUMMARY Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those in a younger pregnant population, even in healthy individuals with no other comorbidities. There are several studies that suggest advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetric care with anticipated delivery at age 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.
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Senanayake H, Mariani I, Valente EP, Piccoli M, Armocida B, Businelli C, Rishard M, Covi B, Lazzerini M. Outcomes of induction versus spontaneous onset of labour at 40 and 41 GW: findings from a prospective database, Sri Lanka. BMC Pregnancy Childbirth 2022; 22:518. [PMID: 35761191 PMCID: PMC9235207 DOI: 10.1186/s12884-022-04800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/01/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives The World Health Organization recommends induction of labour (IOL) for low risk pregnancy from 41 + 0 gestational weeks (GW). Nevertheless, in Sri Lanka IOL at 40 GW is a common practice. This study compares maternal/newborn outcomes after IOL at 40 GW (IOL40) or 41 GW (IOL41) versus spontaneous onset of labour (SOL). Methods Data were extracted from the routine prospective individual patient database of the Soysa Teaching Hospital for Women, Colombo. IOL and SOL groups were compared using logistic regression. Results Of 13,670 deliveries, 2359 (17.4%) were singleton and low risk at 40 or 41 GW. Of these, 456 (19.3%) women underwent IOL40, 318 (13.5%) IOL41, and 1585 (67.2%) SOL. Both IOL40 and IOL41 were associated with an increased risk of any maternal/newborn negative outcomes (OR = 2.21, 95%CI = 1.75–2.77, p < 0.001 and OR = 1.91, 95%CI = 1.47–2.48, p < 0.001 respectively), maternal complications (OR = 2.18, 95%CI = 1.71–2.77, p < 0.001 and OR = 2.34, 95%CI = 1.78–3.07, p < 0.001 respectively) and caesarean section (OR = 2.75, 95%CI = 2.07–3.65, p < 0.001 and OR = 3.01, 95%CI = 2.21–4.12, p < 0.001 respectively). Results did not change in secondary and sensitivity analyses. Conclusions Both IOL groups were associated with higher risk of negative outcomes compared to SOL. Findings, potentially explained by selection bias, local IOL protocols and CS practices, are valuable for Sri Lanka, particularly given contradictory findings from other settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04800-1.
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Kim TW, Park SS, Park HS. Physical exercise ameliorates memory impairment in offspring of old mice. J Exerc Rehabil 2022; 18:155-161. [PMID: 35846229 PMCID: PMC9271648 DOI: 10.12965/jer.2244262.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/28/2022] [Indexed: 11/29/2022] Open
Abstract
For humans, maternal old age means the age of 35 or older at the time of childbirth. Maternal metabolism not only affects the cognitive function of the offspring, but also affects their physical and neurological development. This study aims to elucidate the effects of exercise training on spatial learning memory, neurogenesis, and apoptosis in the off-spring of old mice. Using mice, the offspring of old mothers showed impaired spatial learning memory, decreased brain-derived neurotrophic factor and postsynaptic density protein 95 levels, suppressed neurogenesis, and increased hippocampal apoptotic cell death. In contrast, the offspring of the old mothers had improved spatial learning memory, increased brain-derived neurotrophic factor and postsynaptic density protein 95 levels, increased neurogenesis, and decreased hippocampal apoptotic cell death when they received exercise training. The present results indicate that there is apparent spatial learning memory impairment among the offspring of old mothers, but by contrast, exercise can ameliorate spatial learning memory impairment. Exercise can be an effective countermeasure against memory decline in the offspring of old mothers.
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Affiliation(s)
- Tae-Woon Kim
- Department of Human Health Care, Gyeongsang National University, Jinju, Korea
| | - Sang-Seo Park
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hye-Sang Park
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea
- Corresponding author: Hye-Sang Park, Department of Physiology, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea,
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Claramonte Nieto M, Mula Used R, Castellet Roig C, Rodríguez I, Rodríguez Melcon A, Serra Zantop B, Prats Rodríguez P. Maternal and perinatal outcomes in women ≥40 years undergoing induction of labor compared with women <35 years: Results from 4027 mothers. J Obstet Gynaecol Res 2022; 48:2377-2384. [PMID: 35751564 DOI: 10.1111/jog.15339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/31/2022] [Accepted: 06/10/2022] [Indexed: 11/26/2022]
Abstract
AIM Cesarean section is known to be increased with advanced maternal age in women undergoing induction of labor (IOL), but there is less information regarding other possible adverse maternal and fetal outcomes. METHODS Retrospective cohort study of singleton, nulliparous, at-term women undergoing IOL between January 2007 and September 2020. Outcomes studied were: cesarean section, failed induction rate, fetal distress, post-partum hemorrhage, post-partum hysterectomy, and need of transfusion. Neonatal variables analyzed were: Apgar score, umbilical cord pH, need of admission to neonatal intensive care unit, and mortality. RESULTS A total of 4027 women met the inclusion criteria; 1968 (48.9%) of mothers were <35 years, 1283 (31.9%) were 35-39 years, 658 (16.3%) were 40-44 years, and 118 (2.9%) were ≥45 years. Results showed a significantly increased incidence of c-section in women ≥35 years, with an OR 1.79 (95% CI 1.50-2.14) for women 40-44 years and OR 3.95 (95% CI 2.66-5.98) for women ≥45 years. The main indication for cesarean delivery was failed IOL, and this risk was also significantly increased in women ≥40 years. These differences remained significant after adjustment for confounding factors. No other adverse maternal or fetal outcomes showed an association with age. CONCLUSION Maternal age ≥40 years was associated with an increased risk of c-section after IOL at term compared with younger women, mainly because of failed induction, but no association with other adverse maternal or neonatal outcomes were found in our population. Risks and benefits of IOL in older women should be individually evaluated and adequately discussed with mothers.
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Affiliation(s)
- Marta Claramonte Nieto
- Department of Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain.,Fetal Medicine Unit, Department Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - Raquel Mula Used
- Department of Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain.,Fetal Medicine Unit, Department Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - Cristina Castellet Roig
- Department of Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - Ignacio Rodríguez
- Department of Epidemiology and Statistics, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - Alberto Rodríguez Melcon
- Department of Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - Bernat Serra Zantop
- Department of Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - Pilar Prats Rodríguez
- Fetal Medicine Unit, Department Obstetrics, Gynecology, Reproductive Medicine, Hospital Universitari Quiron Dexeus, Barcelona, Spain
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Sharami SH, Kabodmehri R, Hosseinzadeh F, Montazeri S, Ghalandari M, Dalil Heirati SF, Ershadi S. Effects of maternal age on the mode of delivery following induction of labor in nulliparous term pregnancies: A retrospective cohort study. Health Sci Rep 2022; 5:e651. [DOI: 10.1002/hsr2.651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Seyedeh Hajar Sharami
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al‐Zahra Hospital Guilan University of Medical Sciences Rasht Iran
| | - Roya Kabodmehri
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al‐Zahra Hospital Guilan University of Medical Sciences Rasht Iran
| | - Fatemeh Hosseinzadeh
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al‐Zahra Hospital Guilan University of Medical Sciences Rasht Iran
| | - Sina Montazeri
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al‐Zahra Hospital Guilan University of Medical Sciences Rasht Iran
| | - Maryam Ghalandari
- Department of Epidemiology and Biostatistics, School of Public Health Shahid Sadoughi University of Medical Sciences Yazd Iran
| | - Seyedeh Fatemeh Dalil Heirati
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al‐Zahra Hospital Guilan University of Medical Sciences Rasht Iran
| | - Sarvenaz Ershadi
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al‐Zahra Hospital Guilan University of Medical Sciences Rasht Iran
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Sima YT, Skjærven R, Kvalvik LG, Morken NH, Klungsøyr K, Sørbye LM. Cesarean delivery in Norwegian nulliparous women with singleton cephalic term births, 1967-2020: a population-based study. BMC Pregnancy Childbirth 2022; 22:419. [PMID: 35585522 PMCID: PMC9118652 DOI: 10.1186/s12884-022-04755-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Nulliparous women contribute to increasing cesarean delivery in the Nordic countries and advanced maternal age has been suggested as responsible for rise in cesarean delivery rates in many developed countries. The aim was to describe changes in cesarean delivery rates among nulliparous women with singleton, cephalic, term births by change in sociodemographic factors across 50 years in Norway. Methods We used data from the Medical Birth Registry of Norway and included 1 067 356 women delivering their first, singleton, cephalic, term birth between 1967 and 2020. Cesarean delivery was described by maternal age (5-year groups), onset of labor (spontaneous, induced and pre-labor CD), and time periods: 1967–1982, 1983–1998 and 1999–2020. We combined women’s age, onset of labor and time period into a compound variable, using women of 20–24 years, with spontaneous labor onset during 1967–1982 as reference. Multivariable regression models were used to estimate adjusted relative risk (ARR) of cesarean delivery with 95% confidence interval (CI). Results Overall cesarean delivery increased both in women with and without spontaneous onset of labor, with a slight decline in recent years. The increase was mainly found among women < 35 years while it was stable or decreased in women > = 35 years. In women with spontaneous onset of labor, the ARR of CD in women > = 40 years decreased from 14.2 (95% CI 12.4–16.3) in 1967–82 to 6.7 (95% CI 6.2–7.4) in 1999–2020 and from 7.0 (95% CI 6.4–7.8) to 5.0 (95% CI 4.7–5.2) in women aged 35–39 years, compared to the reference population. Despite the rise in induced onset of labor over time, the ARR of CD declined in induced women > = 40 years from 17.6 (95% CI 14.4–21.4) to 13.4 (95% CI 12.5–14.3) while it was stable in women 35–39 years. Conclusion Despite growing number of Norwegian women having their first birth at a higher age, the increase in cesarean delivery was found among women < 35 years, while it was stable or decreased in older women. The increase in cesarean delivery cannot be solely explained by the shift to an older population of first-time mothers. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04755-3.
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Affiliation(s)
- Yeneabeba Tilahun Sima
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Rolv Skjærven
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Liv Grimstvedt Kvalvik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Linn Marie Sørbye
- Norwegian Research Centre for Women's Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Krogh LQ, Boie S, Henriksen TB, Thornton J, Fuglsang J, Glavind J. Induction of labour at 39 weeks versus expectant management in low-risk obese women: study protocol for a randomised controlled study. BMJ Open 2022; 12:e057688. [PMID: 35470194 PMCID: PMC9039382 DOI: 10.1136/bmjopen-2021-057688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Obesity is associated with many pregnancy complications, including both fetal macrosomia and prolonged labour. As a result, there is often also an increased risk of caesarean section. In other settings, labour induction near to term reduces adverse outcomes such as stillbirth and birth injury, without causing more caesarean deliveries. It has been suggested that induction will reduce adverse events in this setting too, but there have been no trials and the effect on caesarean section is unknown. The objective of this study is to compare induction of labour in gestational week 39 with expectant management on the risk of caesarean section in women with body mass index ≥30 kg/m2. METHODS AND ANALYSIS An open label randomised controlled multicentre trial are conducted at Danish delivery departments with an in-house neonatal intensive care unit. Recruitment started October 2020. A total of 1900 women with a prepregnancy body mass index ≥30 kg/m2 are randomised in a 1:1 ratio to either labour induction at 39 weeks and 0 to 3 days of gestation or to expectant management; that is, waiting for spontaneous labour onset or induction if medically indicated. The primary outcome is caesarean section. Data will be analysed according to intention-to-treat. ETHICS AND DISSEMINATION The Central Denmark Region Committee on Biomedical Research Ethics approved the study. The study is conducted in accordance with the ethical principles outlined in the latest version of the 'Declaration of Helsinki' and the 'Guideline for Good Clinical Practice' related to experiments on humans. The trial findings will be disseminated to participants, clinicians, commissioning groups and via peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT04603859.
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Affiliation(s)
- Lise Qvirin Krogh
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sidsel Boie
- Department of Obstetrics and Gynaecology, Randers Regional Hospital, Randers, Denmark
| | - Tine Brink Henriksen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pediatrics, Aarhus University Hospital, Aarhus N, Denmark
| | - Jim Thornton
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jens Fuglsang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Julie Glavind
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Meyer R, Levin G. Maternal and perinatal outcome of induction at 39 weeks versus expectant management in labor after cesarean section. Int J Gynaecol Obstet 2022; 159:480-486. [PMID: 35212398 DOI: 10.1002/ijgo.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/04/2022] [Accepted: 02/21/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To study induction of labor (IOL) at 39 weeks compared with expectant management among women undergoing labor after cesarean section (LAC) with no prior vaginal delivery. METHODS A retrospective cohort study including all women undergoing LAC with no prior vaginal delivery, between March 2011 and January 2021. We allocated the study cohort into two groups: IOL at 390/7 to 396/7 and all LACs at ≥400/7 weeks of gestation. The primary outcome was a composite of adverse neonatal outcome. The secondary outcome was a composite of adverse maternal outcome. RESULTS Overall, 1022 women met inclusion criteria, of whom 89 (8.7%) had IOL at 390/7 -396/7 weeks and 933 (91.3%) had LAC at ≥400/7 weeks. The composite neonatal outcome rate was comparable between groups (0.186). There were three uterine ruptures (3.4%) in the IOL group and 11 (1.2%) in the LAC at ≥40 weeks group (P = 0.115). The rate of the composite maternal outcomes occurrence was higher in the IOL group (18.0% vs. 10.1%, P = 0.022). CONCLUSION IOL at 39 weeks among women undergoing LAC with no prior vaginal delivery is not associated with improved neonatal outcomes when compared with expectant management but may be associated with a higher rate of adverse maternal outcomes.
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Affiliation(s)
- Raanan Meyer
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Ramat-Gan, Israel
| | - Gabriel Levin
- The Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Carlson NS, Dunn Amore A, Ellis JA, Page K, Schafer R. American College of Nurse-Midwives Clinical Bulletin Number 18: Induction of Labor. J Midwifery Womens Health 2022; 67:140-149. [PMID: 35119782 DOI: 10.1111/jmwh.13337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022]
Abstract
Induction of labor is an increasingly common component of intrapartum care in the United States. This rise is fueled by a nationwide escalation in both medically indicated and elective inductions at or beyond term, supported by recent research showing some benefits of induction over expectant management. However, induction of labor medicalizes the birth experience and may lead to a complex cascade of interventions. The purpose of this Clinical Bulletin is twofold: (1) to guide clinicians on the use of person-centered decision-making when discussing induction of labor and (2) to review evidence-based practice recommendations for intrapartum midwifery care during labor induction.
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Affiliation(s)
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- American College of Nurse-Midwives, Silver Spring, Maryland
| | | | | | | | - Katie Page
- President, RMWC Alumnae and Randolph College Alumni Association; President, VA Affiliate of ACNM
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Pregnancy After 40: Recommendations for Counseling, Evaluation, and Management From Preconception to Delivery. Obstet Gynecol Surv 2022; 77:111-121. [DOI: 10.1097/ogx.0000000000000967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Yosef T, Getachew D. Proportion and Outcome of Induction of Labor Among Mothers Who Delivered in Teaching Hospital, Southwest Ethiopia. Front Public Health 2022; 9:686682. [PMID: 35004556 PMCID: PMC8732857 DOI: 10.3389/fpubh.2021.686682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Despite the induction of labor (IOL) having had some undesired consequences, it also has several benefits for maternal and perinatal outcomes. This study aimed to assess the proportion and outcome of IOL among mothers who delivered in Teaching Hospital, southwest Ethiopia. Methods: A retrospective cross-sectional study was conducted from June 10 to June 20, 2019, among 294 mothers who gave birth between November 30, 2018, and May 30, 2019, by reviewing their cards using a structured checklist to assess the prevalence, outcome, and consequences of induction of labor. A binary logistic regression analysis was computed to look for the association between outcome variables and independent variables. Results: The prevalence of labor induction was 20.4%. The most commonly reported cause of induction was preeclampsia (41.6%). The factors associated with IOL were mothers aged 25–34 years [AOR = 2.55, 95% CI (1.18–5.50)] and ≥35 years [AOR = 10.6, 95% CI (4.20–26.9)], having no history of antenatal care [AOR = 2.12, 95% CI (1.10–4.07)], and being Primipara AOR = 2.33, 95% CI (1.18–3.24)]. Of the 60 induced mothers, 23.3% had failed induction. The proportion of mothers with dead fetal outcomes and maternal complications was 5 and 41.7%, respectively. The unfavorable Bishop Score before induction [AOR = 1.85, 95% CI (1.32–4.87)] and induction using misoprostol [AOR = 1.48, 95% CI (1.24–5.23)] were the factors associated with failed induction of labor. Conclusion: The prevalence of induced labor was considerably higher than rates in other Ethiopian studies; however, the prevalence of induction failure was comparable to other studies done in Ethiopia. The study found that Bishop's unfavorable score before induction and induction using misoprostol was the factor associated with unsuccessful induction. Therefore, the health professionals should confirm the favorability of the cervical status before the IOL to increase the success rate of induction of labor.
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Affiliation(s)
- Tewodros Yosef
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan Teferi, Ethiopia
| | - Dawit Getachew
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan Teferi, Ethiopia
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Dong S, Bapoo S, Shukla M, Abbasi N, Horn D, D’Souza R. Induction of labour in low-risk pregnancies before 40 weeks of gestation: a systematic review and meta-analysis of randomized trials. Best Pract Res Clin Obstet Gynaecol 2022; 79:107-125. [DOI: 10.1016/j.bpobgyn.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/12/2022]
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Burn SC, Yao R, Diaz M, Rossi J, Contag S. Impact of labor induction at 39 weeks gestation compared with expectant management on maternal and perinatal morbidity among a cohort of low-risk women. J Matern Fetal Neonatal Med 2021; 35:9208-9214. [PMID: 34965815 DOI: 10.1080/14767058.2021.2021396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine maternal and perinatal outcomes after induction of labor (IOL) at 39 weeks compared with expectant management. METHODS This is a retrospective national cohort study from the National Center for Health Statistics birth database. The study included singleton, low-risk pregnancies with a non-anomalous fetus delivered at 39-42 weeks gestation between 2015 and 2018. Maternal outcomes available included chorioamnionitis (Triple I), blood transfusion, intensive care unit (ICU) admission, uterine rupture, cesarean delivery (CD), and cesarean hysterectomy. Fetal and infant outcomes included stillbirth, 5-min Apgar ≤3, prolonged ventilation, seizures, ICU admission, and death within 28 days. We compared women undergoing IOL at 39 weeks to those managed expectantly. Non-adjusted and adjusted relative risks (aRRs) were estimated using multivariate log-binomial regression analysis. RESULTS There were 15,900,956 births available for review of which 5,017,524 met inclusion and exclusion criteria. For the maternal outcomes, the IOL group was less likely to require a CD (aRR 0.880; 95% CI [0.874-0.886]; p value < .01) or develop Triple I (aRR 0.714; 95% CI [0.698-0.730]; p value < .01) but demonstrated a small increase in the cesarean hysterectomy rate (aRR 1.231; 95% CI [1.029-1.472]; p value < .01). Among perinatal outcomes, the stillbirth rate (aRR 0.195; 95% CI [0.153-0.249]; p value < .01), 5-min Apgar ≤3 (aRR 0.684; 95% CI [0.647-0.723]; p value < .01), prolonged ventilation (aRR 0.840; 95% CI [0.800-0.883]; p value < .01), neonatal intensive care (NICU) admission (aRR 0.862; 95% CI [0.849-0.875]; p value < .01) were lower after 39 week IOL compared with expectant management. There were no differences in risk for neonatal seizures (aRR 0.848; 95% CI [0.718-1.003]; p value 0.011) or death (aRR 1.070; 95% CI [0.722-1.586]; p value 0.660). CONCLUSIONS IOL at 39 weeks of gestation in a low-risk cohort is associated with a lower risk of CD and maternal infection, stillbirth, and lower neonatal morbidity. There was no effect on the risk for neonatal seizures or death.
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Affiliation(s)
- Sabrina C Burn
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, USA
| | - Ruofan Yao
- Department of Obstetrics & Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Maria Diaz
- Department of Obstetrics & Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jordan Rossi
- Department of Obstetrics & Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Stephen Contag
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, USA
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Optimal timing of labour induction in contemporary clinical practice. Best Pract Res Clin Obstet Gynaecol 2021; 79:18-26. [PMID: 35000808 DOI: 10.1016/j.bpobgyn.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/22/2022]
Abstract
Induction of labour (IoL) is generally conducted when maternal and foetal risks of remaining pregnant outweigh the risks of delivery. With emerging literature around non-medically indicated IoL, contemporary clinical practice has seen an increase in IoL at 39 weeks' gestation. This review highlights recent evidence on the most common indications for IoL including gestational diabetes, hypertensive disorders of pregnancy, intrahepatic cholestasis of pregnancy, and post-term pregnancies. It also summarizes the evidence related to the timing of IoL for other common conditions based on recent literature reviews.
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Sharp A, Patient C, Pickett J, Belham M. Pregnancy-related inappropriate sinus tachycardia: A cohort analysis of maternal and fetal outcomes. Obstet Med 2021; 14:230-234. [PMID: 34880936 DOI: 10.1177/1753495x21990196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/30/2020] [Indexed: 11/15/2022] Open
Abstract
Background Little literature exists regarding the syndrome of inappropriate sinus tachycardia during pregnancy. We aimed to further understand the natural history of inappropriate sinus tachycardia in pregnancy, and to explore maternal and fetal outcomes. Methods A retrospective, observational cohort analysis of 19 pregnant women who presented with inappropriate sinus tachycardia. Results 42% attended the emergency department on more than one occasion with symptoms of inappropriate sinus tachycardia; 32% required hospital admission and 26% required pharmacological therapy. There were no maternal deaths, instances of heart failure or acute coronary syndrome, and no thromboembolic or haemorrhagic complications during pregnancy. Rates of caesarean section were similar to the background rate of our unit (32% and 27%, respectively). Rates of induction were notably elevated (58% vs 25%). Conclusion Inappropriate sinus tachycardia in pregnancy is associated with high rates of hospitalization and induction of labour, which may not be mandatory given the clinical findings in this group of women.
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Affiliation(s)
- Alexander Sharp
- Department of Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charlotte Patient
- Department of Obstetrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Janet Pickett
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark Belham
- Department of Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Lau SL, Kwan A, Tse WT, Poon LC. The use of ultrasound, fibronectin and other parameters to predict the success of labour induction. Best Pract Res Clin Obstet Gynaecol 2021; 79:27-41. [PMID: 34879989 DOI: 10.1016/j.bpobgyn.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/31/2021] [Indexed: 01/03/2023]
Abstract
Induction of labour is a common obstetrical procedure and is undertaken when the benefits of delivery are considered to outweigh the risks of continuation of pregnancy. However, more than one-fifth of induction cases fail to result in vaginal births and lead to unplanned caesarean deliveries, which compromise the birth experience and have negative clinical and resource implications. The need for accurate prediction of successful labour induction is increasingly recognised and many researchers have attempted to evaluate the potential predictability of different factors including maternal characteristics, Bishop score, various biochemical markers and ultrasound markers and derive predictive models to address this issue.
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Affiliation(s)
- So Ling Lau
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Angel Kwan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Wing Ting Tse
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong.
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Lean SC, Jones RL, Roberts SA, Heazell AEP. A prospective cohort study providing insights for markers of adverse pregnancy outcome in older mothers. BMC Pregnancy Childbirth 2021; 21:706. [PMID: 34670515 PMCID: PMC8527686 DOI: 10.1186/s12884-021-04178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 09/28/2021] [Indexed: 11/26/2022] Open
Abstract
Background Advanced maternal age (≥35 years) is associated with increased rates of adverse pregnancy outcome. Better understanding of underlying pathophysiological processes may improve identification of older mothers who are at greatest risk. This study aimed to investigate changes in oxidative stress and inflammation in older women and identify clinical and biochemical predictors of adverse pregnancy outcome in older women. Methods The Manchester Advanced Maternal Age Study (MAMAS) was a multicentre, observational, prospective cohort study of 528 mothers. Participants were divided into three age groups for comparison 20–30 years (n = 154), 35–39 years (n = 222) and ≥ 40 years (n = 152). Demographic and medical data were collected along with maternal blood samples at 28 and 36 weeks’ gestation. Multivariable analysis was conducted to identify variables associated with adverse outcome, defined as one or more of: small for gestational age (< 10th centile), FGR (<5th centile), stillbirth, NICU admission, preterm birth < 37 weeks’ gestation or Apgar score < 7 at 5 min. Biomarkers of inflammation, oxidative stress and placental dysfunction were quantified in maternal serum. Univariate and multivariable logistic regression was used to identify associations with adverse fetal outcome. Results Maternal smoking was associated with adverse outcome irrespective of maternal age (Adjusted Odds Ratio (AOR) 4.22, 95% Confidence Interval (95%CI) 1.83, 9.75), whereas multiparity reduced the odds (AOR 0.54, 95% CI 0.33, 0.89). In uncomplicated pregnancies in older women, lower circulating anti-inflammatory IL-10, IL-RA and increased antioxidant capacity (TAC) were seen. In older mothers with adverse outcome, TAC and oxidative stress markers were increased and levels of maternal circulating placental hormones (hPL, PlGF and sFlt-1) were reduced (p < 0.05). However, these biomarkers only had modest predictive accuracy, with the largest area under the receiver operator characteristic (AUROC) of 0.74 for placental growth factor followed by TAC (AUROC = 0.69). Conclusions This study identified alterations in circulating inflammatory and oxidative stress markers in older women with adverse outcome providing preliminary evidence of mechanistic links. Further, larger studies are required to determine if these markers can be developed into a predictive model of an individual older woman’s risk of adverse pregnancy outcome, enabling a reduction in stillbirth rates whilst minimising unnecessary intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04178-6.
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Affiliation(s)
- Samantha C Lean
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, St. Mary's Hospital, 5th Floor (Research), Oxford Road, Manchester, M13 9WL, UK
| | - Rebecca L Jones
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, St. Mary's Hospital, 5th Floor (Research), Oxford Road, Manchester, M13 9WL, UK
| | - Stephen A Roberts
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, St. Mary's Hospital, 5th Floor (Research), Oxford Road, Manchester, M13 9WL, UK.
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Abstract
PURPOSE OF REVIEW Stillbirth has a high global prevalence and has not improved despite other advances in maternal and perinatal outcomes in the last 20 years. The global applicability of research is challenged by the fact that most evidence originates from high-income countries, whereas the burden is greatest in low- and middle-income countries. Robust universally applicable evidence is therefore desired to address this problem. RECENT FINDINGS Good quality evidence has identified key risk factors for stillbirth. However, an effective universally applicable model is yet to be developed. Published prediction models lack internal or external validation, suffer from the risk of bias or cannot be applied to different populations. Term induction of labour suggests good clinical outcomes with no increase in obstetric interventions but must be considered within the context of the healthcare system's feasibility, cost-effectiveness and the experiences of women. SUMMARY The most realistic focus to reduce stillbirth is placental insufficiency. Globally, the greatest benefit will come from treating those with the highest risk of disease, such as those in low and middle-income countries. Further high-quality trials need to be conducted in these settings as a priority.
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Wilkinson C. Outpatient labour induction. Best Pract Res Clin Obstet Gynaecol 2021; 77:15-26. [PMID: 34556409 DOI: 10.1016/j.bpobgyn.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/26/2022]
Abstract
The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.
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Affiliation(s)
- Chris Wilkinson
- Women's and Children's Hospital, North Adelaide, 5006, South Australia, Australia; Robinson Institute, University of Adelaide, Adelaide, 5000, South Australia, Australia.
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Evidence around early induction of labor in women of advanced maternal age and those using assisted reproductive technology. Best Pract Res Clin Obstet Gynaecol 2021; 77:42-52. [PMID: 34538560 DOI: 10.1016/j.bpobgyn.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/20/2021] [Accepted: 08/10/2021] [Indexed: 11/21/2022]
Abstract
Worldwide, there has been a trend toward later motherhood. Concurrently, the incidence of subfertility has been on the rise, necessitating conception using assisted reproductive technologies (ARTs). These pregnancies are considered high risk due to fetal complications such as antepartum stillbirth and growth restriction and maternal complications such as increase in maternal morbidity and mortality. Early induction of labor can help to mitigate these risks. However, this has to be balanced against the iatrogenic harms of earlier delivery to both the baby, including respiratory distress and NICU stay, and the mother who might experience longer labor and other complications such as uterine hyperstimulation. Induction of labor at 39 weeks is the optimal timing for preventing antepartum stillbirth and avoiding iatrogenic harm. Delivery by elective cesarean section is not advocated as its benefits in these patients are unclear compared with the short- and long-term complications of a major abdominal surgery.
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Drife JO. The history of labour induction: How did we get here? Best Pract Res Clin Obstet Gynaecol 2021; 77:3-14. [PMID: 34330639 DOI: 10.1016/j.bpobgyn.2021.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/02/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
The mean duration of human pregnancy is 280 days but the range is wide, and "term" has been defined to range from 37 to 42 weeks. In the 18th and 19th centuries, labour induction was used mainly in cases of pelvic deformity, before the foetus grew too large to be delivered. Induction methods were unreliable until the 20th century, when pituitary extract, and then synthetic oxytocin and prostaglandins, became available. "Disproportion" was the leading indication for induction until the 1950s, when it became clear that prolonged pregnancy was associated with increased perinatal mortality. Pregnancy dating was improved by ultrasound, which also showed that foetal growth slows at term. Induction rates rose during the 1970s, causing public concern about obstetric intervention. In the 21st century, large-scale randomised trials showed that perinatal mortality is lowest at 39-40 weeks, and that induction at that time does not increase the rate of operative delivery.
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Affiliation(s)
- James Owen Drife
- Emeritus Professor of Obstetrics and Gynaecology, University of Leeds, Leeds, UK.
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Mendez-Figueroa H, Chen HY, Chauhan SP. Adverse Outcomes among Low-Risk Pregnancies at 39 to 41 Weeks: Stratified by Birth Weight Percentile. Am J Perinatol 2021; 38:e269-e283. [PMID: 32340043 DOI: 10.1055/s-0040-1709673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aimed to assess the risk of adverse outcomes among low-risk pregnancies at 39 to 41 weeks, stratified by birth weight percentile. STUDY DESIGN This retrospective cohort study utilized the U.S. vital statistics datasets (2013-2017) and evaluated low-risk women with nonanomalous cephalic singleton gestations who labored and delivered at 39 to 41 weeks, regardless of ultimate mode of delivery. Newborns were categorized as small (<10th percentile), large (>90th percentile), or appropriate (10-90th percentile) for gestational ages (SGA, LGA, and AGA, respectively). The primary outcome, composite neonatal adverse outcome (CNAO), included Apgar's score <5 at 5 minutes, assisted ventilation >6 hours, seizure, or neonatal death. The secondary outcome, composite maternal adverse outcome (CMAO), included intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy. Multivariable Poisson's regression was used to estimate the association (using adjusted relative risk [aRR] and 95% confidence interval [CI]). RESULTS Of 19.8 million live births during the study interval, approximately 8.9 million (44.9%) met the inclusion criteria, with 9.9% being SGA, 9.2% being LGA, and 80.9% being AGA. SGA newborns delivered at 40 (aRR = 1.17; 95% CI: 1.12-1.23) and at 41 weeks (aRR = 1.55; 95% CI: 1.45-1.66) had a higher risk of CNAO than at 39 weeks. Similarly, LGA newborns delivered at 40 (aRR = 1.13; 95% CI: 1.07-1.19) and 41 weeks (aRR = 1.44; 95% CI: 1.35-1.54) and AGA newborns delivered at 40 (aRR = 1.24; 95% CI: 1.21-1.26) and 41 weeks (aRR = 1.57; 95% CI: 1.53-1.61) also had a higher risk of CNAO than at 39 weeks. CMAO was also significantly higher at 40 and 41 weeks than at 39 weeks, regardless of whether the mothers delivered SGA, LGA, or AGA newborns. CONCLUSION Among low-risk pregnancies, the risks of composite neonatal and maternal adverse outcomes increase from 39 through 41 weeks' gestation, irrespective of whether newborns are SGA, LGA, or AGA.
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Affiliation(s)
- Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Han Yang Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Teal EN, Gaw SL, Has P, Lewkowitz AK. Relationship between maternal age and labor induction duration and outcomes in nulliparous women. J Matern Fetal Neonatal Med 2021; 35:6973-6980. [PMID: 34102937 DOI: 10.1080/14767058.2021.1932807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the relationship between maternal age and labor induction duration among nulliparous women. METHODS This retrospective cohort study included nulliparous women with non-anomalous, term, singleton pregnancies undergoing labor induction with intact membranes at a tertiary-care academic hospital from January 2015 to April 2017. Maternal age was stratified as follows: <25 years, 25-29 years, 30-34 years, 35-39 years, and ≥ 40 years. The primary outcome was induction duration, defined as the time the first induction agent was administered to time of birth. Secondary outcomes were cesarean delivery, cesarean indication, hemorrhage, blood transfusion, peripartum infection, composite neonatal morbidity, and induction duration among the subset of women who ultimately underwent cesarean. The data were analyzed using chi-squared and Fisher exact tests. Multivariable regression was used to adjust for maternal race/ethnicity, maternal body mass index, gestational age at start of induction, and induction indication. Hazard ratios were used to calculate induction duration among women who underwent cesarean delivery, stratified by age and adjusted by the same variables. RESULTS Among the 955 patients included, the median induction duration was 32.3 h (interquartile range (IQR) 20.4-41.0 h). Women 40 years and older had a slight increase in induction duration (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.01-1.05) and a seven-fold increased risk of induction lasting 60 h or longer (adjusted relative risk (aRR) 7.3, CI 1.8-29.9) when compared to those under 25 years of age; otherwise, there was no association between maternal age and labor induction duration. There was no association between age and cesarean delivery, cesarean indication, hemorrhage, transfusion, peripartum infection, or adverse neonatal outcomes. Furthermore, there was no association between maternal age and induction duration even among women who ultimately underwent cesarean. CONCLUSION We found no association between maternal age and induction duration for women under 40 years of age. For women 40 years of age and older, these was an increased risk of labor induction lasting 60 h or longer. Despite this, we found no association between maternal age and cesarean delivery or other adverse maternal or fetal outcomes.
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Affiliation(s)
- Elizabeth Nicole Teal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie L Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Phinnara Has
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam K Lewkowitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
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Tan PC, Othman A, Win ST, Hong JGS, Elias N, Omar SZ. Induction of labour from 39 weeks in low-risk multiparas with ripe cervixes: A randomised controlled trial. Aust N Z J Obstet Gynaecol 2021; 61:882-890. [PMID: 34089525 DOI: 10.1111/ajo.13377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/07/2021] [Accepted: 04/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Induction of labour (IOL) in low-risk nulliparas at 39 weeks reduces caesarean delivery. Multiparas with ripe cervixes typically have vaginal delivery within eight hours. Delivery at night and weekend are associated with higher maternal and neonatal mortality. AIMS To evaluate IOL in full-term multiparas with ripe cervixes to achieve delivery at normal working hours and improve maternal satisfaction. METHODS A randomised trial was performed in a tertiary hospital in Malaysia. Low-risk multiparas with ripe cervixes (Bishop score ≥6) were recruited at 38+4 -40+0 weeks, then randomised to planned labour induction at 39+0 weeks or expectant care. Primary outcomes were delivery during 'normal working hours' 09:00-17:00 hours, Monday-Friday and patient satisfaction by visual numerical rating scale. RESULTS For IOL (n = 80) vs expectant care (n = 80) arms respectively, primary outcomes of delivery at normal working hours was 27/80 (34%) vs 29/78 (37%), relative risk (RR) 0.9, 95% CI 0.5-1.7, P = 0.41, patient satisfaction was 8.0 ± 1.8 vs 7.8 ± 1.6, P = 0.41; presentation for spontaneous labour or rupture of membranes were 27/80 (34%) vs 70/79 (89%), RR 0.4, 95% CI 0.3-0.5, P < 0.001; and for labour induction 52/80 (65%) vs 15/79 (19%), RR 3.4, 95% CI 2.1-5.5, P < 0.001. Caesarean delivery was 8/80 (10%) vs 4/79 (5%), RR 2.0, 95% CI 0.62-6.3, P = 0.25; and mean birthweight was 3.1 ± 0.3 vs 3.3 ± 0.4 kg, P = 0.06 for IOL vs expectant care, respectively. CONCLUSION Labour induction in low-risk multiparas does not increase births during working hours or improve patient satisfaction. Antenatal clinic visits and non-birth hospitalisation were significantly reduced.
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Affiliation(s)
- Peng Chiong Tan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Aida Othman
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sandar Tin Win
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jesrine Gek Shan Hong
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nurezwana Elias
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Siti Zawiah Omar
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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