Balloon catheter for induction of labor in nulliparous women with prelabor rupture of the membranes at term. A preliminary report

Double Balloon Catheter (Plus Oxytocin) versus Dinoprostone Vaginal Insert for Term Rupture of Membranes: A Randomized Controlled Trial (RUBAPRO)

Background: The aim of this study is to demonstrate that a double balloon catheter combined with oxytocin decreases time between induction of labor and delivery (TID) as compared to a vaginal dinoprostone insert in cases of premature rupture of membranes at term. Methods: This is a prospective, randomized, controlled trial including patient undergoing labor induction for PROM at term with an unfavorable cervix in Clermont-Ferrand university hospital. We compared the double balloon catheter over a period of 12 h with adjunction of oxytocin 6 h after catheter insertion versus dinoprostone vaginal insert. After device ablation, cervical ripening continued only with oxytocin. The main outcome was TID. Secondary outcomes concerned delivery mode, as well as maternal and fetal outcome, and were adjusted for parity. Results: 40 patients per group were randomized. Each group had similar baseline characteristics. The study failed to demonstrate reduced TID (16.2 versus 20.2 h, ES = 0.16 (−0.27 to 0.60), p = 0.12) in the catheter group versus dinoprostone except in nulliparous women (17.0 versus 26.5 h, ES = 0.62 (0.10 to 1.14), p = 0.006). The rate of vaginal delivery <24 h significantly increased with combined induction (88.5% versus 66.6%, p = 0.03). No statistical difference was observed concerning caesarean rate (12.5% versus 17.5%, p > 0.05), chorioamnionitis (0% versus 2.5%, p = 1), postpartum endometritis, or maternal or neonatal outcomes. Procedure-related pain and tolerance to devices were found to be similar for the two methods. Interpretation: The double balloon catheter combined with oxytocin is an alternative for cervical ripening in case of PROM at term, and may reduce TID in nulliparous women.

Balloon catheter use for cervical ripening in women with term pre-labor rupture of membranes: A 5-year cohort study

INTRODUCTION

To investigate the safety of balloon catheter for cervical ripening in women with term pre-labor rupture of membranes (PROM) and to compare the incidence of maternal and neonatal infections in women with PROM and women with intact membranes undergoing cervical ripening with a balloon catheter.

MATERIAL AND METHODS

This retrospective cohort study of 1923 women with term singleton pregnancy and an unfavorable cervix undergoing cervical ripening with a balloon catheter was conducted in Helsinki University Hospital between January 2014 and December 2018. For each case of PROM, two controls were assigned. The main outcome measures were the rates of maternal and neonatal infections. Statistical analyses were performed by SPSS.

RESULTS

In all, 641 (33.3%) women following PROM and 1282 (66.6%) women with intact amniotic membranes underwent labor induction. The rates of intrapartum infection (3.7% vs 7.7%; P = .001) and neonatal infection (1.7% vs 3.8%; P = .01) were not increased in women induced by balloon catheter following PROM. Intrapartum infections were associated with nulliparity (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6-6.5), history of previous cesarean section (OR 2.8, 95% CI 1.2-6.4), extended gestational age ≥41 weeks (OR 1.9, 95% CI 1.2-3.0) and an induction to delivery interval of 48 hours or more (OR 2.0, 95% CI 1.2-3.3). The risk of neonatal infection was associated with nulliparity (OR 3.3, 95% CI 1.4-8.0), gestational age ≥41 weeks (OR 1.9, 95% CI 1.09-3.36) and induction to delivery interval of 48 hours or more (OR 3.4, 95% CI 1.9-6.0).

CONCLUSIONS

Use of balloon catheter in women with term PROM appears safe and was not associated with increased maternal or neonatal infectious morbidity.

Induction of labour in case of premature rupture of membranes at term with an unfavourable cervix: protocol for a randomised controlled trial comparing double balloon catheter (+oxytocin) and vaginal prostaglandin (RUBAPRO) treatments

INTRODUCTION

Premature rupture of membranes (PROM) occurs at term in 8% of pregnancies. Several studies have demonstrated that the risk of chorioamnionitis and neonatal sepsis increases with duration of PROM. Decreasing the time interval between PROM and delivery is associated with lower rates of maternal infections. In case of an unfavourable cervix, the use of prostaglandin for cervical maturation demonstrates some advantages over oxytocin. The use of double balloon catheter in reduction of PROM duration has not been evaluated in the literature.

METHODS AND ANALYSIS

We are conducting a prospective, monocentric, randomised clinical trial on pregnant women with an unfavourable cervix showing PROM at term (RUBAPRO).After 12-24 hours of PROM, women are randomly assigned to one group treated with a double balloon catheter for 12 hours, with oxytocin administered after 6 hours or to the control group treated with 24 hours of vaginal prostaglandin followed by oxytocin infusion alone. Patients (n=80) are randomised at a 1:1 ratio with stratification on parity.The inclusion criteria are a Bishop score of <6, cephalic presentation at term and confirmed PROM. Women with suspected chorioamnionitis; group B streptococcus (GBS) carrier; a history of caesarean delivery or any contraindication for vaginal delivery are excluded.The time from induction to delivery is the primary outcome. Secondary outcomes were mode of delivery, maternofetal morbidity and the effect of parity on strategies for reduction of PROM duration.To sufficiently demonstrate a difference (10 hours) between groups-with a statistical power of 90% and a two-tailed α of 5%-40 patients per group will be required.

ETHICS AND DISSEMINATION

Written informed consent is required from participants.National Ethics Committee approval was obtained in August 2017. The results will be published in a peer-reviewed journal and presented at relevant conferences. Access to raw data will be available only to members of the research team.

TRIAL REGISTRATION NUMBER

NCT03310333.

Foley Plus Oxytocin Compared With Oxytocin for Induction After Membrane Rupture: A Randomized Controlled Trial

OBJECTIVE

To evaluate the use of a transcervical Foley catheter plus oxytocin infusion compared with oxytocin infusion alone for labor induction and cervical ripening in women 34 weeks of gestation or greater with prelabor rupture of membranes.

METHODS

This is a randomized, multicenter trial of women with a live, singleton gestation at 34 weeks of gestation or greater with prelabor rupture of membranes, an unfavorable cervical examination (less than or equal to 2 cm dilated and less than or equal to 80% effaced), and no contraindication to labor. Participants were randomly allocated to a transcervical Foley catheter inflated to 30 cc with concurrent oxytocin infusion or oxytocin infusion alone. Oxytocin administration was standardized across sites. The primary study outcome was interval from induction to delivery. To detect a 2.5-hour difference in the interval from induction to delivery, we required outcome data on 194 women, assuming 80% power and a two-tailed α of 5%. Analysis was by intent to treat.

RESULTS

We enrolled 201 women: 93 were allocated to Foley and 108 to oxytocin. Demographics were similar between the groups. Time to delivery was not significantly different between groups: in the Foley group, it was 13.9 hours (±6.9 SD) compared with 14.4 hours (±7.9 SD) in the oxytocin group (P=.69). There were more cases of clinical chorioamnionitis (8% compared with 0%, P<.01) in the Foley group compared with the oxytocin group. There were no differences for other infectious morbidities or any other variable studied.

CONCLUSION

In patients with prelabor rupture of membranes, the use of a transcervical Foley catheter in addition to oxytocin does not shorten the time to delivery compared with oxytocin alone, but may increase the incidence of intraamniotic infection.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01973036.

Risk of maternal, fetal and neonatal complications associated with the use of the transcervical balloon catheter in induction of labour: A systematic review

Induction of labour is one of the most frequently applied obstetrical interventions globally. Many studies have compared the use of balloon catheters with pharmacological agents. Although the safety of the balloon catheter is often mentioned, little has been written about the total spectrum of maternal and fetal morbidity associated with induction of labour using a balloon catheter. We evaluated the safety of labour induction with a transcervical balloon catheter by conducting a literature review with pooled risk assessments of the maternal, fetal and neonatal morbidity. We searched Medline, EMBASE and CINAHL as well as the Cochrane database using the Keywords 'induction of labour', 'cervical ripening', 'transcervical balloon', 'balloon catheter' and 'Foley balloon'. We did not use language or date restrictions. Randomized and quasi-randomized controlled trials as well as observational studies that contained original data on occurrence of maternal, fetal or neonatal morbidity during induction of labour with the balloon catheter were included. Studies were excluded if the balloon catheter was used concurrently with oxytocin and concurrently or consecutively with misoprostol, dinoprostone or extra-amniotic saline infusion. Study selection and quality assessment was performed by two authors independently using a standardized critical appraisal instrument. Outcomes were reported as weighted mean rates. We detected 84 articles reporting on 13,791 women. The overall risk of developing intrapartum maternal infection was 11.3% (912 of 8079 women), 3.3% (151 of 4538 women) for postpartum maternal infection and 4.6% (203 of 4460 women) for neonatal infection. Uterine hypercontractility occurred in 2.7% (148 of 5439) of the women. Uterine rupture after previous caesarean section occurred in 1.9% of women (26 of 1373), while other major maternal complications had an occurrence rate of <1%. The risk for developing minor maternal complications was <2%. The risk of developing a non-reassuring fetal heart rate was 10.8% (793 of 7336 women), 10.1% (507 of 5008 women) for fetal distress and 14.0% (460 of 3295 women) for meconium stained liquor. Neonatal death occurred in 0.29% (6 of 2058) of the deliveries and NICU admission in 7.2% (650 of 9065 deliveries). This review shows that labour induction with a balloon catheter is a safe intervention, with intrapartum maternal infection being the only reasonable risk above 10%.

Induction of labor by Foley catheter compared with spontaneous onset of labor after previous cesarean section: a cohort study

OBJECTIVE

To evaluate the safety of induction of labor (IOL) with Foley catheter (FC) in women with a history of previous cesarean section (CS) and to assess risk factors for repeat CS and adverse maternal outcomes.

STUDY DESIGN

Cohort study of 1559 women with a history of previous CS in Helsinki University Hospital, Finland between 2013 and 2014.

RESULTS

Three hundred and sixty-one women (23.2%) underwent IOL by FC and 1198 (76.8%) had spontaneous onset of labor. The rate of repeat CS was higher in women undergoing IOL (38% vs 20.2%; P<0.001). The overall rate of uterine rupture was 0.3% in induced labor and 0.8% in spontaneous onset of labor (P=0.47). Adverse maternal outcomes were not significantly different. The intrapartum and postpartum infection rates were higher in women undergoing IOL compared with spontaneous onset of labor (6.1% vs 1.8%; P>0.001 and 5.3% vs 1.3%; P<0.001, respectively).

CONCLUSION

FC appears safe and effective method for IOL in women with a history of previous CS.

Labor induction in the patient with preterm premature rupture of membranes

Preterm premature rupture of membranes (PPROM) affects up to one-third of all preterm births and confers serious maternal risks, including intra-amniotic infection, and an increased risk of neonatal complications, including respiratory distress and intraventricular hemorrhage. Management of PPROM is a highly individualized process that requires an accurate determination of gestational age and causal factors, as well as the balancing of maternal and fetal risks. In this review of the existing literature on induction of labor in PPROM, we examine the differences in appropriate management of patients with early (32 weeks 0 days to 33 weeks 6 days) and near term (34 weeks 0 days to 36 weeks 6 days) PPROM, and compare the safety and efficacy of available treatment options. This review of previous research findings provides general guidelines for clinical decision making and highlights the need for future research on management of PPROM.

Foley Catheter vs Prostaglandin as Ripening Agent in Pregnant Women With Premature Rupture of Membranes

Context: Although studies support the efficacy of the Foley catheter (FC) as a cervical ripening agent in pregnant women at term with intact membranes, its efficacy has not been well studied in women with premature rupture of membranes (PROM).

Objective: To compare the interval to delivery in women with PROM who underwent induction of labor and cervical ripening with mechanical (FC) vs nonmechanical (prostaglandin [PG]) cervical ripening agents.

Design: Retrospective medical record review at 2 hospitals of pregnant women who delivered between January 2009 and April 2011.

Setting: Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, and Christiana Care Health System in Newark, Delaware.

Patients: Pregnant women with singleton gestations 36 weeks or greater who presented with PROM.

Interventions: Cervical ripening with FC or PG.

Main Outcome Measures: The primary outcome was time from induction until delivery. Secondary outcomes included epidural use, maximum temperature during labor, number of vaginal examinations, occurrence of tachysystole, oxytocin dose, delivery mode, chorioamnionitis, and neonatal Apgar score.

Results: Of 155 medical records of patients who met the inclusion criteria, 33 women underwent cervical ripening with PG (ie, misoprostol) and 122 with FC. The interval to delivery was almost halved in women who underwent cervical ripening with FC compared with misoprostol (736 vs 1354 minutes; P<.01). Compared with the women in the misoprostol group, those in the FC group received a statistically significant higher dose of oxytocin (P<.01). There were no statistically significant differences between the groups with respect to the remaining secondary outcomes. Of note, all of the women who received FC were from Christiana Care Health System, and all women who received misoprostol were from Thomas Jefferson University Hospital.

Conclusion: Foley catheters may help shorten the interval to delivery in women who are candidates for cervical ripening after PROM at or near term. There does not appear to be an increased risk for cesarean delivery or chorioamnionitis in those treated with FC.

Umbilical cord prolapse

Umbilical cord prolapse is an obstetric emergency that can have negative outcomes for the fetus. It is diagnosed by a palpable or visible cord and is often accompanied by severe, rapid fetal heart rate decelerations. Cases of cord prolapse should be delivered as soon as possible, usually by cesarean section. While awaiting delivery, the fetal presenting part should be elevated off the cord either manually or by filling the bladder. Although an untreated case of umbilical cord prolapse can lead to severe fetal morbidity and mortality, prompt and appropriate management leads to good overall outcomes.