Pub Date : 2024-10-01DOI: 10.1016/j.ajogmf.2024.101470
Background
Activity restriction is a common recommendation given to patients during pregnancy for various indications, despite lack of definitive data showing improvements in pregnancy outcomes.
Objective
To determine if activity restriction (AR) in pregnancy is associated with decreased odds of adverse pregnancy outcomes (APOs).
Study design
Secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) prospective cohort. Nulliparous singletons were followed at 8 sites from October 2010–September 2013. Demographic and clinical data were collected at 4 timepoints, and participants were surveyed about AR recommendations at 22w0d-29w6d and delivery. We excluded participants missing data on AR and age. Participants were grouped according to history of AR, and APOs included: gestational hypertension (gHTN), preeclampsia/eclampsia, preterm birth (PTB), and small for gestational age (SGA) neonate. Associations between AR and APOs were examined using uni- and multivariable logistic regression models adjusting for a priori identified APO risk factors.
Results
Of 10,038 nuMoM2b participants, 9,312 met inclusion criteria and 1,386 (14.9%) were recommended AR; participants identifying as Black (aOR 0.81 [95% CI 0.68–0.98]) or Hispanic (aOR 0.73 [95% CI 0.61–0.87]) were less likely to be placed on AR when compared to those identifying as White. Overall, 3,197 (34.3%) experienced at least one APO (717 [51.7%] of participants with AR compared to 2,480 [31.3%] participants without AR). After adjustment for baseline differences, the AR group had increased odds of gHTN (aOR 1.61 [95% CI 1.35–1.92]), preeclampsia/eclampsia (aOR 2.52 [95% CI 2.06–3.09]) and iatrogenic and spontaneous PTB (aOR 2.98 [95% CI 2.41–3.69]), but not delivery of an SGA neonate.
Conclusion
AR in pregnancy was independently associated with increased odds of hypertensive disorders of pregnancy and PTB, but future prospective work is needed to determine potential causality. Further, participants identifying as Black or Hispanic were significantly less likely to be recommended AR compared to those identifying as White. While AR is not an evidence-based practice, these findings suggest bias may impact which patients receive advice to limit activity in pregnancy.
背景：尽管缺乏明确的数据显示妊娠结局有所改善，但限制活动是妊娠期因各种适应症而向患者提出的常见建议：研究设计：研究设计：对无胎儿妊娠结局研究进行二次分析：研究设计：对无子宫妊娠结局研究：待产母亲监测（nuMoM2b）前瞻性队列进行二次分析。从 2010 年 10 月至 2013 年 9 月，在 8 个地点对无妊娠期的单胎进行了随访。我们在 4 个时间点收集了人口统计学和临床数据，并就 22w0d-29w6d 和分娩时的 AR 建议对参与者进行了调查。我们排除了缺失 AR 和年龄数据的参与者。根据AR病史对参与者进行分组，APO包括：妊娠高血压（gHTN）、子痫前期/子痫、早产（PTB）和胎龄小（SGA）新生儿。使用单变量和多变量逻辑回归模型研究了AR与APO之间的关系，并对事先确定的APO风险因素进行了调整：在 10,038 名 nuMoM2b 参与者中，9,312 人符合纳入标准，1,386 人（14.9%）被建议使用 AR；与白人相比，黑人 [aOR 0.81 (95% CI 0.68-0.98)] 或西班牙裔 [aOR 0.73 (95% CI 0.61-0.87)] 参与者使用 AR 的可能性较低。总体而言，有 3197 人（34.3%）至少经历过一次 APO [有 AR 的参与者为 717 人（51.7%），无 AR 的参与者为 2480 人（31.3%）]。在对基线差异进行调整后，AR 组发生 gHTN [aOR 1.61 (95% CI 1.35-1.92)]、子痫前期/子痫 [aOR 2.52 (95% CI 2.06-3.09)]、先天性和自发性 PTB [aOR 2.98 (95% CI 2.41-3.69)]的几率增加，但不包括分娩 SGA 新生儿：结论：妊娠期AR与妊娠期高血压疾病和先天性脑瘫发生几率的增加有独立关联，但需要未来的前瞻性工作来确定潜在的因果关系。此外，与白人相比，黑人或西班牙裔受试者被建议进行 AR 的可能性要低得多。虽然AR并不是一种循证实践，但这些研究结果表明，偏见可能会影响哪些患者接受限制孕期活动的建议。
{"title":"Activity restriction and risk of adverse pregnancy outcomes","authors":"","doi":"10.1016/j.ajogmf.2024.101470","DOIUrl":"10.1016/j.ajogmf.2024.101470","url":null,"abstract":"<div><h3>Background</h3><div>Activity restriction is a common recommendation given to patients during pregnancy for various indications, despite lack of definitive data showing improvements in pregnancy outcomes.</div></div><div><h3>Objective</h3><div>To determine if activity restriction (AR) in pregnancy is associated with decreased odds of adverse pregnancy outcomes (APOs).</div></div><div><h3>Study design</h3><div>Secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) prospective cohort. Nulliparous singletons were followed at 8 sites from October 2010–September 2013. Demographic and clinical data were collected at 4 timepoints, and participants were surveyed about AR recommendations at 22w0d-29w6d and delivery. We excluded participants missing data on AR and age. Participants were grouped according to history of AR, and APOs included: gestational hypertension (gHTN), preeclampsia/eclampsia, preterm birth (PTB), and small for gestational age (SGA) neonate. Associations between AR and APOs were examined using uni- and multivariable logistic regression models adjusting for <em>a priori</em> identified APO risk factors.</div></div><div><h3>Results</h3><div>Of 10,038 nuMoM2b participants, 9,312 met inclusion criteria and 1,386 (14.9%) were recommended AR; participants identifying as Black (aOR 0.81 [95% CI 0.68–0.98]) or Hispanic (aOR 0.73 [95% CI 0.61–0.87]) were less likely to be placed on AR when compared to those identifying as White. Overall, 3,197 (34.3%) experienced at least one APO (717 [51.7%] of participants with AR compared to 2,480 [31.3%] participants without AR). After adjustment for baseline differences, the AR group had increased odds of gHTN (aOR 1.61 [95% CI 1.35–1.92]), preeclampsia/eclampsia (aOR 2.52 [95% CI 2.06–3.09]) and iatrogenic and spontaneous PTB (aOR 2.98 [95% CI 2.41–3.69]), but not delivery of an SGA neonate.</div></div><div><h3>Conclusion</h3><div>AR in pregnancy was independently associated with increased odds of hypertensive disorders of pregnancy and PTB, but future prospective work is needed to determine potential causality. Further, participants identifying as Black or Hispanic were significantly less likely to be recommended AR compared to those identifying as White. While AR is not an evidence-based practice, these findings suggest bias may impact which patients receive advice to limit activity in pregnancy.</div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142047293","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-30DOI: 10.1016/j.ajogmf.2024.101508
Uma M Reddy, Grecio J Sandoval, Alan T N Tita, Robert M Silver, Gail Mallett, Kim Hill, Yasser Y El-Sayed, Madeline Murguia Rice, Ronald J Wapner, Dwight J Rouse, George R Saade, John M Thorp, Suneet P Chauhan, Maged M Costantine, Edward K Chien, Brian M Casey, Sindhu K Srinivas, Geeta K Swamy, Hyagriv N Simhan, George A Macones, William A Grobman
<p><strong>Background: </strong>Following the results of the ARRIVE trial, which demonstrated a reduction in cesarean delivery with no increase in adverse perinatal outcomes after elective induction of labor (IOL) in low-risk nulliparous patients at 39 weeks' gestation compared with expectant management, the use of induction has increased. Current evidence is insufficient to recommend mid-high-dose over low-dose regimens for routine IOL.</p><p><strong>Objective(s): </strong>We sought to evaluate the association of oxytocin regimen with cesarean delivery and an adverse perinatal composite outcome in low-risk nulliparous patients undergoing IOL at 39 weeks of gestation or greater.</p><p><strong>Study design: </strong>This is a secondary analysis of the NICHD Maternal-Fetal Medicine Units Network ARRIVE randomized trial. Patients induced with a mid-to high-dose oxytocin regimen (MHD; starting or incremental increase >2 mU/min) were compared with those receiving a low-dose oxytocin regimen (LD; starting and incremental increase ≤2 mU/min). The co-primary outcomes for this secondary analysis were 1) cesarean delivery and 2) composite of perinatal death or severe neonatal complications. Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) and 97.5% confidence intervals (CI) for the co-primary endpoints, 95% CI for binomial outcomes and multinomial logistic regression was used to estimate adjusted odds ratios (aOR) and 95% CIs for multinomial outcomes.</p><p><strong>Results: </strong>Of 6,106 participants enrolled in the primary trial, 2,933 underwent induction with oxytocin: 861 in the MHD group and 2,072 in the LD group. The lower frequency of cesarean delivery in the MHD group compared with the LD group (20.3% vs. 25.2%, RR 0.81, 95%CI (0.69-0.94)) was not significant after adjustment (aRR 0.90, 97.5%CI (0.76-1.07)). The composite of perinatal death or severe neonatal complications was more frequent in the MHD group compared with the LD group (6.7% vs. 4.3%, RR 1.55, 95%CI (1.13-2.14)) and remained significant after adjustment (aRR 1.61, 97.5%CI (1.11-2.35)). The majority of the cases in the composite were from the respiratory support (5.2% vs. 3.1%) component with an increase in transient tachypnea of the newborn (3.8% vs. 2.5%, aRR 1.63, 95% CI (1.04-2.54)). The duration of neonatal respiratory support for one day was significantly higher in the MHD group compared with the LD group (3.5% vs. 1.4%, aRR 2.59, 95%CI (1.52-4.39)); however, support beyond one day was not different between the two groups. The MHD group, when compared with the LD group had a higher operative vaginal delivery rate (10.0% vs. 7.0%, aRR 1.54, 95%CI (1.18-2.00)) and shorter duration of time from start of oxytocin to delivery [crude median (interquartile range) 12 (8-17) vs. 13 (9-19) hours, adjusted median difference -2 (-2 to -1), p<0.001], respectively.</p><p><strong>Conclusion(s): </strong>Mid-high-dose oxytocin regimen use for IOL in nullipa
{"title":"Oxytocin regimen used for induction of labor and pregnancy outcomes.","authors":"Uma M Reddy, Grecio J Sandoval, Alan T N Tita, Robert M Silver, Gail Mallett, Kim Hill, Yasser Y El-Sayed, Madeline Murguia Rice, Ronald J Wapner, Dwight J Rouse, George R Saade, John M Thorp, Suneet P Chauhan, Maged M Costantine, Edward K Chien, Brian M Casey, Sindhu K Srinivas, Geeta K Swamy, Hyagriv N Simhan, George A Macones, William A Grobman","doi":"10.1016/j.ajogmf.2024.101508","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2024.101508","url":null,"abstract":"<p><strong>Background: </strong>Following the results of the ARRIVE trial, which demonstrated a reduction in cesarean delivery with no increase in adverse perinatal outcomes after elective induction of labor (IOL) in low-risk nulliparous patients at 39 weeks' gestation compared with expectant management, the use of induction has increased. Current evidence is insufficient to recommend mid-high-dose over low-dose regimens for routine IOL.</p><p><strong>Objective(s): </strong>We sought to evaluate the association of oxytocin regimen with cesarean delivery and an adverse perinatal composite outcome in low-risk nulliparous patients undergoing IOL at 39 weeks of gestation or greater.</p><p><strong>Study design: </strong>This is a secondary analysis of the NICHD Maternal-Fetal Medicine Units Network ARRIVE randomized trial. Patients induced with a mid-to high-dose oxytocin regimen (MHD; starting or incremental increase >2 mU/min) were compared with those receiving a low-dose oxytocin regimen (LD; starting and incremental increase ≤2 mU/min). The co-primary outcomes for this secondary analysis were 1) cesarean delivery and 2) composite of perinatal death or severe neonatal complications. Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) and 97.5% confidence intervals (CI) for the co-primary endpoints, 95% CI for binomial outcomes and multinomial logistic regression was used to estimate adjusted odds ratios (aOR) and 95% CIs for multinomial outcomes.</p><p><strong>Results: </strong>Of 6,106 participants enrolled in the primary trial, 2,933 underwent induction with oxytocin: 861 in the MHD group and 2,072 in the LD group. The lower frequency of cesarean delivery in the MHD group compared with the LD group (20.3% vs. 25.2%, RR 0.81, 95%CI (0.69-0.94)) was not significant after adjustment (aRR 0.90, 97.5%CI (0.76-1.07)). The composite of perinatal death or severe neonatal complications was more frequent in the MHD group compared with the LD group (6.7% vs. 4.3%, RR 1.55, 95%CI (1.13-2.14)) and remained significant after adjustment (aRR 1.61, 97.5%CI (1.11-2.35)). The majority of the cases in the composite were from the respiratory support (5.2% vs. 3.1%) component with an increase in transient tachypnea of the newborn (3.8% vs. 2.5%, aRR 1.63, 95% CI (1.04-2.54)). The duration of neonatal respiratory support for one day was significantly higher in the MHD group compared with the LD group (3.5% vs. 1.4%, aRR 2.59, 95%CI (1.52-4.39)); however, support beyond one day was not different between the two groups. The MHD group, when compared with the LD group had a higher operative vaginal delivery rate (10.0% vs. 7.0%, aRR 1.54, 95%CI (1.18-2.00)) and shorter duration of time from start of oxytocin to delivery [crude median (interquartile range) 12 (8-17) vs. 13 (9-19) hours, adjusted median difference -2 (-2 to -1), p<0.001], respectively.</p><p><strong>Conclusion(s): </strong>Mid-high-dose oxytocin regimen use for IOL in nullipa","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142366790","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-27DOI: 10.1016/j.ajogmf.2024.101510
Md-PhD Perrine Coste-Mazeau, Pr Denis Gallot, Dr François Siegerth, Dr Angeline Garuchet Bigot, Dr Emmanuel Decroisette, Pr Julie Blanc, Dr Muriel Cantaloube, Dr Sabrina Crépin, Pr Julien Magne, Ms Anais Labrunie, Dr Renaud Martin, Dr Miassa Hessas
<p><strong>Background: </strong>Labor is induced in over 25% of women in France. Prostaglandins, especially intravaginal dinoprostone (Propess®), are widely used to initiate cervical ripening. If labor does not start within 24 hours, there is uncertainty about whether to administer a second dinoprostone pessary or to use oxytocin to induce labor in order to achieve a vaginal delivery.</p><p><strong>Objectives: </strong>Our principal objective was to determine whether placement of a second Propess®, followed by oxytocin (Syntocinon®) if necessary, in pregnant women for whom the first Propess® failed to induce cervical ripening increases the vaginal delivery rate compared to direct oxytocin injection. The vaginal delivery rate was therefore the primary outcome. The secondary outcomes were the cervical ripening failure rate and maternal and fetal morbidity and mortality.</p><p><strong>Study design: </strong>RE-DINO is a prospective, open-label, multicenter, randomized superiority trial with two parallel arms running in 7 French hospitals. Patients at > 37 weeks of gestation who had unfavorable cervical conditions (Bishop score < 6) 24 hours after placement of the first Propess® (vaginal patch featuring progressive continuous diffusion of 10 mg dinoprostone), with fetuses in cephalic presentation, were included.</p><p><strong>Results: </strong>160 pregnant women were randomized, 80 patients in each group, from December 2016 through April 2022. Baseline characteristics such as age, BMI, maternal age at induction and Bishop score at induction were similar between both groups. Vaginal delivery occurred in 76.3% of cases in the 2<sup>nd</sup> Propess<sup>ࣨ</sup> group and 73.8% of cases in the Syntocinon® group (RR = 1.03 [0.86; 1.24], p=0.715). Although the cesarean section rate was similar in each group, there were significantly more cesarean sections for arrest of dilatation (52.6% vs 19%; p=0.0262) in the Propess® group and a larger, borderline-significant difference in patients having operative vaginal delivery (24.6% vs 11.9%; p=0.07) for abnormal fetal heart rate (80% vs 29%; p=0.05). There was significantly more failure of cervical ripening in the Propess<sup>ࣨ</sup> group (57.1% vs 19%; RR=2.59 ; 95% CI [1.64; 4.11]; p < 0.0001) and the interval between study treatment and delivery was also significantly longer (28.1h vs 9,7h; p<0.0001). There was a higher incidence of post-partum hemorrhage in the Propess<sup>ࣨ</sup> group, although this was not significant (11.3% vs 5% ; p=0,15), but also more newborns with acidosis (39.3% vs 27.9% ; p=0.18) or severe acidosis (8,6% vs 3.4% ; p=0.27), more meconium fluid (11.3% vs 6.3% ; p =0.26) and transferred to intensive care (5% vs 2.5% ; p=0.68).</p><p><strong>Conclusion: </strong>Our data showed no superiority of a second dinoprostone pessary over oxytocin in patients not responding to initial prostaglandins E2 maturation for labor induction. Repeated use of Propess® is not useful for induction of labor
背景介绍在法国，超过 25% 的妇女需要引产。前列腺素，尤其是阴道内地诺前列酮（Propess®），被广泛用于启动宫颈成熟。如果在 24 小时内没有开始分娩，则不确定是使用第二个地诺前列酮栓剂还是使用催产素催产，以实现阴道分娩：我们的主要目的是确定与直接注射催产素相比，为第一次使用地诺前列酮催产失败的孕妇放置第二个地诺前列酮栓，必要时再使用催产素（Syntocinon®）是否会提高阴道分娩率。因此，阴道分娩率是主要结果。次要结果是宫颈成熟失败率以及母体和胎儿的发病率和死亡率：研究设计：RE-DINO 是一项前瞻性、开放标签、多中心、随机优选试验，在法国 7 家医院同时进行。研究对象包括妊娠期大于 37 周、首次使用 Propess®（阴道贴片，10 毫克地诺前列酮渐进式持续扩散）24 小时后宫颈状况不佳（Bishop 评分小于 6 分）且胎儿呈头位的孕妇：从 2016 年 12 月到 2022 年 4 月，160 名孕妇接受了随机治疗，每组 80 人。两组孕妇的年龄、体重指数、引产时的产妇年龄和引产时的毕夏普评分等基线特征相似。第 2 次 Propessࣨ组有 76.3% 的病例经阴道分娩，而 Syntocinon® 组有 73.8% 的病例经阴道分娩（RR = 1.03 [0.86; 1.24]，P=0.715）。虽然各组的剖宫产率相似，但 Propess® 组因宫口扩张停止而进行剖宫产的比例明显更高（52.6% vs 19%；P=0.0262），而因胎心率异常（80% vs 29%；P=0.05）而进行手术阴道分娩的患者比例差异更大，接近显著水平（24.6% vs 11.9%；P=0.07）。Propessࣨ组宫颈成熟失败率明显更高（57.1% vs 19%; RR=2.59 ; 95% CI [1.64; 4.11]; p <0.0001），研究治疗与分娩之间的间隔时间也明显更长（28.1h vs 9,7h；Pࣨ组，尽管这并不显著（11.但也有更多新生儿出现酸中毒（39.3% vs 27.9%; p=0.18）或严重酸中毒（8.6% vs 3.4%; p=0.27）、更多胎粪积液（11.3% vs 6.3%; p=0.26）和转入重症监护（5% vs 2.5%; p=0.68）：我们的数据显示，对初次使用前列腺素E2成熟剂引产无效的患者，第二次使用地诺前列酮栓剂并不比催产素更有优势。重复使用 Propess® 对引产没有帮助。
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Pub Date : 2024-09-26DOI: 10.1016/j.ajogmf.2024.101493
{"title":"Corrigendum to ‘Prevention of preterm birth in twin pregnancies’ American Journal of Obstetrics & Gynecology MFM/ Volume 4 (2022) 100551","authors":"","doi":"10.1016/j.ajogmf.2024.101493","DOIUrl":"10.1016/j.ajogmf.2024.101493","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142322073","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.ajogmf.2024.101502
Ruixiang Cai, Lingyan Chen, Yunguang Xing, Yuguo Deng, Juan Li, Fangfang Guo, Li Liu, Cuihua Xie, Jinying Yang
Background: Intravenous calcium administration has shown promise in enhancing uterine contractions and reducing blood loss during cesarean section, but this regimen has not been compared in vaginal labor induction.
Objective: To determine the efficacy of oxytocin combined with calcium versus oxytocin alone for inducing labor among women with term premature rupture of membranes (PROM).
Study design: This single-blind, randomized control trial was conducted between October 2022 and May 2023 in a tertiary university hospital. Patients diagnosed with PROM were randomly allocated into two groups. The intervention group received a bolus of 10 mL of calcium gluconate followed by a continuous infusion of oxytocin via a pump (n = 210), whereas the control group received only oxytocin infusion (n = 218). The primary outcome was successful vaginal deliveries within 24 hours of labor induction. Secondary outcomes included the interval from labor induction to delivery, vaginal delivery blood loss, and maternal and neonatal complications.
Results: Baseline characteristics, including maternal age, BMI, Bishop score before labor induction, were comparable between groups. The rate of vaginal delivery within 24 hours of labor induction was statistically higher in the intervention group (79.52% vs. 70.64%; P = 0.04). Participants in intervention group experienced a shortened interval between induction and delivery (10.48 h vs. 11.25h; P = 0.037), and demonstrated a higher success rate in induction of labor assessed by the onset of active phase (93.80% vs. 87.61%; P = 0.04) without increasing the cesarean rate. Reduced hemorrhage was presented in the intervention group (242.5ml vs. 255.0ml; P = 0.0015) while the maternal and neonatal outcomes were comparable between groups.
Conclusion: The co-administration of calcium and oxytocin in labor induction among pregnancies with PROM was more efficient and safer than oxytocin alone. Our research suggests that the combination therapy of calcium and oxytocin may offer significant advantages during the process of labor induction and result in better outcomes.
{"title":"Oxytocin with calcium vs. oxytocin for induction of labor in women with term premature rupture of membranes: A randomized controlled trial: Oxytocin with calcium gluconate for labor induction.","authors":"Ruixiang Cai, Lingyan Chen, Yunguang Xing, Yuguo Deng, Juan Li, Fangfang Guo, Li Liu, Cuihua Xie, Jinying Yang","doi":"10.1016/j.ajogmf.2024.101502","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2024.101502","url":null,"abstract":"<p><strong>Background: </strong>Intravenous calcium administration has shown promise in enhancing uterine contractions and reducing blood loss during cesarean section, but this regimen has not been compared in vaginal labor induction.</p><p><strong>Objective: </strong>To determine the efficacy of oxytocin combined with calcium versus oxytocin alone for inducing labor among women with term premature rupture of membranes (PROM).</p><p><strong>Study design: </strong>This single-blind, randomized control trial was conducted between October 2022 and May 2023 in a tertiary university hospital. Patients diagnosed with PROM were randomly allocated into two groups. The intervention group received a bolus of 10 mL of calcium gluconate followed by a continuous infusion of oxytocin via a pump (n = 210), whereas the control group received only oxytocin infusion (n = 218). The primary outcome was successful vaginal deliveries within 24 hours of labor induction. Secondary outcomes included the interval from labor induction to delivery, vaginal delivery blood loss, and maternal and neonatal complications.</p><p><strong>Results: </strong>Baseline characteristics, including maternal age, BMI, Bishop score before labor induction, were comparable between groups. The rate of vaginal delivery within 24 hours of labor induction was statistically higher in the intervention group (79.52% vs. 70.64%; P = 0.04). Participants in intervention group experienced a shortened interval between induction and delivery (10.48 h vs. 11.25h; P = 0.037), and demonstrated a higher success rate in induction of labor assessed by the onset of active phase (93.80% vs. 87.61%; P = 0.04) without increasing the cesarean rate. Reduced hemorrhage was presented in the intervention group (242.5ml vs. 255.0ml; P = 0.0015) while the maternal and neonatal outcomes were comparable between groups.</p><p><strong>Conclusion: </strong>The co-administration of calcium and oxytocin in labor induction among pregnancies with PROM was more efficient and safer than oxytocin alone. Our research suggests that the combination therapy of calcium and oxytocin may offer significant advantages during the process of labor induction and result in better outcomes.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297362","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.ajogmf.2024.101500
Carmen M A Santol, Shakthi Unnithan, Tracy Truong, Sarah K Dotters-Katz, Jerome J Federspiel
Background: Pre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings.
Objectives: We investigated the relationship between facility delivery volume and rates of non-transfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features.
Study design: This is a retrospective cohort study using the Nationwide Readmissions Database (2015-2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was non-transfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and non-transfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, non-transfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery.
Results: The cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25th percentile-75th percentile: 2.2-6.5). Non-transfusion SMM occurred in 7% of patients readmitted to facilities with >2,000 deliveries compared to 9% with 1-2,000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1,000 deliveries, the odds of a non-transfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99) CONCLUSIONS: Non-transfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.
{"title":"Maternal morbidity in postpartum severe preeclampsia by obstetric delivery volume.","authors":"Carmen M A Santol, Shakthi Unnithan, Tracy Truong, Sarah K Dotters-Katz, Jerome J Federspiel","doi":"10.1016/j.ajogmf.2024.101500","DOIUrl":"10.1016/j.ajogmf.2024.101500","url":null,"abstract":"<p><strong>Background: </strong>Pre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings.</p><p><strong>Objectives: </strong>We investigated the relationship between facility delivery volume and rates of non-transfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features.</p><p><strong>Study design: </strong>This is a retrospective cohort study using the Nationwide Readmissions Database (2015-2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was non-transfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and non-transfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, non-transfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery.</p><p><strong>Results: </strong>The cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25<sup>th</sup> percentile-75<sup>th</sup> percentile: 2.2-6.5). Non-transfusion SMM occurred in 7% of patients readmitted to facilities with >2,000 deliveries compared to 9% with 1-2,000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1,000 deliveries, the odds of a non-transfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99) CONCLUSIONS: Non-transfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297360","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.ajogmf.2024.101506
Douglas S Richards, Sarah J Ilstrup, M Sean Esplin, Donna Dizon-Townson, Allison M Butler, Brett D Einerson
<p><strong>Background: </strong>A common approach to attempt to reduce maternal morbidity from hemorrhage is to recognize patients at increased risk, and to make advance preparations for possible blood transfusion in these patients. Preparation may consist of a hold clot, type and screen, or crossmatch. Most hospitals, including ours, have pathways or guidelines that lay out which of these preparations should be made at the time a patient is admitted to labor and delivery. These are often based on risk factors for hemorrhage, but don't take into account the probability that transfusion will be needed. The cost effectiveness of performing a type and screen or routine crossmatch on patients admitted for delivery has been questioned. Several studies have shown that the chance of transfusions in individuals giving birth is very low. In terms of the need for routine blood preparation, the need for urgent transfusion is most relevant. This has not been included in studies of transfusion rates.</p><p><strong>Objectives: </strong>The purpose of this study was to quantify the relative importance of risk factors present on admission for needing a blood transfusion and to develop a formula to define each individual's risk. This could then be used to decide an appropriate level of initial blood preparation for patients at different risk levels.</p><p><strong>Study design: </strong>Risk factors for hemorrhage and the level of transfusion preparation were extracted from the medical records of a cohort of 89,881 patients delivering in an 18-hospital health care system over 40 months. We tabulated the number who required at least one RBC transfusion and the number needing an urgent transfusion- defined as receiving blood during labor or within 4 hours after delivery. Odds ratios for requiring a transfusion were calculated for each risk factor. We then calculated the probability of needing a transfusion for each patient based on their risk factor profile.</p><p><strong>Results: </strong>643 patients had any transfusion during their hospitalization (0.72 % of deliveries), and 311 had an urgent transfusion (0.35% of deliveries). The calculated probability of needing a transfusion was less than 1% in 87.8% of patients and was greater than 5% in 1.2% of patients. The chance of needing a transfusion was highest for placenta accreta spectrum, admission Hgb <8.0, and placenta previa. A second tier of risk factors included abruption, bleeding with no specific diagnosis, and Hgb between 8.0 and 10.0.</p><p><strong>Conclusion: </strong>In our cohort, very few patients received a transfusion. Applying a formula derived from patient- specific risk factors, we found that almost all patients have a very low probability of needing a transfusion, especially an urgent transfusion. Based on these results, we suggest that a hold clot be used except for the highest risk patients or in settings with barriers to procuring blood in the rare case of urgent transfusion need. Making this
{"title":"Risk factor stratification for urgent and non-urgent transfusion in patients giving birth.","authors":"Douglas S Richards, Sarah J Ilstrup, M Sean Esplin, Donna Dizon-Townson, Allison M Butler, Brett D Einerson","doi":"10.1016/j.ajogmf.2024.101506","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2024.101506","url":null,"abstract":"<p><strong>Background: </strong>A common approach to attempt to reduce maternal morbidity from hemorrhage is to recognize patients at increased risk, and to make advance preparations for possible blood transfusion in these patients. Preparation may consist of a hold clot, type and screen, or crossmatch. Most hospitals, including ours, have pathways or guidelines that lay out which of these preparations should be made at the time a patient is admitted to labor and delivery. These are often based on risk factors for hemorrhage, but don't take into account the probability that transfusion will be needed. The cost effectiveness of performing a type and screen or routine crossmatch on patients admitted for delivery has been questioned. Several studies have shown that the chance of transfusions in individuals giving birth is very low. In terms of the need for routine blood preparation, the need for urgent transfusion is most relevant. This has not been included in studies of transfusion rates.</p><p><strong>Objectives: </strong>The purpose of this study was to quantify the relative importance of risk factors present on admission for needing a blood transfusion and to develop a formula to define each individual's risk. This could then be used to decide an appropriate level of initial blood preparation for patients at different risk levels.</p><p><strong>Study design: </strong>Risk factors for hemorrhage and the level of transfusion preparation were extracted from the medical records of a cohort of 89,881 patients delivering in an 18-hospital health care system over 40 months. We tabulated the number who required at least one RBC transfusion and the number needing an urgent transfusion- defined as receiving blood during labor or within 4 hours after delivery. Odds ratios for requiring a transfusion were calculated for each risk factor. We then calculated the probability of needing a transfusion for each patient based on their risk factor profile.</p><p><strong>Results: </strong>643 patients had any transfusion during their hospitalization (0.72 % of deliveries), and 311 had an urgent transfusion (0.35% of deliveries). The calculated probability of needing a transfusion was less than 1% in 87.8% of patients and was greater than 5% in 1.2% of patients. The chance of needing a transfusion was highest for placenta accreta spectrum, admission Hgb <8.0, and placenta previa. A second tier of risk factors included abruption, bleeding with no specific diagnosis, and Hgb between 8.0 and 10.0.</p><p><strong>Conclusion: </strong>In our cohort, very few patients received a transfusion. Applying a formula derived from patient- specific risk factors, we found that almost all patients have a very low probability of needing a transfusion, especially an urgent transfusion. Based on these results, we suggest that a hold clot be used except for the highest risk patients or in settings with barriers to procuring blood in the rare case of urgent transfusion need. Making this ","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.ajogmf.2024.101501
Vincenzo Berghella, Victoria Adewale, Tanvi Rana, Giulia Bonanni, Suneet P Chauhan, Federica Bellussi, Dwight Rouse, Jon Barrett
With approximately 145 million births occurring worldwide each year - over 30 million by cesarean delivery, the need for evaluation of maternal and perinatal outcomes in different delivery scenarios is more pressing than ever. Recently, in a meta-analysis of the available randomized controlled trials (RCTs), planned cesarean delivery was associated with decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death. For mothers, planned cesarean delivery was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1-2 years. Conversely, planned vaginal delivery has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned cesarean delivery. Nonetheless, several risk factors for cesarean delivery are increasing - such as older maternal age, obesity, diabetes, excessive gestational weight gain, and birth weight - while maternal pelvises are getting smaller. Concerns about the potential long-term risks of multiple cesarean deliveries, such as placenta accreta spectrum disorders, highlight the need for a balanced evaluation of both delivery modes. However, the total fertility rate is decreasing in the US and around the world, with many people wanting two or fewer babies, which decreases future risk of placenta accreta incurred by multiple cesarean deliveries in these individuals. Furthermore, one in four obstetricians-gynecologists has undergone a cesarean delivery on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and cesarean delivery rates less than about 19% have been associated with higher perinatal and maternal mortality. Thus, we propose that it is imperative that we prioritize conducting randomized trials to compare planned cesarean to planned vaginal delivery for NSTV pregnancies. Such trials would need to include 8,000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including non-biologic outcomes such as patient satisfaction, postpartum depression, breastfeeding rates, mother-infant bonding, post-traumatic stress, and cost-effectiveness. The time for such a trial is now, as it holds the potential to inform and improve obstetrical care practices globally.
{"title":"What is the best mode of delivery in nulliparous, singleton, term, vertex pregnancies of individuals ≥ 35 years old?: Short title: What is the best mode of delivery in nulliparous, singleton, term, vertex pregnancies?","authors":"Vincenzo Berghella, Victoria Adewale, Tanvi Rana, Giulia Bonanni, Suneet P Chauhan, Federica Bellussi, Dwight Rouse, Jon Barrett","doi":"10.1016/j.ajogmf.2024.101501","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2024.101501","url":null,"abstract":"<p><p>With approximately 145 million births occurring worldwide each year - over 30 million by cesarean delivery, the need for evaluation of maternal and perinatal outcomes in different delivery scenarios is more pressing than ever. Recently, in a meta-analysis of the available randomized controlled trials (RCTs), planned cesarean delivery was associated with decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death. For mothers, planned cesarean delivery was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1-2 years. Conversely, planned vaginal delivery has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned cesarean delivery. Nonetheless, several risk factors for cesarean delivery are increasing - such as older maternal age, obesity, diabetes, excessive gestational weight gain, and birth weight - while maternal pelvises are getting smaller. Concerns about the potential long-term risks of multiple cesarean deliveries, such as placenta accreta spectrum disorders, highlight the need for a balanced evaluation of both delivery modes. However, the total fertility rate is decreasing in the US and around the world, with many people wanting two or fewer babies, which decreases future risk of placenta accreta incurred by multiple cesarean deliveries in these individuals. Furthermore, one in four obstetricians-gynecologists has undergone a cesarean delivery on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and cesarean delivery rates less than about 19% have been associated with higher perinatal and maternal mortality. Thus, we propose that it is imperative that we prioritize conducting randomized trials to compare planned cesarean to planned vaginal delivery for NSTV pregnancies. Such trials would need to include 8,000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including non-biologic outcomes such as patient satisfaction, postpartum depression, breastfeeding rates, mother-infant bonding, post-traumatic stress, and cost-effectiveness. The time for such a trial is now, as it holds the potential to inform and improve obstetrical care practices globally.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297380","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.ajogmf.2024.101507
Sydney M Thayer, Sarah Y Cohen, Samantha As Williams, Lori Stevenson, Kali Stewart, Bree Goodman, Nandini Raghuraman, Ebony B Carter, Anthony O Odibo, Jeannie C Kelly
{"title":"Optimizing Induction of Labor: the Birth Efficiency and Satisfaction Induction of Labor (BEST IOL) Study.","authors":"Sydney M Thayer, Sarah Y Cohen, Samantha As Williams, Lori Stevenson, Kali Stewart, Bree Goodman, Nandini Raghuraman, Ebony B Carter, Anthony O Odibo, Jeannie C Kelly","doi":"10.1016/j.ajogmf.2024.101507","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2024.101507","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297361","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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