Pub Date : 2026-01-28DOI: 10.1016/j.ajogmf.2026.101903
Claire Thuillier, Anne-Sophie Boucherie, Juliette François, Anne Rousseau, Patrick Rozenberg, Thibaud Quibel
Background: The optimal timing of delivery after a prior cesarean is debated. Induction of labor may reduce the risk of repeat cesarean delivery, but its safety remains unclear.
Objective: To assess the risks of cesarean delivery and maternal-neonatal morbidity associated with induction of labor versus expectant management from 38 weeks gestation onward in primiparous women with one prior cesarean delivery.
Study design: This secondary analysis of the randomized LUS Trial included primiparous women eligible for a trial of labor after cesarean from 38 weeks and 0 days. Cesarean delivery rates and maternal-fetal morbidity were compared according to the intended management strategy: induction of labor or expectant management. Comparisons were made between women who underwent induction of labor at a specific gestational week and those who remained pregnant at the end of that week (expectant management group). Maternal and neonatal morbidities were assessed using composite criteria. Multivariable logistic regression models were adjusted for maternal characteristics (body mass index, diabetes, hypertensive disorders, suspected macrosomia) and hospital status.
Results: Among the 2,948 LUS Trial participants, 2,267 primiparous women at ≥ 38 weeks of gestation with a prior cesarean delivery were eligible and 1,778 (78.4%) underwent a trial of labor after cesarean. Among them, 372 (20.9%) had an induction of labor and 1,406 (79.1%) had a spontaneous labor. The cesarean delivery rate was 44.2% (1,002/2,267) in the overall population. Cesarean delivery rates were similar in the induction of labor and expectant management groups week-by-week before 40 weeks 0 days. Induction of labor between 40 weeks 0 days and 40 weeks 6 days was associated with a significant lower cesarean delivery risk compared to expectant management beyond 41 weeks 0 days (adjusted OR 0.66, 95% CI 0.30 -0.87). Induction of labor at 39, 40, or 41 weeks was not associated with an increased composite maternal or neonatal morbidity.
Conclusion: In women with one prior cesarean delivery, induction of labor at 40 weeks compared with expectant management beyond 41 weeks reduces the cesarean delivery risk without increasing adverse maternal or neonatal outcomes.
背景：剖宫产后的最佳分娩时间是有争议的。引产可以降低再次剖宫产的风险，但其安全性尚不清楚。目的：评估有一次剖宫产史的初产妇在妊娠38周后剖宫产的风险和与引产相关的母婴发病率。研究设计：这项随机LUS试验的二级分析纳入了符合剖宫产后分娩试验条件的38周零0天的初产妇。根据预期的管理策略：引产或待产，比较剖宫产率和母胎发病率。对在特定妊娠周进行引产的妇女和在妊娠周结束时仍怀孕的妇女（待产管理组）进行比较。使用综合标准评估孕产妇和新生儿发病率。多变量logistic回归模型调整了产妇特征（体重指数、糖尿病、高血压疾病、疑似巨大儿）和医院状况。结果：在2,948名LUS试验参与者中，2,267名妊娠≥38周且有剖宫产史的初产妇符合条件，1,778名（78.4%）接受了剖宫产后的分娩试验。其中引产372例（20.9%），自然分娩1406例（79.1%）。剖宫产率为44.2%（1,002/2,267）。引产组和待产组在40周0天前各周剖宫产率相似。与41周0天以上的孕妇相比，40周0天至40周6天的引产与剖宫产风险显著降低相关（调整OR 0.66, 95% CI 0.30 -0.87）。39、40或41周引产与孕产妇或新生儿综合发病率增加无关。结论：对于有过一次剖宫产史的妇女，40周引产与41周以上的准产相比，可降低剖宫产的风险，且不会增加产妇或新生儿的不良结局。
{"title":"Impact of labor induction on cesarean risk and maternal-fetal outcomes by gestational age in primiparas with a previous cesarean delivery: LUSTrial secondary analysis.","authors":"Claire Thuillier, Anne-Sophie Boucherie, Juliette François, Anne Rousseau, Patrick Rozenberg, Thibaud Quibel","doi":"10.1016/j.ajogmf.2026.101903","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2026.101903","url":null,"abstract":"<p><strong>Background: </strong>The optimal timing of delivery after a prior cesarean is debated. Induction of labor may reduce the risk of repeat cesarean delivery, but its safety remains unclear.</p><p><strong>Objective: </strong>To assess the risks of cesarean delivery and maternal-neonatal morbidity associated with induction of labor versus expectant management from 38 weeks gestation onward in primiparous women with one prior cesarean delivery.</p><p><strong>Study design: </strong>This secondary analysis of the randomized LUS Trial included primiparous women eligible for a trial of labor after cesarean from 38 weeks and 0 days. Cesarean delivery rates and maternal-fetal morbidity were compared according to the intended management strategy: induction of labor or expectant management. Comparisons were made between women who underwent induction of labor at a specific gestational week and those who remained pregnant at the end of that week (expectant management group). Maternal and neonatal morbidities were assessed using composite criteria. Multivariable logistic regression models were adjusted for maternal characteristics (body mass index, diabetes, hypertensive disorders, suspected macrosomia) and hospital status.</p><p><strong>Results: </strong>Among the 2,948 LUS Trial participants, 2,267 primiparous women at ≥ 38 weeks of gestation with a prior cesarean delivery were eligible and 1,778 (78.4%) underwent a trial of labor after cesarean. Among them, 372 (20.9%) had an induction of labor and 1,406 (79.1%) had a spontaneous labor. The cesarean delivery rate was 44.2% (1,002/2,267) in the overall population. Cesarean delivery rates were similar in the induction of labor and expectant management groups week-by-week before 40 weeks 0 days. Induction of labor between 40 weeks 0 days and 40 weeks 6 days was associated with a significant lower cesarean delivery risk compared to expectant management beyond 41 weeks 0 days (adjusted OR 0.66, 95% CI 0.30 -0.87). Induction of labor at 39, 40, or 41 weeks was not associated with an increased composite maternal or neonatal morbidity.</p><p><strong>Conclusion: </strong>In women with one prior cesarean delivery, induction of labor at 40 weeks compared with expectant management beyond 41 weeks reduces the cesarean delivery risk without increasing adverse maternal or neonatal outcomes.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":" ","pages":"101903"},"PeriodicalIF":3.1,"publicationDate":"2026-01-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146094388","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 : 2026-01-28DOI: 10.1016/j.ajogmf.2026.101895
Andrea Henkel, Amythis Soltani, Samantha Kay Wagner, Kate A Shaw
{"title":"The impact of lactation after loss on reproductive grief: a planned secondary analysis of a randomized trial.","authors":"Andrea Henkel, Amythis Soltani, Samantha Kay Wagner, Kate A Shaw","doi":"10.1016/j.ajogmf.2026.101895","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2026.101895","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":" ","pages":"101895"},"PeriodicalIF":3.1,"publicationDate":"2026-01-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146094348","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 : 2026-01-28DOI: 10.1016/j.ajogmf.2026.101904
Amir Snir, Omri Zamstein, Tamar Wainstock, Eyal Sheiner
{"title":"Small for Gestational Age and Autism Spectrum Disorder in Childhood: Investigating a Potential Contributory Association.","authors":"Amir Snir, Omri Zamstein, Tamar Wainstock, Eyal Sheiner","doi":"10.1016/j.ajogmf.2026.101904","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2026.101904","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":" ","pages":"101904"},"PeriodicalIF":3.1,"publicationDate":"2026-01-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146094374","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 : 2026-01-25DOI: 10.1016/j.ajogmf.2026.101902
Daniel R. Liesman MD, Steven T. Papastefan MD, Manmeet Singh MS, Amir M. Alhajjat MD, Aimen F. Shaaban MD, Ashish Premkumar MD, PhD
{"title":"Factors associated with the uptake of prenatal repair for fetal myelomeningocele","authors":"Daniel R. Liesman MD, Steven T. Papastefan MD, Manmeet Singh MS, Amir M. Alhajjat MD, Aimen F. Shaaban MD, Ashish Premkumar MD, PhD","doi":"10.1016/j.ajogmf.2026.101902","DOIUrl":"10.1016/j.ajogmf.2026.101902","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"8 4","pages":"Article 101902"},"PeriodicalIF":3.1,"publicationDate":"2026-01-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146067362","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 : 2026-01-24DOI: 10.1016/j.ajogmf.2026.101901
Maurizio Di Serio, Enrico Corno, Sara dell'Omo, Patrizia Melioli, Giorgia Contardi, Adriane Nigro, Serena Neri, Tullio Ghi, Andrea Dall'Asta
Objective: To evaluate the correlation between levator ani muscle (LAM) coactivation and labor outcome in a cohort of nulliparous women with singleton gestation at term.
Methods: Single-centre prospective observational study including nulliparous women with low-risk term pregnancy with cephalic presenting fetus enrolled between 39 and 40 weeks of gestation. At routine term obstetric assessment, trained midwives performed transperineal ultrasound on the midsagittal plane to evaluate the antero-posterior diameter of the LAM. The minimal distance between the postero-inferior border of the pubic symphysis and the anterior border of the puborectalis muscle was evaluated at rest and at the acme of a pushing effort. LAM coactivation was defined as a reduction of the antero-posterior diameter of the levator hiatus during the pushing efforts. The primary outcome was to compare the duration of the second stage of labor between coactivating versus non-coactivating women and evaluate the occurrence of composite adverse labor outcome (CAO) as defined by the occurrence of any among episiotomy, vacuum or cesarean delivery for second stage dystocia, obstetric anal sphincter inury (OASI) and severe post-partum hemorrhage.
Results: 201 women were included, of whom 42 (20.9%) had LAM coactivation. Women with LAM coactivation showed longer active second stage duration when compared to the non-coactivation group (84±50 minutes vs 64±45, p=0.02) and higher rates of CAO (31.0% vs 12.5%, p<0.01) and OASI (5.4% vs 0%, p<0.01). LAM coactivation only was associated with composite adverse labor outcome (34.3% vs 18.1%, p<0.01).
Conclusions: Within a population of singleton term pregnancies at low risk the antepartum demonstration of LAM coactivation at TP ultrasound is associated with an increased duration of the second stage of labor and higher frequency of CAO including OASIs.
目的：探讨未生育足月单胎妊娠妇女提肛肌（LAM）协同激活与分娩结局的关系。方法：单中心前瞻性观察研究，纳入孕39 ~ 40周的低危足月未生育且胎儿头位的妇女。在常规的产科评估中，训练有素的助产士在正中矢状面进行经会阴超声来评估LAM的前后直径。耻骨联合后下边界和耻骨直肠肌前边界之间的最小距离在休息和推力的顶点时进行评估。LAM共激活被定义为推入过程中提上睑肌裂孔前后直径减小。主要结局是比较共激活与非共激活妇女的第二阶段分娩持续时间，并评估复合不良分娩结局（CAO）的发生情况，其定义为在会阴切开术、真空或剖宫产中发生任何第二阶段难产、产科肛门括约肌损伤（OASI）和严重产后出血。结果：纳入201例妇女，其中42例（20.9%）发生LAM共激活。与非共激活组相比，LAM共激活组的活跃第二阶段持续时间更长（84±50分钟vs 64±45分钟，p=0.02）， CAO发生率更高（31.0% vs 12.5%）。结论：在低风险单胎足月妊娠人群中，产前超声显示LAM共激活与第二产程持续时间增加和CAO（包括OASIs）频率更高有关。
{"title":"Antepartum two-dimensional sonographic evaluation of levator ani muscle coactivation and correlation with labor outcomes in nulliparous women at term gestation.","authors":"Maurizio Di Serio, Enrico Corno, Sara dell'Omo, Patrizia Melioli, Giorgia Contardi, Adriane Nigro, Serena Neri, Tullio Ghi, Andrea Dall'Asta","doi":"10.1016/j.ajogmf.2026.101901","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2026.101901","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the correlation between levator ani muscle (LAM) coactivation and labor outcome in a cohort of nulliparous women with singleton gestation at term.</p><p><strong>Methods: </strong>Single-centre prospective observational study including nulliparous women with low-risk term pregnancy with cephalic presenting fetus enrolled between 39 and 40 weeks of gestation. At routine term obstetric assessment, trained midwives performed transperineal ultrasound on the midsagittal plane to evaluate the antero-posterior diameter of the LAM. The minimal distance between the postero-inferior border of the pubic symphysis and the anterior border of the puborectalis muscle was evaluated at rest and at the acme of a pushing effort. LAM coactivation was defined as a reduction of the antero-posterior diameter of the levator hiatus during the pushing efforts. The primary outcome was to compare the duration of the second stage of labor between coactivating versus non-coactivating women and evaluate the occurrence of composite adverse labor outcome (CAO) as defined by the occurrence of any among episiotomy, vacuum or cesarean delivery for second stage dystocia, obstetric anal sphincter inury (OASI) and severe post-partum hemorrhage.</p><p><strong>Results: </strong>201 women were included, of whom 42 (20.9%) had LAM coactivation. Women with LAM coactivation showed longer active second stage duration when compared to the non-coactivation group (84±50 minutes vs 64±45, p=0.02) and higher rates of CAO (31.0% vs 12.5%, p<0.01) and OASI (5.4% vs 0%, p<0.01). LAM coactivation only was associated with composite adverse labor outcome (34.3% vs 18.1%, p<0.01).</p><p><strong>Conclusions: </strong>Within a population of singleton term pregnancies at low risk the antepartum demonstration of LAM coactivation at TP ultrasound is associated with an increased duration of the second stage of labor and higher frequency of CAO including OASIs.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":" ","pages":"101901"},"PeriodicalIF":3.1,"publicationDate":"2026-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146053739","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 : 2026-01-21DOI: 10.1016/j.ajogmf.2026.101898
Kylie Cataldo, Robert Long, Isoken Olomu, Rene Cortese, Hanne M Hoffmann
Background: Spontaneous labor onset peaks during the late evening and early morning hours, indicating a circadian influence on parturition. However, the effect of the time of day of labor induction on labor duration and obstetrical outcomes remains unexplored. We hypothesize that the time of day of labor induction affects induction of labor duration and the risk of cesarean delivery.
Objective: This study aimed to determine whether the time of day of labor induction impacts induction of labor duration and delivery outcomes in term pregnancies, and whether maternal characteristics such as body mass index and parity modulate this effect.
Study design: This retrospective cohort study analyzed 3363 term pregnant participants who underwent induction at a single US hospital between 2019 and 2022. Time of induction was defined as the time of administration of the first cervical ripening agent or synthetic oxytocin (ie, Pitocin). Induction of labor duration was calculated as the time from induction to delivery. Multivariable analyses, survival models, and circadian rhythm analyses were performed to evaluate associations between time of day of labor induction, induction of labor duration, cesarean delivery, and neonatal outcomes.
Results: Induction of labor duration followed a significant circadian rhythm (P<.05, Lomb-Scargle), with a gradual lengthening in duration when induction was initiated later in the day, peaking at 11:00 ᴘᴍ (average duration of 21.0 vs 14.8 hours at 5:00 ᴀᴍ; P<.01, Kruskal-Wallis test). Participants induced during the early morning had up to 6 hours shorter labor compared with those induced in the late evening (P<.01). The optimal time of day for initiating labor induction was influenced by body mass index and parity, with significant differences in delivery probability by time of day of labor induction among nulliparous obese (P<.05, 2-way analysis of variance), and parous obese participants (P<.05). Time of induction was associated with reduced cesarean delivery rates and did not impact rates of neonatal intensive care unit admission or adverse neonatal outcomes.
Conclusion: The time of day when labor induction was initiated influenced induction of labor duration, with the shortest duration observed when induction occurred during early morning hours. No increase in adverse maternal or fetal outcomes was identified after accounting for the time of day of labor induction. The optimal time of day for inducing labor is influenced by body mass index and parity and should be considered when performing this common obstetrical intervention.
{"title":"Time of day of induction impacts the total duration of labor.","authors":"Kylie Cataldo, Robert Long, Isoken Olomu, Rene Cortese, Hanne M Hoffmann","doi":"10.1016/j.ajogmf.2026.101898","DOIUrl":"10.1016/j.ajogmf.2026.101898","url":null,"abstract":"<p><strong>Background: </strong>Spontaneous labor onset peaks during the late evening and early morning hours, indicating a circadian influence on parturition. However, the effect of the time of day of labor induction on labor duration and obstetrical outcomes remains unexplored. We hypothesize that the time of day of labor induction affects induction of labor duration and the risk of cesarean delivery.</p><p><strong>Objective: </strong>This study aimed to determine whether the time of day of labor induction impacts induction of labor duration and delivery outcomes in term pregnancies, and whether maternal characteristics such as body mass index and parity modulate this effect.</p><p><strong>Study design: </strong>This retrospective cohort study analyzed 3363 term pregnant participants who underwent induction at a single US hospital between 2019 and 2022. Time of induction was defined as the time of administration of the first cervical ripening agent or synthetic oxytocin (ie, Pitocin). Induction of labor duration was calculated as the time from induction to delivery. Multivariable analyses, survival models, and circadian rhythm analyses were performed to evaluate associations between time of day of labor induction, induction of labor duration, cesarean delivery, and neonatal outcomes.</p><p><strong>Results: </strong>Induction of labor duration followed a significant circadian rhythm (P<.05, Lomb-Scargle), with a gradual lengthening in duration when induction was initiated later in the day, peaking at 11:00 ᴘᴍ (average duration of 21.0 vs 14.8 hours at 5:00 ᴀᴍ; P<.01, Kruskal-Wallis test). Participants induced during the early morning had up to 6 hours shorter labor compared with those induced in the late evening (P<.01). The optimal time of day for initiating labor induction was influenced by body mass index and parity, with significant differences in delivery probability by time of day of labor induction among nulliparous obese (P<.05, 2-way analysis of variance), and parous obese participants (P<.05). Time of induction was associated with reduced cesarean delivery rates and did not impact rates of neonatal intensive care unit admission or adverse neonatal outcomes.</p><p><strong>Conclusion: </strong>The time of day when labor induction was initiated influenced induction of labor duration, with the shortest duration observed when induction occurred during early morning hours. No increase in adverse maternal or fetal outcomes was identified after accounting for the time of day of labor induction. The optimal time of day for inducing labor is influenced by body mass index and parity and should be considered when performing this common obstetrical intervention.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":" ","pages":"101898"},"PeriodicalIF":3.1,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146041685","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 : 2026-01-21DOI: 10.1016/j.ajogmf.2026.101893
Daisy León-Martínez, Venise Curry, Kristin Carraway, Cinthia Blat, Kimberly Coleman-Phox, Bridgette E Blebu, Deborah Karasek, Brittany D Chambers Butcher, Patience A Afulani, Martha A Tesfalul, Jennifer N Felder, Guadalupe R Ramirez, Mary A Garza, Lauren Lessard, Christopher Downer, Larry Rand, Charles E McCulloch, Miriam Kuppermann
{"title":"Comparative effectiveness of two enhanced prenatal care models on preterm birth: An exploratory analysis of the EMBRACE randomized trial.","authors":"Daisy León-Martínez, Venise Curry, Kristin Carraway, Cinthia Blat, Kimberly Coleman-Phox, Bridgette E Blebu, Deborah Karasek, Brittany D Chambers Butcher, Patience A Afulani, Martha A Tesfalul, Jennifer N Felder, Guadalupe R Ramirez, Mary A Garza, Lauren Lessard, Christopher Downer, Larry Rand, Charles E McCulloch, Miriam Kuppermann","doi":"10.1016/j.ajogmf.2026.101893","DOIUrl":"https://doi.org/10.1016/j.ajogmf.2026.101893","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":" ","pages":"101893"},"PeriodicalIF":3.1,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146041614","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 : 2026-01-21DOI: 10.1016/j.ajogmf.2026.101897
Ilaria Paladino MD , Vincenzo Berghella MD
<div><h3>Background</h3><div>Several studies compared induction of labor to expectant management in singleton pregnancies with suspected large-for-gestational-age (LGA) or macrosomic fetuses. However, the most appropriate management, including the option of induction of labor, and at what gestational age, remains unclear.</div></div><div><h3>Objective</h3><div>To evaluate the effects of labor induction for pregnancies with LGA or macrosomic fetuses on mode of delivery, and maternal and perinatal morbidity, and to evaluate the best gestational age for such induction if beneficial.</div></div><div><h3>Study design</h3><div>A systematic literature search of electronic databases was conducted through November 1, 2025. Randomized controlled trials (RCTs) including term singleton pregnancies with suspected large-for-gestational-age (LGA) or macrosomic fetuses comparing induction of labor (IOL) with expectant management were included. The primary outcome was cesarean delivery, with secondary maternal and neonatal outcomes assessed. Pooled estimates were initially calculated using a fixed-effects model; random-effects analyses using a restricted maximum likelihood (REML) estimator were subsequently performed and heterogeneity was assessed using the I² and τ² statistics.</div></div><div><h3>Results</h3><div>Five randomized trials including 4083 pregnant individuals were analyzed. Baseline characteristics were comparable between groups. Most participants underwent induction at 38 weeks with the largest RCT (71% of the total sample of this meta-analysis), inducing labor at 38 0/7 to 38 4/7 weeks, for LGA > 90th percentile. For the primary outcome, IOL was associated with significant lower risk of cesarean delivery (27.9% vs 31.9%; risk ratio 0.87, 95% confidence interval 0.79 to 0.96) with no heterogeneity. Among secondary outcomes, induction of labor reduced the incidence of macrosomia ≥4000 g (RR 0.53, 95% CI, 0.48 to 0.59) and ≥4500 g (RR 0.22, 95% CI, 0.12 to 0.39). Shoulder dystocia (RR 0.73, 95% CI, 0.50 to 1.03) and fetal fracture (RR 0.35, 95% CI, 0.12 to 1.05) showed a trend toward risk reduction without reaching statistical significance in random-effects analyses. Phototherapy was more frequent following induction of labor (RR 1.62, 95% CI, 1.17 to 2.25), whereas other neonatal and maternal outcomes did not differ significantly between groups.</div></div><div><h3>Conclusion</h3><div>Induction of labor between 38 0/7 to 38 4/7 weeks for suspected LGA (EFW >90th percentile) or macrosomic fetuses may be a reasonable management option, as it is associated with significant reductions in cesarean delivery, and a potential reduction in shoulder dystocia, and neonatal fractures, compared to expectant management. As the strongest evidence derives from induction at 38 0/7 to 38 4/7 weeks, counseling should emphasize this gestational window. Approximately 25 inductions of labor for EFW >90th percentile at 38 0/7 to 38 4/7 weeks would be required to
背景：几项研究比较了怀疑大胎龄（LGA）或巨大胎儿的单胎妊娠引产和待产管理。然而，最适当的管理，包括引产的选择，以及在什么胎龄，仍不清楚。目的：评价LGA或巨大胎儿妊娠引产对分娩方式、孕产妇及围产儿发病率的影响，并评价引产的最佳胎龄。研究设计：对电子数据库进行系统文献检索，截止日期为2025年11月1日。随机对照试验（RCTs）包括怀疑胎龄大的足月单胎妊娠（LGA）或巨大胎儿，比较引产（IOL）与预期管理。主要结局是剖宫产，其次是孕产妇和新生儿结局。混合估计最初使用固定效应模型计算；随后使用受限最大似然（REML）估计器进行随机效应分析，并使用I²和τ²统计量评估异质性。结果：分析了5项随机试验，包括4083名孕妇。各组间基线特征具有可比性。大多数参与者在38周时进行了引产，最大的RCT（占该荟萃分析总样本的71%），在38周0/7 - 38周4/7引产，LGA bb0第90百分位。对于主要结局，人工晶状体与剖宫产风险显著降低相关（27.9% vs 31.9%；风险比0.87,95%可信区间0.79-0.96）。没有异质性。在次要结局中，引产降低了巨大儿≥4000 g （RR 0.53, 95% CI 0.48-0.59）和≥4500 g （RR 0.22, 95% CI 0.12-0.39）的发生率。在随机效应分析中，肩难产（RR 0.73, 95% CI 0.50-1.03）和胎儿骨折（RR 0.35, 95% CI 0.12-1.05）有降低风险的趋势，但无统计学意义。引产后光疗更常见（RR 1.62, 95% CI 1.17-2.25），而其他新生儿和产妇结局在两组间无显著差异。结论：对于疑似LGA （EFW bb0 90百分位数）或巨大胎儿，在38 0/7 - 38 4/7周引产可能是一个合理的处理选择，因为与预期处理相比，它与剖宫产的显著减少有关，并且可能减少肩部难产和新生儿骨折。由于最有力的证据来自于38 0/7 - 38 4/7周的引产，咨询应强调这一妊娠窗口期。在38 0/7 - 38 4/7周时，EFW bb的第90百分位需要大约25次引产才能防止一次剖宫产。
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Pub Date : 2026-01-20DOI: 10.1016/j.ajogmf.2026.101891
Alesha White MD , Jessica E. Pruszynski PhD , Quyen N. Do PhD , Diane M. Twickler MD , Catherine Y. Spong MD , Christina L. Herrera MD
<div><h3>BACKGROUND</h3><div>Antenatal diagnosis of placenta accreta spectrum is imperfect, with cases undiagnosed before delivery, resulting in suboptimal outcomes. Currently, there is no agreed-upon standardized protocol for risk stratification of placenta accreta spectrum. Most patients are identified in the second or third trimester of pregnancy, although findings on first-trimester ultrasound may be associated with the development of placenta accreta spectrum. To date, there is no recommended risk stratification algorithm that applies first-trimester findings in a systematic manner with outcome data.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to develop a risk stratification algorithm for placenta accreta spectrum in the first trimester of pregnancy in symptomatic patients.</div></div><div><h3>STUDY DESIGN</h3><div>A retrospective observational study of first-trimester sonograms between January 2021 and February 2024 compared the performance of low implantation with previous cesarean delivery to a newly developed risk stratification algorithm. Low implantation was diagnosed when the distance of the inferior border of trophoblastic change or the border of the gestational sac was ≤5 cm from the external os on ultrasound imaging. Pregnancies were analyzed based on gestational sac location (<10 weeks of gestation) or decidual basalis (≥10 weeks of gestation) and the smallest myometrial thickness to assess placenta accreta spectrum risk. Test parameters of low implantation and the new risk stratification algorithm were calculated. Interreader variability of the smallest myometrial thickness measurement using the kappa statistic and the McNemar test was performed.</div></div><div><h3>RESULTS</h3><div>Of 6213 patients with first-trimester sonography and known delivery outcome, 1252 had a previous cesarean delivery. Moreover, 257 of 1252 patients (20.5%) had low implantation. Of the 12 patients with confirmed placenta accreta spectrum, 10 had low implantation. The sensitivity, specificity, and positive predictive value of low implantation for placenta accreta spectrum were 83.3%, 80.0%, and 3.8%, respectively. Of the 257 patients, 245 had adequate images to test the new algorithm. Of the 245 patients, 10 (4.1%) screened positive. Placenta accreta spectrum was confirmed in 9 of 10 patients with positive screens, with sensitivity, specificity, and positive predictive value for placenta accreta spectrum of 90.0%, 99.6%, and 90.0%, respectively. Weighted kappa statistic of 0.65 (95% confidence interval, 0.46–0.83) and a McNemar test <em>P</em> value of .24 indicated substantial agreement.</div></div><div><h3>CONCLUSION</h3><div>Our first-trimester risk stratification algorithm was more sensitive and specific for placenta accreta spectrum with higher positive predictive value when compared to low implantation with previous cesarean delivery alone. In addition, interreader agreement was high. Future prospective studies to validate this ris
{"title":"First-trimester risk stratification algorithm for placenta accreta spectrum","authors":"Alesha White MD , Jessica E. Pruszynski PhD , Quyen N. Do PhD , Diane M. Twickler MD , Catherine Y. Spong MD , Christina L. Herrera MD","doi":"10.1016/j.ajogmf.2026.101891","DOIUrl":"10.1016/j.ajogmf.2026.101891","url":null,"abstract":"<div><h3>BACKGROUND</h3><div>Antenatal diagnosis of placenta accreta spectrum is imperfect, with cases undiagnosed before delivery, resulting in suboptimal outcomes. Currently, there is no agreed-upon standardized protocol for risk stratification of placenta accreta spectrum. Most patients are identified in the second or third trimester of pregnancy, although findings on first-trimester ultrasound may be associated with the development of placenta accreta spectrum. To date, there is no recommended risk stratification algorithm that applies first-trimester findings in a systematic manner with outcome data.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to develop a risk stratification algorithm for placenta accreta spectrum in the first trimester of pregnancy in symptomatic patients.</div></div><div><h3>STUDY DESIGN</h3><div>A retrospective observational study of first-trimester sonograms between January 2021 and February 2024 compared the performance of low implantation with previous cesarean delivery to a newly developed risk stratification algorithm. Low implantation was diagnosed when the distance of the inferior border of trophoblastic change or the border of the gestational sac was ≤5 cm from the external os on ultrasound imaging. Pregnancies were analyzed based on gestational sac location (<10 weeks of gestation) or decidual basalis (≥10 weeks of gestation) and the smallest myometrial thickness to assess placenta accreta spectrum risk. Test parameters of low implantation and the new risk stratification algorithm were calculated. Interreader variability of the smallest myometrial thickness measurement using the kappa statistic and the McNemar test was performed.</div></div><div><h3>RESULTS</h3><div>Of 6213 patients with first-trimester sonography and known delivery outcome, 1252 had a previous cesarean delivery. Moreover, 257 of 1252 patients (20.5%) had low implantation. Of the 12 patients with confirmed placenta accreta spectrum, 10 had low implantation. The sensitivity, specificity, and positive predictive value of low implantation for placenta accreta spectrum were 83.3%, 80.0%, and 3.8%, respectively. Of the 257 patients, 245 had adequate images to test the new algorithm. Of the 245 patients, 10 (4.1%) screened positive. Placenta accreta spectrum was confirmed in 9 of 10 patients with positive screens, with sensitivity, specificity, and positive predictive value for placenta accreta spectrum of 90.0%, 99.6%, and 90.0%, respectively. Weighted kappa statistic of 0.65 (95% confidence interval, 0.46–0.83) and a McNemar test <em>P</em> value of .24 indicated substantial agreement.</div></div><div><h3>CONCLUSION</h3><div>Our first-trimester risk stratification algorithm was more sensitive and specific for placenta accreta spectrum with higher positive predictive value when compared to low implantation with previous cesarean delivery alone. In addition, interreader agreement was high. Future prospective studies to validate this ris","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"8 4","pages":"Article 101891"},"PeriodicalIF":3.1,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146020110","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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