Pub Date : 2024-09-30DOI: 10.1016/j.ajogmf.2024.101508
Uma M. Reddy MD, MPH , Grecio J. Sandoval PhD , Alan T.N. Tita MD, PhD , Robert M. Silver MD , Gail Mallett RN, MS, CCRC , Kim Hill RN, BSN , Yasser Y. El-Sayed MD , Madeline Murguia Rice PhD , Ronald J. Wapner MD , Dwight J. Rouse MD , George R. Saade MD , John M. Thorp Jr MD , Suneet P. Chauhan MD, Hon DSc , Maged M. Costantine MD , Edward K. Chien MD , Brian M. Casey MD , Sindhu K. Srinivas MD, MSCE , Geeta K. Swamy MD , Hyagriv N. Simhan MD , George A. Macones MD, MSCE , William A. Grobman MD, MBA
<div><h3>BACKGROUND</h3><div>Following the results of the A Randomized Trial of Induction Versus Expectant Management trial, which demonstrated a reduction in cesarean delivery with no increase in adverse perinatal outcomes after elective induction of labor in low-risk nulliparous patients at 39 weeks of gestation compared with expectant management, the use of induction of labor has increased. Current evidence is insufficient to recommend mid- to high-dose regimens over low-dose regimens for routine induction of labor.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to evaluate the association between oxytocin regimen and cesarean delivery and an adverse perinatal composite outcome in low-risk nulliparous patients undergoing induction of labor at ≥39 weeks of gestation.</div></div><div><h3>STUDY DESIGN</h3><div>This was a secondary analysis of the <em>Eunice Kennedy Shriver</em> National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network's A Randomized Trial of Induction Versus Expectant Management randomized trial. Patients who received a mid- to high-dose oxytocin regimen (starting or incremental increase >2 mU/min) were compared with those who received a low-dose oxytocin regimen (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. Multivariate Poisson regression was used to estimate adjusted relative risks and 97.5% confidence intervals for the co-primary endpoints and 95% confidence intervals for binomial outcomes, and multinomial logistic regression was used to estimate adjusted odds ratios and 95% adjusted relative risks for multinomial outcomes.</div></div><div><h3>RESULTS</h3><div>Of 6106 participants enrolled in the primary trial, 2933 underwent induction of labor with oxytocin: 861 in the mid- to high-dose group and 2072 in the low-dose group. The lower frequency of cesarean delivery in the mid- to high-dose group than in the low-dose group (20.3% vs 25.2%, respectively; relative risk, 0.81; 95% confidence interval, 0.69–0.94) was not significant after adjustment (adjusted relative risk, 0.90; 97.5% confidence interval, 0.76–1.07). The composite of perinatal death or severe neonatal complications was more frequent in the mid- to high-dose group than in the low-dose group (6.7% vs 4.3%, respectively; relative risk, 1.55; 95% confidence interval, 1.13–2.14) and remained significant after adjustment (adjusted relative risk, 1.61; 97.5% confidence interval, 1.11–2.35). Most cases in the composite were from the respiratory support (5.2% in the mid- to high-dose group vs 3.1% in the low-dose group) component, with an increase in transient tachypnea in newborns (3.8% in the mid- to high-dose group vs 2.5% in the low-dose group; adjusted relative risk, 1.63; 95% confidence interval, 1.04–2.54). The duration of neonatal respiratory support for 1 day was sign
{"title":"Oxytocin regimen used for induction of labor and pregnancy outcomes","authors":"Uma M. Reddy MD, MPH , Grecio J. Sandoval PhD , Alan T.N. Tita MD, PhD , Robert M. Silver MD , Gail Mallett RN, MS, CCRC , Kim Hill RN, BSN , Yasser Y. El-Sayed MD , Madeline Murguia Rice PhD , Ronald J. Wapner MD , Dwight J. Rouse MD , George R. Saade MD , John M. Thorp Jr MD , Suneet P. Chauhan MD, Hon DSc , Maged M. Costantine MD , Edward K. Chien MD , Brian M. Casey MD , Sindhu K. Srinivas MD, MSCE , Geeta K. Swamy MD , Hyagriv N. Simhan MD , George A. Macones MD, MSCE , William A. Grobman MD, MBA","doi":"10.1016/j.ajogmf.2024.101508","DOIUrl":"10.1016/j.ajogmf.2024.101508","url":null,"abstract":"<div><h3>BACKGROUND</h3><div>Following the results of the A Randomized Trial of Induction Versus Expectant Management trial, which demonstrated a reduction in cesarean delivery with no increase in adverse perinatal outcomes after elective induction of labor in low-risk nulliparous patients at 39 weeks of gestation compared with expectant management, the use of induction of labor has increased. Current evidence is insufficient to recommend mid- to high-dose regimens over low-dose regimens for routine induction of labor.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to evaluate the association between oxytocin regimen and cesarean delivery and an adverse perinatal composite outcome in low-risk nulliparous patients undergoing induction of labor at ≥39 weeks of gestation.</div></div><div><h3>STUDY DESIGN</h3><div>This was a secondary analysis of the <em>Eunice Kennedy Shriver</em> National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network's A Randomized Trial of Induction Versus Expectant Management randomized trial. Patients who received a mid- to high-dose oxytocin regimen (starting or incremental increase >2 mU/min) were compared with those who received a low-dose oxytocin regimen (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. Multivariate Poisson regression was used to estimate adjusted relative risks and 97.5% confidence intervals for the co-primary endpoints and 95% confidence intervals for binomial outcomes, and multinomial logistic regression was used to estimate adjusted odds ratios and 95% adjusted relative risks for multinomial outcomes.</div></div><div><h3>RESULTS</h3><div>Of 6106 participants enrolled in the primary trial, 2933 underwent induction of labor with oxytocin: 861 in the mid- to high-dose group and 2072 in the low-dose group. The lower frequency of cesarean delivery in the mid- to high-dose group than in the low-dose group (20.3% vs 25.2%, respectively; relative risk, 0.81; 95% confidence interval, 0.69–0.94) was not significant after adjustment (adjusted relative risk, 0.90; 97.5% confidence interval, 0.76–1.07). The composite of perinatal death or severe neonatal complications was more frequent in the mid- to high-dose group than in the low-dose group (6.7% vs 4.3%, respectively; relative risk, 1.55; 95% confidence interval, 1.13–2.14) and remained significant after adjustment (adjusted relative risk, 1.61; 97.5% confidence interval, 1.11–2.35). Most cases in the composite were from the respiratory support (5.2% in the mid- to high-dose group vs 3.1% in the low-dose group) component, with an increase in transient tachypnea in newborns (3.8% in the mid- to high-dose group vs 2.5% in the low-dose group; adjusted relative risk, 1.63; 95% confidence interval, 1.04–2.54). The duration of neonatal respiratory support for 1 day was sign","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 12","pages":"Article 101508"},"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 : 2024-09-26DOI: 10.1016/j.ajogmf.2024.101493
Amanda Roman MD , Alexandra Ramirez MD , Nathan S. Fox MD
{"title":"Corrigendum to ‘Prevention of preterm birth in twin pregnancies’ American Journal of Obstetrics & Gynecology MFM/ Volume 4 (2022) 100551","authors":"Amanda Roman MD , Alexandra Ramirez MD , Nathan S. Fox MD","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":"6 10","pages":"Article 101493"},"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 : 2024-09-23DOI: 10.1016/j.ajogmf.2024.101504
Rachel S. Ruderman MD, MPH, Sunitha C. Suresh MD, Ashish Premkumar MD, PhD, Jungeun Lee MS, Olivert Mbah MPH, Melinique Walls BA, Emily White Vangompel MD, MPH
{"title":"Validation of the Patient-Reported Outcomes Measurement Information System Medication Adherence Scale for pregnant patients taking aspirin","authors":"Rachel S. Ruderman MD, MPH, Sunitha C. Suresh MD, Ashish Premkumar MD, PhD, Jungeun Lee MS, Olivert Mbah MPH, Melinique Walls BA, Emily White Vangompel MD, MPH","doi":"10.1016/j.ajogmf.2024.101504","DOIUrl":"10.1016/j.ajogmf.2024.101504","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101504"},"PeriodicalIF":3.8,"publicationDate":"2024-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142355718","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 : 2024-09-21DOI: 10.1016/j.ajogmf.2024.101500
Carmen M.A. Santoli MD , Shakthi Unnithan MS , Tracy Truong MS , Sarah K. Dotters-Katz MD, MMHPE , Jerome J. Federspiel MD, PhD
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.
Objective
We investigated the relationship between facility delivery volume and rates of nontransfusion 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 nontransfusion 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 nontransfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, nontransfusion 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). Nontransfusion SMM occurred in 7% of patients readmitted to facilities with >2000 deliveries compared to 9% with 1 to 2000 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 1000 deliveries, the odds of a nontransfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99).
Conclusion
Nontransfusion 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. Santoli MD , Shakthi Unnithan MS , Tracy Truong MS , Sarah K. Dotters-Katz MD, MMHPE , Jerome J. Federspiel MD, PhD","doi":"10.1016/j.ajogmf.2024.101500","DOIUrl":"10.1016/j.ajogmf.2024.101500","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Objective</h3><div>We investigated the relationship between facility delivery volume and rates of nontransfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features.</div></div><div><h3>Study Design</h3><div>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 nontransfusion 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 nontransfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, nontransfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery.</div></div><div><h3>Results</h3><div>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). Nontransfusion SMM occurred in 7% of patients readmitted to facilities with >2000 deliveries compared to 9% with 1 to 2000 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 1000 deliveries, the odds of a nontransfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99).</div></div><div><h3>Conclusion</h3><div>Nontransfusion 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.</div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101500"},"PeriodicalIF":3.8,"publicationDate":"2024-09-21","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 : 2024-09-21DOI: 10.1016/j.ajogmf.2024.101506
Douglas S. Richards MD , Sarah J. Ilstrup MD , M. Sean Esplin MD , Donna Dizon-Townson MD , Allison M. Butler MStat , Brett D. Einerson MD
<div><h3>Background</h3><div>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 do not 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.</div></div><div><h3>Objective</h3><div>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.</div></div><div><h3>Study Design</h3><div>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 healthcare 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.</div></div><div><h3>Results</h3><div>A total of 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.</div></div><div><h3>Conclusion</h3><div>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 tra
{"title":"Risk factor stratification for urgent and nonurgent transfusion in patients giving birth","authors":"Douglas S. Richards MD , Sarah J. Ilstrup MD , M. Sean Esplin MD , Donna Dizon-Townson MD , Allison M. Butler MStat , Brett D. Einerson MD","doi":"10.1016/j.ajogmf.2024.101506","DOIUrl":"10.1016/j.ajogmf.2024.101506","url":null,"abstract":"<div><h3>Background</h3><div>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 do not 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.</div></div><div><h3>Objective</h3><div>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.</div></div><div><h3>Study Design</h3><div>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 healthcare 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.</div></div><div><h3>Results</h3><div>A total of 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.</div></div><div><h3>Conclusion</h3><div>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 tra","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101506"},"PeriodicalIF":3.8,"publicationDate":"2024-09-21","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 : 2024-09-21DOI: 10.1016/j.ajogmf.2024.101501
Vincenzo Berghella MD , Victoria Adewale MD , Tanvi Rana MD , Giulia Bonanni MD , Suneet P. Chauhan MD, Hon DSc , Federica Bellussi MD, PhD , Dwight Rouse MD, MPH , Jon Barrett MD
With approximately 145 million births occurring worldwide each year—over 30 million by cesarean delivery (CD), 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, planned CD was associated with significantly decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery (VD). Among singleton pregnancies, planned CD was associated with a significantly lower rate of perinatal death. For mothers, planned CD was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1 to 2 years. Conversely, planned VD has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned CD. Nonetheless, several risk factors for CD 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 CD on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and CD 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 VD for NSTV pregnancies. Such trials would need to include 8000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including nonbiologic 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","authors":"Vincenzo Berghella MD , Victoria Adewale MD , Tanvi Rana MD , Giulia Bonanni MD , Suneet P. Chauhan MD, Hon DSc , Federica Bellussi MD, PhD , Dwight Rouse MD, MPH , Jon Barrett MD","doi":"10.1016/j.ajogmf.2024.101501","DOIUrl":"10.1016/j.ajogmf.2024.101501","url":null,"abstract":"<div><div>With approximately 145 million births occurring worldwide each year—over 30 million by cesarean delivery (CD), 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, planned CD was associated with significantly decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery (VD). Among singleton pregnancies, planned CD was associated with a significantly lower rate of perinatal death. For mothers, planned CD was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1 to 2 years. Conversely, planned VD has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned CD. Nonetheless, several risk factors for CD 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 CD on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and CD 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 VD for NSTV pregnancies. Such trials would need to include 8000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including nonbiologic 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.</div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101501"},"PeriodicalIF":3.8,"publicationDate":"2024-09-21","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.2024.101502
Ruixiang Cai MD, Lingyan Chen MD, Yunguang Xing BD, Yuguo Deng MD, Juan Li MD, Fangfang Guo BD, Li Liu BD, Cuihua Xie BD, Jinying Yang PhD
BACKGROUND
Intravenous calcium administration has shown promise in enhancing uterine contractions and reducing blood loss during cesarean delivery, but this regimen has not been compared in vaginal labor induction.
OBJECTIVE
This study aimed to determine the efficacy of oxytocin combined with calcium vs oxytocin alone for inducing labor in women with term premature rupture of membranes.
STUDY DESIGN
This single-blind, randomized controlled trial was conducted between October 2022 and May 2023 at a tertiary university hospital. Patients diagnosed with premature rupture of membranes were randomly allocated into 2 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 after labor induction. The 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, body mass index, and Bishop score before labor induction, were comparable between the groups. The rate of vaginal delivery within 24 hours after labor induction was statistically higher in the intervention group (79.52% vs 70.64%; P=.04). The participants in the intervention group experienced a shortened interval between labor induction and delivery (10.48 vs 11.25 hours; P=.037) and demonstrated a higher success rate in labor induction assessed by the onset of the active phase (93.80% vs 87.61%; P=.04) without increasing the cesarean delivery rate. Reduced hemorrhage was observed in the intervention group (242.5 vs 255.0 mL; P=.0015), and the maternal and neonatal outcomes were comparable between the groups.
CONCLUSION
The coadministration of calcium and oxytocin in labor induction among pregnancies with premature rupture of membranes was more efficient and safer than the administration of 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","authors":"Ruixiang Cai MD, Lingyan Chen MD, Yunguang Xing BD, Yuguo Deng MD, Juan Li MD, Fangfang Guo BD, Li Liu BD, Cuihua Xie BD, Jinying Yang PhD","doi":"10.1016/j.ajogmf.2024.101502","DOIUrl":"10.1016/j.ajogmf.2024.101502","url":null,"abstract":"<div><h3>BACKGROUND</h3><div>Intravenous calcium administration has shown promise in enhancing uterine contractions and reducing blood loss during cesarean delivery, but this regimen has not been compared in vaginal labor induction.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to determine the efficacy of oxytocin combined with calcium vs oxytocin alone for inducing labor in women with term premature rupture of membranes.</div></div><div><h3>STUDY DESIGN</h3><div>This single-blind, randomized controlled trial was conducted between October 2022 and May 2023 at a tertiary university hospital. Patients diagnosed with premature rupture of membranes were randomly allocated into 2 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 after labor induction. The secondary outcomes included the interval from labor induction to delivery, vaginal delivery blood loss, and maternal and neonatal complications.</div></div><div><h3>RESULTS</h3><div>Baseline characteristics, including maternal age, body mass index, and Bishop score before labor induction, were comparable between the groups. The rate of vaginal delivery within 24 hours after labor induction was statistically higher in the intervention group (79.52% vs 70.64%; <em>P</em>=.04). The participants in the intervention group experienced a shortened interval between labor induction and delivery (10.48 vs 11.25 hours; <em>P</em>=.037) and demonstrated a higher success rate in labor induction assessed by the onset of the active phase (93.80% vs 87.61%; <em>P</em>=.04) without increasing the cesarean delivery rate. Reduced hemorrhage was observed in the intervention group (242.5 vs 255.0 mL; <em>P</em>=.0015), and the maternal and neonatal outcomes were comparable between the groups.</div></div><div><h3>CONCLUSION</h3><div>The coadministration of calcium and oxytocin in labor induction among pregnancies with premature rupture of membranes was more efficient and safer than the administration of 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.</div></div><div><h3>Video Abstract</h3><div><span><span><span><span><video><source></source></video></span><span><span>Download: <span>Download video (8MB)</span></span></span></span><span><span><p><span>Video</span>. </p></span></span></span></span></div></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101502"},"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.2024.101507
Sydney M. Thayer MD, Sarah Y. Cohen MD, MPH, Samantha A.S. Williams BS, Lori Stevenson MSN, RNC-OB, Kali Stewart MD, Bree Goodman MD, Nandini Raghuraman MD, MSCI, Ebony B. Carter MD, MPH, Anthony O. Odibo MD, MSCE, Jeannie C. Kelly MD, MS
{"title":"Optimizing induction of labor: the Birth Efficiency and Satisfaction Induction of Labor (BEST induction of labor) study","authors":"Sydney M. Thayer MD, Sarah Y. Cohen MD, MPH, Samantha A.S. Williams BS, Lori Stevenson MSN, RNC-OB, Kali Stewart MD, Bree Goodman MD, Nandini Raghuraman MD, MSCI, Ebony B. Carter MD, MPH, Anthony O. Odibo MD, MSCE, Jeannie C. Kelly MD, MS","doi":"10.1016/j.ajogmf.2024.101507","DOIUrl":"10.1016/j.ajogmf.2024.101507","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101507"},"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}
Pub Date : 2024-09-19DOI: 10.1016/j.ajogmf.2024.101497
Simon H. Thomsen MD , Ida C.B. Lund MD, PhD , Iben Bache MD, PhD , Naja Becher MD, PhD , Ida Vogel MD, PhD, DMSc
<div><h3>Background</h3><div>Mosaicism, characterized by the presence of two or more chromosomally distinct cell lines, is detected in 2% to 4% of chorionic villus samples (CVSs). In these cases, the aberration may be confined to the placenta or additionally present in the fetus. Fetal involvement may manifest as fetal malformations, while confined placental mosaicism (CPM) poses risks such as preterm birth and low birth weight. Differentiating between true fetal mosaicism and CPM at the time of the chorionic villus sampling is challenging and requires follow-up by an amniocentesis and ultrasonography.</div></div><div><h3>Objective</h3><div>To estimate the risk of fetal involvement or adverse pregnancy outcomes for specific chromosomes after detecting mosaicism for an autosomal trisomy in a CVS and identify high (red), intermediate (yellow), and low (green) risk chromosomes. Further, to explore possible associations with level of mosaicism and screening parameters.</div></div><div><h3>Study Design</h3><div>A retrospective descriptive study of all singleton pregnancies with mosaicism detected in CVSs from 1983 to 2021 identified in the Danish Cytogenetic Central Registry and the Danish Fetal Medicine Database.</div></div><div><h3>Results</h3><div>Of 90,973 CVSs, 528 cases had mosaicism involving an autosomal trisomy and where genetic follow-up had been performed. The overall risk of fetal involvement was 13% (69/528) with extensive variations depending on which chromosome was involved (eg, trisomy 7: 0% [0/55] or trisomy 21: 46% [19/41]). Higher levels of mosaicism in the CVS suggested fetal involvement as mean mosaic level was 55% in true fetal mosaics vs 28% in cases confined to the placenta (<em>P</em>=.0002). In cases with CPM (459/528), the risk of delivering small-for-gestational-age neonates was 14% (48/341). The risk of preterm birth (before 37 weeks) was 15% (51/343). The collective risk of adverse outcome was 22% (76/343) in pregnancies that continued and where information on birth weight and gestational age at birth was available. Adverse outcomes varied substantially between chromosomes. Also, multiple-of-the-median (MoM) values of pregnancy-associated plasma protein A was predictive of these issues as it was significantly lower in cases with adverse outcome compared to cases with a normal outcome (small for gestational age: 0.23 MoM vs 0.47 MoM, <em>P</em><.0001) or preterm birth: 0.25 MoM vs 0.47 MoM, <em>P</em><.0001). After the introduction of combined first-trimester screening (cFTS) in 2004, the detection of cases with fetal involvement seemed to increase as the risk before 2004 was 9% (16/174) compared to 15% (53/354) after 2004 (risk ratio: 1.7 [95% CI: 1.0; 2.8]). The risk of adverse outcome in CPM pregnancies increased from 16% (22/139) before 2004 to 27% (55/204) after 2004 (risk ratio 1.7 [95% CI: 1.1; 2.7]).</div></div><div><h3>Conclusion</h3><div>Introducing cFTS increased the detection of placental mosaicism with f
{"title":"Placental mosaicism for autosomal trisomies: comprehensive follow-up of 528 Danish cases (1983–2021)","authors":"Simon H. Thomsen MD , Ida C.B. Lund MD, PhD , Iben Bache MD, PhD , Naja Becher MD, PhD , Ida Vogel MD, PhD, DMSc","doi":"10.1016/j.ajogmf.2024.101497","DOIUrl":"10.1016/j.ajogmf.2024.101497","url":null,"abstract":"<div><h3>Background</h3><div>Mosaicism, characterized by the presence of two or more chromosomally distinct cell lines, is detected in 2% to 4% of chorionic villus samples (CVSs). In these cases, the aberration may be confined to the placenta or additionally present in the fetus. Fetal involvement may manifest as fetal malformations, while confined placental mosaicism (CPM) poses risks such as preterm birth and low birth weight. Differentiating between true fetal mosaicism and CPM at the time of the chorionic villus sampling is challenging and requires follow-up by an amniocentesis and ultrasonography.</div></div><div><h3>Objective</h3><div>To estimate the risk of fetal involvement or adverse pregnancy outcomes for specific chromosomes after detecting mosaicism for an autosomal trisomy in a CVS and identify high (red), intermediate (yellow), and low (green) risk chromosomes. Further, to explore possible associations with level of mosaicism and screening parameters.</div></div><div><h3>Study Design</h3><div>A retrospective descriptive study of all singleton pregnancies with mosaicism detected in CVSs from 1983 to 2021 identified in the Danish Cytogenetic Central Registry and the Danish Fetal Medicine Database.</div></div><div><h3>Results</h3><div>Of 90,973 CVSs, 528 cases had mosaicism involving an autosomal trisomy and where genetic follow-up had been performed. The overall risk of fetal involvement was 13% (69/528) with extensive variations depending on which chromosome was involved (eg, trisomy 7: 0% [0/55] or trisomy 21: 46% [19/41]). Higher levels of mosaicism in the CVS suggested fetal involvement as mean mosaic level was 55% in true fetal mosaics vs 28% in cases confined to the placenta (<em>P</em>=.0002). In cases with CPM (459/528), the risk of delivering small-for-gestational-age neonates was 14% (48/341). The risk of preterm birth (before 37 weeks) was 15% (51/343). The collective risk of adverse outcome was 22% (76/343) in pregnancies that continued and where information on birth weight and gestational age at birth was available. Adverse outcomes varied substantially between chromosomes. Also, multiple-of-the-median (MoM) values of pregnancy-associated plasma protein A was predictive of these issues as it was significantly lower in cases with adverse outcome compared to cases with a normal outcome (small for gestational age: 0.23 MoM vs 0.47 MoM, <em>P</em><.0001) or preterm birth: 0.25 MoM vs 0.47 MoM, <em>P</em><.0001). After the introduction of combined first-trimester screening (cFTS) in 2004, the detection of cases with fetal involvement seemed to increase as the risk before 2004 was 9% (16/174) compared to 15% (53/354) after 2004 (risk ratio: 1.7 [95% CI: 1.0; 2.8]). The risk of adverse outcome in CPM pregnancies increased from 16% (22/139) before 2004 to 27% (55/204) after 2004 (risk ratio 1.7 [95% CI: 1.1; 2.7]).</div></div><div><h3>Conclusion</h3><div>Introducing cFTS increased the detection of placental mosaicism with f","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101497"},"PeriodicalIF":3.8,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297364","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1016/j.ajogmf.2024.101505
Sarah Heerboth MD , Katharine E. Bruce MPH, Terri L. Fletcher PhD, Alison M. Stuebe MD, MSc, Alison N. Goulding MD, MSCR
{"title":"Postpartum post-traumatic stress symptoms and their association with mood and parenting stress","authors":"Sarah Heerboth MD , Katharine E. Bruce MPH, Terri L. Fletcher PhD, Alison M. Stuebe MD, MSc, Alison N. Goulding MD, MSCR","doi":"10.1016/j.ajogmf.2024.101505","DOIUrl":"10.1016/j.ajogmf.2024.101505","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":"6 11","pages":"Article 101505"},"PeriodicalIF":3.8,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297365","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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