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Complications of Delivery Before 39 Weeks: OB Perspective

This article discusses the rates and reasons for late-preterm birth, indications and contraindications for labor induction, and the advantages and disadvantages of the procedure. It also provides recommendations for preterm birth management.

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Complications of Delivery Before 39 Weeks: OB Perspective

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  1. Complications of Delivery Before 39 Weeks: OB Perspective Roger B. Newman MD Maas Endowed Chair For Reproductive Sciences Professor and Vice-ChairmanDepartment of Ob-GynMedical University of South Carolina

  2. Complications of Delivery <39 WksLearning Objectives • Rates of late-preterm birth in US • Reasons for the increase • Indications/contraindications for IOL • Advantages/disadvantages of IOL • Recommendations

  3. Preterm Birth in US • Has increased 20% in past 15 years: 10.6% in 1990 to 12.7% in 2005 • “Late-Preterm” (34-36 weeks) increasing at a greater rate than other PTB subgroups • “Late-Preterm” birth rate was 7.3% in 1990 vs 9.1% in 2005; 25% increase

  4. Delivery Indications: Late- Preterm Births • 292,627 late-preterm births in 2001: US Birth Cohort Linked Birth / Death Files (singletons) • 76.8% had maternal/fetal indication or spontaneous labor; 23.2% (67.909) no recorded indication • No recorded indication associated with: older age, non-Hispanic white, ≥ 13 yrs of education, multiparity, southern, midwest, or western region, or prior child ≥ 4000 g birth weight Reddy et al, Pediatrics 2009

  5. Induction of Labor United States • Doubled from ’90 to ’06: 9.5% to 22.5% Some for medical/Ob indications Most: marginal or elective • Why? Better cervical ripening agents Patient/MD convenience Relaxed attitudes re: marginal indications Concerns re: fetal death with expect Rx CDC 2009; Rayburn, AJOG 2002; Moore, Clin Ob-Gyn 2006

  6. Accuracy of Vital Statistic DataBirth Certificates • Ohio Perinatal Quality Collaborative 2008 20 Ohio hospitals • To decrease nonmedically-indicated scheduled deliveries • All scheduled deliveries: 36-38 6/7 wks • Comparison of chart abstraction vs birth certificates • 11% in BC vs 1% in chart

  7. Birth Certificate Data vs Chart Abstracted Data Bailit; Induction rates derived from birth certificate data. Am J Obstet Gynecol 2010

  8. Conceptual Diagram

  9. Timing of Indicated Late-Preterm and Early-Term Birth • Workshop Feb. 2011, sponsored by Eunice Kennedy Shriver NICHD and SMFM • Synthesize available evidence regarding conditions resulting in medically-indicated late-preterm or early-term births • Based on available data and expert opinion, optimal timing for delivery was determined by consensus Spong, Mercer, D’Alton et al OBGYN, 2011

  10. Induction of LaborContraindications • Prior classical CS • Prior transmural uterine incision • Placenta or vasa previa • Umbilical cord prolapse • Transverse lie

  11. Induction of LaborDisadvantages • Increased Cesarean rate • Iatrogenic prematurity • Cost

  12. Induction of Labor37-38 wks vs ≥39 wks • Prospective observational study 18,000 deliveries in 27 HCA hospitals 3 month epoch in 2007 • Planned elective IOL: 31% of all deliveries • Population 790 at 37-38 wks (28.3%) 2004 at ≥39 wks (71.7%) Clark, AJOG, 2009

  13. Induction of Labor37-38 wks vs ≥39 wks • Results: higher NICU adm (7.7 vs 3.0%) • Cesarean rates correlated with cx dilatation in both nullips and multips • Term should no longer be 37 wks Clark, AJOG, 2009

  14. Induction of LaborNulliparity • Matched cohort of nullips, singleton, ceph • Population: Belgium 7683: elective IOL 7683: spontaneous labor • 38-41 weeks • BW 3000-4000gms • Cervical status and ripening not known Cammu, AJOG 2002

  15. Induction of LaborNulliparity • Higher Cesarean: 10 vs 7% (1st stage problems) • Higher instrumental delivery: 32 vs 29% • More epidurals: 80 vs 58% • More NICU: 11 vs 9% • Nullips should be informed before elective IOL Cammu, AJOG 2002

  16. Induction of LaborNulliparity • Retrospective cohort: Tacoma, Wash • Elective IOL (n=263) Low risk at 38-41 wks Compared to spon labor • Primary outcome: Cesarean OR 2.4, CI 1.2,4.9 • Longer labor (4 hrs) and more cost ($273)

  17. Induction of LaborNulliparity • Multiple cohort studies: Cesarean rate doubled for elective and medical inductions • Primarily due to unfav cervix: Bishop ≤5 • RPT showed no diff in Cesarean with favorable cx (Bishop ≥ 5) Nielsen, J Mat Fet Neo Med 2005

  18. Bishop’s Score ScoreDilatationEffacementStationPositionConsistency 0 closed  0 – 30% -3 posterior firm  1 1-2 cm 40 -50% -2 mid-position moderately firm  2 3-4 cm 60 -70% -1,0 anterior Soft   3 5+ cm 80+% +1,+2 A point is added: Preeclampsia/Each prior vaginal delivery A point is subtracted: Postdates/Nulliparity/pPROM Cesarean RatesFirst Time MothersWomen with Past Vaginal Deliveries BS  0 - 3 45% 7.7% BS 4 – 6 10%  3.9% BS 7 - 10 1.4% 0 .9%

  19. Bishop’s Score

  20. Induction of LaborNulliparity • Retrospective cohort: Northwestern • Elective IOL (n=294) Nullip Bishop ≥ 5 39-40 5/7 wks Compared to expectantly managed • Primary Outcome: Cesarean ( 21 vs 20%) • IOL: longer labor (13 vs 9 hrs) Osmundson, ObstetGynecol, 2010

  21. Induction of LaborMultiparas • No increased Cesarean rate • Most data retrospective, but one small PRT • Large population-based cohort 1775 low risk multips at term IOL vs 5785 similar pts with spon labor Cervical ripening agents if unripe Cesarean similar: 3.8 vs 3.6% (RR 1.07) Nielsen, J Mat Fet Neo Med 2005; Dublin, AJOG 2000

  22. Induction of LaborRespiratory Morbidity • 33,289 deliveries ≥ 37 wks • RDS or TTN requiring adm to NICU • Comparison with overall baseline term rates • Elective induction at term with vag deliv 37-37 6/7: 12.6/1000, OR 2.5, CI 1.5-4.22 38-38 6/7: 7.0/1000, OR 1.4, CI 0.8-2.2 39-39 6/7: 3.2/1000, OR 0.6, CI 0.4-1.0 Morrison, BJOG, 1995

  23. Induction of LaborRespiratory Morbidity • Same comparison in failed IOL/Cesarean 37-37 6/7: 57.7/1000, OR 11.2, CI 5.4-13.1 38-38 6/7: 9.4/1000, OR 1.8, CI 0.6-5.9 39-39 6/7: 16.2/1000, OR 3.2, CI 1.4-7.4 • Elective delivery by Cesarean without labor: Increased freq at all gestational ages Morrison, BJOG 1995

  24. Timing of Elective Repeat Cesarean • MFMU Network: secondary analysis of Cesarean registry • 19 academic centers 1999-2002 • N=13,258 for elective term repeat Cesarean 37 wks: 6.3% 38 wks: 29.5% 39 wks: 49.1% Tita, NEJM, 2009

  25. Timing of Elective Repeat Cesarean • Composite outcome: respiratory, sepsis, hypoglycemia, NICU admit, death 37wks: 15.3%, OR 2.1, CI 1.7-2.5 38 wks: 11.0%, OR 1.5, CI 1.3-1.7 39 wks: 8.0% • Individual outcomes also signif different • No diff between 39 and 40 wks • Increased morbidity at 41 wks Tita, NEJM 2009

  26. Elective Repeat Cesarean Delivery & Incidence of Primary Outcome

  27. Timing of Elective Repeat Cesarean • 2-3 stillbirths avoided with delivery < 39 wks • 176 extra cases of primary outcome • 145 extra admissions to NICU • 63 extra cases of RDS • Also increased morbidity 38 4/7-38 6/7 Tita, NEJM 2009

  28. Neonatal MorbidityElective Cesarean • Elective Cesarean at term: breech, social, CPD, repeat, fundal scar • Amsterdam ’94-’98: n=324 • Decreased respiratory morbidity with advancing gest age (p<0.05) 37-37 6/7 wks: 8.4% 38-38 6/7wks: 4.4% 39+ wks: 1.8% van den Berg, EJOG, 2001

  29. Economic ConsequencesDecision Analysis • Cohort of 100,000 patients Induction at 39, 40, 41 wks vs expectant Rx All patients delivered by 42 wks • IOL at 39 weeks 12,000 excess Cesareans Additional cost: $100 million 133 fetal deaths avoided Regardless of cx ripeness or parity Kaufman, AJOG, 2002

  30. Decision Analysis • IOL less expensive Later gestational ages Multips Favorable cervix • Most costly Nullips with unfavorable cervix Cost halved with favorable cervix (Bishop > 5) Still overall added expense Kaufman, AJOG, 2002

  31. Induction of LaborBottom Line • No evidence for elective IOL • Need large randomized studies Maternal and neonatal safety Reduced unexplained fetal death Cost-effectiveness

  32. Complications of Delivery <39 WksFinal Thoughts • IOL only if continuing preg has greater maternal/fetal risks than the intervention • No elective IOL at term without indications Increased Cesarean rate Iatrogenic prematurity Increased cost No proven benefits • Bishop score best at predicting success • Elective primary or repeat Cesarean < 39 weeks inappropriate without indication • Term should now be considered 39 weeks

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