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Elective Delivery Before 39 Weeks: Unnecessary Risk for Minimal Benefit

Elective Delivery Before 39 Weeks: Unnecessary Risk for Minimal Benefit. Chris Glantz, MD, MPH. Elective Delivery. Scheduled, non-urgent Inductions Convenience, non-medical, etc. Cesarean sections Elective repeats, breech, etc. Anxiety, doctor/patient or L&D/OR scheduling considerations.

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Elective Delivery Before 39 Weeks: Unnecessary Risk for Minimal Benefit

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  1. Elective Delivery Before 39 Weeks: Unnecessary Risk for Minimal Benefit Chris Glantz, MD, MPH

  2. Elective Delivery • Scheduled, non-urgent • Inductions • Convenience, non-medical, etc. • Cesarean sections • Elective repeats, breech, etc. • Anxiety, doctor/patient or L&D/OR scheduling considerations

  3. Respiratory Morbidity • NICU Admission • TTN: most common near term • RDS and pneumothorax: rare but serious • Related to gestational age and delivery route • Odds of respiratory morbidity decrease ≈50% per week between 37 and 40 weeks • Cesarean higher risk than vaginal delivery

  4. ACOG Guidelines • Very explicit and consistent over many years! “Fetal pulmonary maturity should be confirmed before elective delivery at less than 39 weeks” Educational Bulletin #230, 1996

  5. ACOG Guidelines • 39 weeks in woman with regular menses: • FHTs for 20 wks by fetoscope or 30 wks by Doppler • 36 weeks since positive serum or urine HCG • Ultrasound CRL at 6-11 wks or measurements at 12-20 wks • Within 1 week in 1st trimester or within 10 days in 2nd trimester

  6. Others Follow Suit • Guidelines for Perinatal Care • Gabbe’s Obstetrics • Hankins’s Operative Obstetrics • Creasy & Resnik’s Maternal-Fetal Medicine • Williams’s Obstetrics • And others

  7. Finger Lakes Data 1998-2003 • GA 35-40 weeks • Low risk and (for CS) not in labor • No identifiable urgency per database • No HTN, DM, SGA, LGA, oligo, PROM, respiratory disease, or prior stillbirth • Malpresentation and RCS okay for CS • Indication RCS≈85% after 35 weeks • Malpresentation next most common

  8. Scheduled Cesarean: Gestational AgesLow risk, not in labor N=3661 (>40% below 39 weeks)

  9. NICU Admission after Scheduled Low-risk Cesarean Section

  10. “Respiratory Distress Syndrome”

  11. Neonatal TransfersLevel I to Level III Low Risk Women with Scheduled Deliveries (Induction or Cesarean)

  12. Odds Ratios for NICU Admission(Relative to 39-40 weeks) Low Risk Women with Scheduled Deliveries (Induction or Cesarean)

  13. Independent Effects(Relative to 39-40 weeks)

  14. Testing for Lung Maturity • Many different possible tests • LS, PG, FLM, Shake, etc. • All have similar accuracy • 95-98% for lung maturity • Not so good for “immaturity” • Third trimester amnio is very safe • Recent studies show minimal risk

  15. Conclusions • Follow ACOG and do not schedule elective deliveries before 39 weeks • Most important for cesarean sections • ACOG does not differentiate between delivery routes • Document that benefits outweigh risks • If elective delivery is planned before 39 weeks, discuss risks with patient; consider fetal lung testing • Plan delivery within 24 hours of positive test

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