Early preterm preeclampsia outcomes by intended mode of delivery.

The optimal route of delivery in early-onset preeclampsia before 34 weeks is debated because many clinicians are reluctant to proceed with induction for perceived high risk of failure. Our objective was to investigate labor induction success rates and compare maternal and neonatal outcomes by intended mode of delivery in women with early preterm preeclampsia. We identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth, or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n = 460) and planned cesarean delivery (n = 454) and women with successful induction of labor (n = 214) and unsuccessful induction of labor (n = 246). We calculated relative risks and 95% confidence intervals to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birthweight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance, marital status, and steroid use. Among the 460 women with induction (50%), 47% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7, and 32 to 33 6/7, the induction of labor success rates were 38% (12 of 32), 39% (70 of 180), and 54% (132 of 248), respectively. Induction of labor compared with planned cesarean delivery was less likely to be associated with placental abruption (adjusted relative risk, 0.33; 95% confidence interval, 0.16-0.67), wound infection or separation (adjusted relative risk, 0.23; 95% confidence interval, 0.06-0.85), and neonatal asphyxia (0.12; 95% confidence interval, 0.02-0.78). Women with vaginal delivery compared with those with failed induction of labor had decreased maternal morbidity (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.82) and no difference in neonatal outcomes. About half of women with preterm preeclampsia who attempted an induction had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high-risk population of women.

Coviello EM ，Iqbal SN ，Grantz KL ，Huang CC ，Landy HJ ，Reddy UM ... -  《-》

Maternal and neonatal outcomes of attempted vaginal compared with planned cesarean delivery in triplet gestations.

The prevailing obstetric practice of planned cesarean delivery for triplet gestations is largely empiric and data on the optimal route of delivery are limited. The primary objectives of this study are to determine the likelihood of success in an attempted vaginal delivery and assess maternal and neonatal outcomes of attempted vaginal vs planned cesarean delivery of triplets using a multiinstitution obstetric cohort. We performed a retrospective cohort study using data from the Consortium on Safe Labor, identifying triplet pregnancies with delivery at a gestational age ≥28 weeks. Women with a history of cesarean delivery and pregnancies complicated by chromosomal or congenital anomalies, twin-twin transfusion syndrome, or a fetal demise were excluded. The attempted vaginal group included all women with spontaneous or induced labor and excluded all women delivering by prelabor cesarean delivery, including those coded as elective or for fetal malpresentation. Primary maternal outcomes included infection (composite of chorioamnionitis, endometritis, wound separation, and wound infection), blood transfusion, or transfer to the intensive care unit. Primary neonatal outcomes included neonatal asphyxia, mechanical ventilation, and composite neonatal morbidity, consisting of ≥1 of the following: birth injury, 5-minute Apgar <4, arterial pH <7.0 or base excess <-12.0, neonatal asphyxia, or neonatal death. For neonatal outcomes, Poisson regression was performed with clustering to account for correlation between neonates within a triplet pregnancy, controlling for confounders as outcome rates allowed. A sensitivity analysis was performed in the subcohort delivering at gestational age ≥34 weeks in which the attempted vaginal delivery group was restricted to include only women with evidence of induction or augmentation or labor. 188 triplet sets were identified of which 80 sets (240 neonates) met inclusion criteria and 24 sets (30%) had an attempted vaginal delivery. The rate of successful attempted vaginal delivery was 16.7% (4 triplet sets; 12 neonates). No women had a combined mode of delivery. Women attempting vaginal delivery were more likely to have preterm labor (45.8 vs 12.5%, P < .001) and receive antenatal corticosteroids (45.8 vs 21.4%, P = .03), however gestational age at delivery did not differ by mode of delivery. Attempted vaginal delivery was associated with a higher risk of maternal transfusion (20.8% vs 3.6%, P = .01) and neonatal mechanical ventilation (26.4% vs 7.7%; adjusted incidence rate ratio, 1.12; 95% confidence interval, 1.01-1.24). There was no significant difference in the risk of asphyxia or composite neonatal morbidity by mode of delivery. In the subcohort sensitivity analysis, attempted vaginal delivery was associated with an increased risk of composite neonatal morbidity (adjusted incidence rate ratio, 12.44; 95% confidence interval, 1.22-127.20) but not maternal transfusion (22.2% vs 3.5%, P = .06) or neonatal mechanical ventilation (adjusted incidence rate ratio, 1.02; 95% confidence interval, 0.89-1.17). In a multicenter US cohort, attempted vaginal delivery of triplets is associated with higher risks of maternal transfusion and neonatal mechanical ventilation. Composite severe neonatal morbidity may be higher with attempted vaginal delivery although studies with greater power are required. The low probability of successful vaginal delivery raises questions regarding the utility of attempted vaginal delivery in triplet gestations. Our data support planned prelabor cesarean delivery as the preferred mode of delivery for triplet gestations.

Lappen JR ，Hackney DN ，Bailit JL 《-》

Maternal and newborn outcomes with elective induction of labor at term.

A growing body of evidence supports improved or not worsened birth outcomes with nonmedically indicated induction of labor at 39 weeks gestation compared with expectant management. This evidence includes 2 recent randomized control trials. However, concern has been raised as to whether these studies are applicable to a broader US pregnant population. Our goal was to compare outcomes for electively induced births at ≥39 weeks gestation with those that were not electively induced. We conducted a retrospective cohort study using chart-abstracted data on births from January 1, 2012, to December 31, 2017, at 21 hospitals in the Northwest United States. The study was restricted to singleton cephalic hospital births at 39+0-42+6 weeks gestation. Exclusions included previous cesarean birth, missing data for delivery type or gestational week at birth, antepartum stillbirth, cesarean birth without any attempt at vaginal birth, fetal anomaly, gestational diabetes mellitus, prepregnancy diabetes mellitus, and prepregnancy hypertension. The rate of cesarean birth for elective inductions at both 39 and 40 weeks gestation was compared with the rate in all other on-going pregnancies in the same gestational week. Maternal outcomes (operative vaginal birth, shoulder dystocia, 3rd- or 4th-degree perineal laceration, pregnancy-related hypertension, and postpartum hemorrhage) and newborn infant outcomes (macrosomia, 5-minute Apgar <7, resuscitation at delivery, intubation, respiratory complications, and neonatal intensive care unit admission) were also compared between elective inductions and on-going pregnancies at 39 and 40 weeks gestation. Logistic regression modeling was used to produce odds ratios for outcomes with adjustment for maternal age and body mass index. Results were stratified by parity and gestational week at birth. Duration of hospital stay (admission to delivery, delivery to discharge, and total stay) were compared between elective inductions and on-going pregnancies. A total of 55,694 births were included in the study cohort: 4002 elective inductions at ≥39+0 weeks gestation and 51,692 births at 39+0-42+6 weeks gestation that were not electively induced. In nulliparous women, elective induction at 39 weeks gestation was associated with a decreased likelihood of cesarean birth (14.7% vs 23.2%; adjusted odds ratio, 0.61; 95% confidence interval, 0.41-0.89) and an increased rate of operative vaginal birth (18.5% vs 10.8%; adjusted odds ratio, 1.8; 95% confidence interval, 1.28-2.54) compared with on-going pregnancies. In multiparous women, cesarean birth rates were similar in the elective inductions and on-going pregnancies. Elective induction at 39 weeks gestation was associated with a decreased likelihood of pregnancy-related hypertension in nulliparous (2.2% vs 7.3%; adjusted odds ratio, 0.28; 95% confidence interval, 0.11-0.68) and multiparous women (0.9% vs 3.5%; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.38). Term elective induction was not associated with any statistically significant increase in adverse newborn infant outcomes. Elective induction of labor at 39 weeks gestation was associated with increased time from admission to delivery for both nulliparous (1.3 hours; 95% confidence interval, 0.2-2.3) and multiparous women (3.4 hours; 95% confidence interval, 3.2-3.6). Elective induction of labor at 39 weeks gestation is associated with a decrease in cesarean birth in nulliparous women, decreased pregnancy-related hypertension in multiparous and nulliparous women, and increased time in labor and delivery. How to use this information remains the challenge.

Souter V ，Painter I ，Sitcov K ，Caughey AB ... -  《-》

Nonmedically indicated induction in morbidly obese women is not associated with an increased risk of cesarean delivery.

The prevalence of morbid obesity (body mass index ≥40 kg/m2) in women aged 20-39 years was 7.5% in 2009 through 2010. Morbid obesity is associated with an increased risk of stillbirth compared with normal body mass index, especially >39 weeks' gestation. The data regarding increased risk of cesarean delivery associated with nonmedically indicated induction of labor compared to expectant management in morbidly obese women are limited. We sought to compare the cesarean delivery rate of nonmedically indicated induction of labor with expectant management in morbidly obese women without other comorbidity. This was a retrospective cohort study from the Consortium on Safe Labor of morbidly obese women with singleton, cephalic gestations without previous cesarean, chronic hypertension, or gestational or pregestational diabetes between 37 0/7 and 41 6/7 weeks' gestation. We examined maternal outcomes including cesarean delivery, operative delivery, third- or fourth-degree laceration, postpartum hemorrhage, and composite maternal outcome (any of: transfusion, intensive care unit admission, venous thromboembolism). We also examined neonatal outcomes including shoulder dystocia, macrosomia (>4000 g), neonatal intensive care unit admission, and composite neonatal outcome (5-min Apgar score <5, stillbirth, neonatal death, or asphyxia or hypoxic-ischemic encephalopathy). Adjusted odds ratios with 95% confidence intervals were calculated, controlling for maternal characteristics, hospital type, and simplified Bishop score. Analyses were conducted at early and full term (37 0/7 to 38 6/7 and 39 0/7 to 40 6/7 weeks' gestation, respectively). Women who delivered between 41 0/7 and 41 6/7 weeks' gestation were included as expectant management group. Of 1894 nulliparous and 2455 multiparous morbidly obese women, 429 (22.7%) and 791 (32.2%) had nonmedically indicated induction, respectively. In nulliparas, nonmedically indicated induction was not associated with increased risks of cesarean delivery and was associated with decreased risks of macrosomia (2.2% vs 11.0%; adjusted odds ratio, 0.24; 95% confidence interval, 0.05-0.70) at early term and decreased neonatal intensive care unit admission (5.1% vs 8.9%; adjusted odds ratio, 0.59; 95% confidence interval, 0.33-0.98) at full term compared with expectant management. In multiparas, nonmedically indicated induction compared with expectant management was associated with a decreased risk of macrosomia at early term (4.2% vs 14.3%; adjusted odds ratio, 0.30; 95% confidence interval, 0.13-0.60), cesarean delivery at full term (5.4% vs 7.9%; adjusted odds ratio, 0.64; 95% confidence interval, 0.41-0.98), and composite neonatal outcome (0% vs 0.6%; adjusted odds ratio, 0.10; 95% confidence interval, <.01-0.89) at full term. In morbidly obese women without other comorbidity, nonmedically indicated induction was not associated with an increased risk of cesarean delivery.

Kawakita T ，Iqbal SN ，Huang CC ，Reddy UM ... -  《-》

Maternal and neonatal outcomes of elective induction of labor.

Caughey AB ，Sundaram V ，Kaimal AJ ，Cheng YW ，Gienger A ，Little SE ，Lee JF ，Wong L ，Shaffer BL ，Tran SH ，Padula A ，McDonald KM ，Long EF ，Owens DK ，Bravata DM ... -  《-》