The role of labor induction in modern obstetrics Grobman, William A.
American journal of obstetrics and gynecology,
March 2024, 2024-Mar, 2024-03-00, 20240301, Letnik:
230, Številka:
3
Journal Article
Recenzirano
Odprti dostop
A primary goal of obstetrical practice is the optimization of maternal and perinatal health. This goal translates into a seemingly simple assessment with regard to considerations of the timing of ...delivery: delivery should occur when the benefits are greater than those of continued pregnancy. In the absence of an indication for cesarean delivery, planned delivery is initiated with induction of labor. When medical or obstetrical complications exist, they may guide recommendations regarding the timing of delivery. In the absence of these complications, gestational age also has been used to guide delivery timing, given its association with both maternal and perinatal adverse outcomes. If there is no medical indication, delivery before 39 weeks has been discouraged, given its association with greater chances of adverse perinatal outcomes. Conversely, it has been recommended that delivery occur by 42 weeks of gestation, given the perinatal risks that accrue in the post-term period. Historically, a 39-week induction of labor, particularly for individuals with no previous birth, has not been routinely offered in the absence of medical or obstetrical indications. That approach was based on numerous observational studies that demonstrated an increased risk of cesarean delivery and other adverse outcomes among individuals who underwent labor induction compared to those in spontaneous labor. However, from a management and person-centered-choice perspective, the relevant comparison is between those undergoing planned labor induction at a given time vs those planning to continue pregnancy beyond that time. When individuals have been compared using that rubric—either in observational studies or randomized trials that have been performed in a wide variety of locations and populations— there has not been evidence that induction increases adverse perinatal or maternal outcomes. Conversely, even when the only indication for delivery is the achievement of a full-term gestational age, evidence suggests that multiple different outcomes, including cesarean delivery, hypertensive disorders of pregnancy, neonatal respiratory impairment, and perinatal mortality, are less likely when induction is performed. This information underscores the importance of making the preferences of pregnant individuals for different birth processes and outcomes central to the approach to delivery timing.
Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its ...clinical effectiveness in nonresearch settings remains uncertain.
To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes.
Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models.
Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74–0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39–0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59–0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26–0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72–0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09–0.76).
This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.
Racial Disparities in Postpartum Pain Management Badreldin, Nevert; Grobman, William A; Yee, Lynn M
Obstetrics and gynecology (New York. 1953),
12/2019, Letnik:
134, Številka:
6
Journal Article
Recenzirano
Odprti dostop
To evaluate racial and ethnic differences in women's postpartum pain scores, inpatient opioid administration, and discharge opioid prescriptions.
We conducted a retrospective cohort study of all ...deliveries at a single high-volume tertiary care center from December 1, 2015, through November 30, 2016. Women were included if they self-identified as non-Hispanic white, non-Hispanic black, or Hispanic; were at least 18 years of age; and did not have documented allergies to nonsteroidal antiinflammatory drugs or morphine. Medical records were queried for three outcomes: 1) patient-reported postpartum pain score (on a scale of 0-10) at discharge (dichotomized less than 5 or 5 or higher), 2) inpatient opioid dosing during postpartum hospitalization (reported as morphine milligram equivalents MMEs per postpartum day), and 3) receipt of an opioid prescription at discharge. The associations between each of these outcomes and maternal race-ethnicity were assessed using multivariable logistic regression models with random effects to account for clustering by discharge physician. A sensitivity analysis was conducted in which women of different race and ethnicity were matched using propensity scores.
A total of 9,900 postpartum women were eligible for analysis. Compared with non-Hispanic white women, Hispanic and non-Hispanic black women had significantly greater odds of reporting a pain score of 5 or higher (adjusted odds ratio aOR 1.61, 95% 1.26-2.06 and aOR 2.18, 95% 1.63-2.91, respectively) but received significantly fewer inpatient MMEs/d (adjusted β -5.03, 95% CI -6.91 to -3.15, and adjusted β -3.54, 95% CI -5.88 to -1.20, respectively). Additionally, Hispanic and non-Hispanic black women were significantly less likely to receive an opioid prescription at discharge (aOR 0.80, 95% CI 0.67 to -0.96 and aOR 0.78, 95% CI 0.62-0.98) compared with non-Hispanic white women. Results of the propensity score analysis largely corroborated those of the primary analysis, with the exception that the difference in inpatient MMEs/d between non-Hispanic white and non-Hispanic black women did not reach statistical significance.
Hispanic and non-Hispanic black women experience disparities in pain management in the postpartum setting that cannot be explained by less perceived pain.
Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, ...significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period.
The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.
The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research.
We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.
The ARRIVE Trial Grobman, William A
Clinical obstetrics and gynecology,
2024-Jun-01, Letnik:
67, Številka:
2
Journal Article
Recenzirano
Timing of delivery such that maternal and perinatal outcomes are optimized is among the most important and commonplace decisions in obstetric care. Given the importance of this determination, it is ...somewhat surprising that there has been, until relatively recently, little in the way of high-quality evidence to guide obstetric clinicians in this decision. This chapter describes the evolution of studies examining the effects of labor induction and the importance of the ARRIVE trial in that context.
Adverse pregnancy outcomes (APOs)-including pre-term birth, pre-eclampsia, and intrauterine growth restriction-are common interrelated disorders caused by placental dysfunction and maternal vascular ...abnormalities (endothelial activation, inflammation, and vasospasm) that occur in approximately 10% to 20% of pregnancies. Women who experience APOs are at increased risk for future cardiovascular disease (CVD). APOs are associated with increased risk of development of hypertension, left ventricular hypertrophy/dysfunction, vascular dysfunction, and renal dysfunction. The vascular abnormalities that are present during an APO also underlie common, difficult-to-treat forms of CVD in women as they age (e.g., cardiac microvascular dysfunction, heart failure with preserved ejection fraction), suggesting shared mechanistic pathways for APOs and CVD. Here, the authors synthesize the current information and knowledge gaps regarding the progression from APO to CVD. Understanding the risk factors for and pathogenesis of APO-related cardiovascular dysfunction is a critical unmet need that could inform efforts to prevent and more effectively treat CVD in women.
Objective Previous studies of induction of labor in the setting of trial of labor after cesarean have compared women undergoing trial of labor after cesarean to those undergoing spontaneous labor. ...However, the clinically relevant comparison is to those undergoing expectant management. The objective of this study was to compare obstetric outcomes between women undergoing induction of labor and those undergoing expectant management ≥39 weeks of gestation. Study Design This was a secondary analysis of data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Cesarean Registry that included women with singleton gestations at a gestational age of ≥39 weeks and a history of 1 low transverse cesarean delivery. Outcomes of induction at 39, 40, and 41 weeks were compared to expectant management beyond each gestational age period using univariable and multivariable analyses. Women with scheduled repeat cesarean deliveries done for the indication of prior cesarean delivery were excluded from the analysis. Results In all, 12,676 women were eligible for analysis. The rate of vaginal birth after cesarean (VBAC) was higher among women undergoing induction of labor at 39 weeks compared to expectant management (73.8% vs 61.3%, P < .001). The risk of uterine rupture also was higher among women undergoing induction of labor at 39 weeks compared to expectant management (1.4% vs 0.5%, P = .006, respectively). In multivariable analysis, induction of labor at 39 weeks remained associated with a significantly higher chance of VBAC and uterine rupture (odds ratio, 1.31; 95% confidence interval, 1.03–1.67; and odds ratio, 2.73; 95% confidence interval, 1.22–6.12, respectively). Conclusion Induction of labor at 39 weeks, when compared to expectant management, was associated with a higher chance of VBAC but also of uterine rupture.
Opioid prescribing patterns among postpartum women Badreldin, Nevert; Grobman, William A.; Chang, Katherine T. ...
American journal of obstetrics and gynecology,
07/2018, Letnik:
219, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Women commonly receive opioid prescriptions following hospitalization. The rise of the opioid epidemic in the United States underscores the importance of a better understanding of prescribing ...patterns. Although delivery is the most frequent reason for hospitalization in the United States, there is inadequate knowledge regarding opioid prescribing at postpartum hospital discharge.
We sought to describe opioid prescribing patterns at the time of discharge following delivery in a large, diverse cohort, and to describe the relationship of these patterns with objective and subjective measures of pain prior to discharge.
This is a retrospective cohort study of all deliveries at a single, high-volume tertiary care center over a 1-year period. Women were excluded from analysis if they had evidence of recent opioid use, or their labor, delivery, or postpartum course was notable for rare, nonroutine events anticipated to increase pain. Medical records were queried for demographic and clinical data, including whether an opioid prescription was provided at discharge, and if so, details of that prescription. The primary outcome was amount of opioid morphine milligram equivalents prescribed at discharge, described separately for women after vaginal and cesarean deliveries. Among women who received a prescription, we additionally assessed associations between prescription quantity and subjective (patient-reported pain score) and objective (inpatient opioid requirement during the final 24 hours of hospitalization) assessments of pain. Descriptive and bivariable analyses were performed.
Of the total 12,611 women, 12,326 were eligible for inclusion. Of 9038 women postvaginal delivery and 3288 women postcesarean delivery, 30.4% and 86.7% received an opioid prescription at discharge, respectively. Of women receiving discharge opioid prescriptions, median morphine milligram equivalents received was 200 (interquartile range: 120–300) following vaginal and 300 (interquartile range: 200–300) following cesarean delivery. Nearly half (45.7%) of women postvaginal delivery and 18.5% of women postcesarean delivery who received an opioid prescription used 0 morphine milligram equivalent during the final hospital day. Similarly, 26.5% and 18.5% of women after vaginal and cesarean delivery, respectively, reported a pain score of 0 of 10 prior to discharge. Regardless of delivery mode, the amount of opioids prescribed did not differ between those who reported a pain score of 0 of 10 and those who reported a pain score of >0 of 10 immediately prior to discharge. Similarly, for women who underwent cesarean delivery, the morphine milligram equivalents prescribed did not differ between those who used 0 morphine milligram equivalents and those who used >0 in the 24 hours prior to hospital discharge.
Postpartum women are commonly prescribed opioids at the time of postpartum hospital discharge. There is a wide range of morphine milligram equivalents prescribed at hospital discharge following delivery, highlighting a lack of standardization. Furthermore, regardless of objective and subjective measures of pain prior to discharge, women received similar amounts of prescription morphine milligram equivalents following either vaginal or cesarean deliveries.
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