Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes

Introduction A potential complication of term prelabor rupture of membranes (term PROM) is chorioamnionitis with an increased burden on neonatal outcomes of chronic lung disease and cerebral palsy. The purpose of the study was to analyze the efficacy of a standing clinical protocol designed to identify women with term PROM at low risk for chorioamnionitis, who may benefit from expectant management, and those at a higher risk for chorioamnionitis, who may benefit from early induction. Material and methods This retrospective study enrolled all consecutive singleton pregnant women with term PROM. Subjects included women with at least one of the following factors: white blood cell count ≥ 15×100/μL, C-reactive protein ≥ 1.5 mg/dL, or positive vaginal swab for beta-hemolytic streptococcus. These women comprised the high risk (HR) group and underwent immediate induction of labor by the administration of intravaginal dinoprostone. Women with none of the above factors and those with a low risk for chorioamnionitis waited for up to 24 hours for spontaneous onset of labor and comprised the low-risk (LR) group. Results Of the 884 consecutive patients recruited, 65 fulfilled the criteria for HR chorioamnionitis and underwent immediate induction, while 819 were admitted for expectant management. Chorioamnionitis and Cesarean section rates were not significantly different between the HR and LR groups. However, the prevalence of maternal fever (7.7% vs. 2.9%; p = 0.04) and meconium-stained amniotic fluid was significantly higher in the HR group than in LR group (6.1% vs. 2.2%; p = 0.04). This study found an overall incidence of 4.2% for chorioamnionitis, 10.9% for Cesarean section, 0.5% for umbilical artery blood pH < 7.10, and 1.9% for admission to the neonatal intensive care unit. Furthermore, no confirmed cases of neonatal sepsis were encountered. Conclusions A clinical protocol designed to manage, by immediate induction, only those women with term PROM who presented with High Risk factors for infection/inflammation achieved similar maternal and perinatal outcomes between such women and women without any risks who received expectant management. This reduced the need for universal induction of term PROM patients, thereby reducing the incidence of maternal and fetal complications without increasing the rate of Cesarean sections.

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Impact of Labor Induction at 39 Weeks Gestation Compared with Expectant Management on Maternal and Perinatal Morbidity among a Cohort of Low-risk Women

10.21203/rs.3.rs-289350/v1 ◽

2021 ◽

Author(s):

Sabrina C. Burn ◽

Ruofan Yao ◽

Maria Diaz ◽

Jordan Rossi ◽

Stephen Contag

Keyword(s):

Cesarean Delivery ◽

Lower Risk ◽

Fetal Death ◽

Expectant Management ◽

Low Risk ◽

P Value ◽

Cesarean Hysterectomy ◽

Increased Risk ◽

Nicu Admission ◽

Low Risk Women

Abstract Objective: To determine rates of maternal and perinatal outcomes after induction of labor (IOL) at 39 weeks compared with expectant management.Methods: Cohort study of low risk women delivered between 39-42 weeks from 2015 to 2018. We excluded births with fetal abnormalities, previous cesarean, multiple pregnancies or those with spontaneous onset of labor (SOL) or indicated delivery at 39 weeks. Data was abstracted from National Center for Health Statistics birth files. Relative risks (aRR) were estimated with multivariable log-binomial regression. Main Outcome Measures: Maternal outcomes: chorioamnionitis (Triple I), blood transfusion, neonatal intensive care unit (NICU) admission, uterine rupture, cesarean delivery and cesarean hysterectomy. Fetal and infant outcomes: fetal death, 5-minute Apgar ≤3, prolonged ventilation, seizures, ICU admission, and death within 28 days. Results: There were 15,900,956 births, with 8,540,063 after exclusions. The IOL group included 1,177,790 births excluding women with diabetes or hypertensive disease. There were 3,835,185 births after 39 weeks excluding women with diabetes or chronic hypertension. With IOL at 39 weeks the risk for blood transfusion (p-value < 0.01; aRR 0.78; 95% CI [0.75-0.82]), Triple I (p-value < 0.01; aRR 0.71; 95% CI [0.70-0.73]) and cesarean delivery (p-value <0.01; aRR 0.87; 95% CI [0.87-0.88]) were lower, albeit increased risk of cesarean hysterectomy (p-value <0.01; aRR 1.23; 95% CI [1.07-1.41]). Neonates had a lower risk for 5-minute Apgar ≤3 (p-value < 0.01; aRR 0.68; 95% CI [0.66-0.71]), prolonged ventilation (p-value < 0.01; aRR 0.84; 95% CI [0.81-0.87]), NICU admission (p-value < 0.01; aRR 0.86; 95% CI [0.85-0.87]), and neonatal seizures (p-value <0.01; aRR 0.85; 95% CI [0.76-0.96]). There was no difference in risk for neonatal death 0.99% (p-value 0.99; aRR 1.00; 95%CI [0.99-1.00]), or fetal death (p-value 0.78; aRR 1.0002; 95%CI [0.99-1.002]. This benefit was greater compared with each subsequent week.Conclusions: Induction of labor at 39 weeks of gestation in a low risk cohort is associated a lower risk of cesarean delivery, transfusions and infection, as well as lower neonatal morbidity, without difference in fetal or neonatal death. This appears to be associated with increased risk for cesarean hysterectomy.

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