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Timing of Induction of Labor: Myths, Facts, and Misunderstandings?

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Timing of Induction of Labor: Myths, Facts, and Misunderstandings? Timing of Induction of Labor: Financial Relationships Myths, Facts, and • No financial disclosures related to this talk Misunderstandings? • Medical Advisor to: • Celmatix • Mindchild Aaron B. Caughey MD, PhD Professor and Chair • Bob’s Red Mill Department of Obstetrics and Gynecology Oregon Health & Science University [email protected] Outline Definitions • Gestational age at term • Early Term 37 0/7 to 38 6/7 • ‘Elective’ IOL varying GA • Full Term 39 0/7 to 40 6/7 • Early Term • Late Term 41 0/7 to 41 6/7 • Late Term • Postterm 42 0/7 and beyond • Full Term • Induction of labor • Outcomes • Cesarean Outcomes by Gestational Age Neonatal Morbidity by GA Neonatal Outcomes 37 38 39 40 41 weeks weeks weeks weeks weeks 5-minute Apgar <7 1.01 % 0.69 % 0.61 % 0.70 % 0.93 % 5-minute Apgar <4 0.19 % 0.13 % 0.11 % 0.12 % 0.14 % Meconium stained 2.27 % 3.24 % 5.20 % 7.39 % 10.33 % amniotic fluid Meconium aspiration 0.07 % 0.08 % 0.12 % 0.19 % 0.27 % Hyaline membrane 0.45 % 0.19 % 0.14 % 0.14 % 0.18 % dz Mech vent >30min 0.57 % 0.32 % 0.28 % 0.29 % 0.38 % Caughey AB, Musci TJ. Obstet Gynecol, 2004;103:57-62 Cheng YW, et al. AJOG, 2008 IUFD/Infant Death Rates - Compare Elective CDs: NICU by GA Tita A et al. NEJM, 2009 Rosenstein MR, et al. Obstet Gynecol, 2012 Elective IOL – What? • Common Medical Indications for IOL • Preeclampsia / Gest HTN • Diabetes Mellitus (A1GDM?) • Postterm (41 wks vs. 42 wks) • Intrauterine Growth Restriction • Nonreassuring fetal testing Elective IOL – What? Elective IOL – Why does it matter? • Not a medical indication for IOL • Impending macrosomia • Indicated IOL • Increased risk for developing: • Preeclampsia • Risks and benefits have been considered • IUGR (e.g. EFW 19%ile) • IOL vs. Expectant Mgmt • Favorable cervix • Elective IOL • Risks and benefits should be considered • IOL vs. Expectant Mgmt Elective IOL Elective IOL – early term Pro Con Pro Con ? neonatal comps Ĺ cesareans Ĺ maternal prefs Ĺ neonatal comps Ĺ md prefs Ĺ maternal prefs Ĺ maternal comps ? cesareans Ĺ md prefs Ĺ costs Ĺ maternal comps Ĺ costs Elective IOL prior to 39 weeks of gestation is not consistent with the standard of care or ACOG and should only be offered in experimental protocols with written informed consent IOL – Early Term Elective IOL – late term • IOL – When to deliver? Pro Con • Preeclampsia / Gest Htn Ļ neonatal comps Ĺ cesareans • Chronic Htn Ĺ maternal comps • Diabetes Mellitus (A1GDM?) Ĺ maternal prefs Ĺ costs • Intrauterine Growth Restriction Ĺ md prefs • 10%ile, 5%ile, 3%ile, changes on Doppler • Nonreassuring fetal testing • Cholestasis • Previa / accreta • Twins (Di-di vs. Mo-di) Elective IOL – late term Elective IOL - CS • Does IOL increase cesarean delivery? Pro Con Ļ neonatal comps Ĺ cesareans Ĺ maternal prefs Ĺ maternal comps Ĺ md prefs Ĺ costs • Cohort and case-control data • IOL increases cesareans • Prospective RCTs • 41 weeks GA – decreases cesareans • <41 weeks GA – ? Induction of Labor Induction of Labor • Comparison of IOL vs. ANT • IOL vs. Expt Mgmt 41 wks and beyond • (Hannah et al., NEJM, 1992 • Sanchez-Ramos et al, OB Gyn, 2003 • Meta-analysis, 16 prospective RCTs • 1701 IOL @ 41 wks vs. 1706 ANT @ 41 wks • C/S higher in ANT group (24.5% vs. 21.2%) • Mode of delivery • IOL Expt Mgmt OR 95% CI • C/S for FD higher as well (8.3 % vs. 5.7%) • CS - 20.1% CS – 22.0% 0.78 – 0.99 • Mec – 22% Mec – 27% 0.49 – 0.88 • Higher rate of meconium in ANT group • PMR – 0.09% PMR – 0.33% 0.14 – 1.18 • No difference noted in neonatal morbidity PMR = perinatal mortality rate Elective IOL at 41 wks or less Induction of Labor - CS • Retrospective studies - more CS with IOL • Prospective studies – fewer CS or no diff • What are the groups being compared? • IOL at 39 weeks vs. Spont labor at 39 weeks • However, in RCT: • IOL at 39 weeks GA vs. • Patients beyond 39 weeks GA Caughey AB, et al. Ann Int Med, 2009;151:252-63. Induction of Labor < 41 wks GA Elective IOL - CS Elective IOL vs. Expt. Mgmt - Cesarean Delivery IOL 38 39 40 41 42 No IOL 38 39 40 41 42 A. Comparison by week of gestation IOL 38 No IOL 38 Æ 39 Æ 40 Æ 41 Æ 42 B. Comparison of IOL and Expectant Management Caughey et al, AJOG 2006;195:700-5 Darney B, et al. OBG. 2013 IOL at term IOL at term • ARRIVE Trial • ARRIVE Trial • 6106 women randomized to IOL vs. Expt Mgmt. at 39 to 39 4/7 wks GA IOL Expt Mgmt IOL Expt Mgmt Grobman W, et al., NEJM 2018 Grobman W, et al. AJOG, NEJM 2018 Elective IOL – full term Elective IOL - CS Pro Con • Prospective RCT at 41 wks – lower CS ? neonatal comps ? cesareans • Prospective RCTs < 41 wks – lower CS Ĺ maternal prefs Ĺ maternal comps • Multiple retrospective studies – higher CS Ĺ md prefs Ĺ costs • Appropriate retrospective studies – lower/no diff in CS • Research protocols vs. Actual practice IOL - patience Is 39 the new 41? • Why Not • The proportion impacted is dramatically different • The risk from 39 to 40 differs from 41 to 42 • ARRIVE is great, but we have many more 41 RCTs • Need to understand global clinical/economic impact • Maybe • Cesarean data is convincing, at least in right settings • Also prevents hypertensive complications • Might be cost effective Summary – Should Every Woman Be Induced at 39 weeks? Thank You • Early Term (37-38 wks GA) • Currently, a bad idea without indication • 41 wks GA (some call this postterm) • ACOG recommends • Improved outcomes • Full Term (39-40 wks GA) • Not a violation of SOC • Evidence is evolving • Depends on environment • Economic Impact Elective IOL - CS Elective IOL vs. Expt. Mgmt - Perinatal Mortality Stock S. BMJ. May, 2012 Case #3 Back to Case #3 • 27 yo G1P0 at 39 1/7 requesting IOL • 27 yo G1P0 at 39 1/7 requesting IOL • Unfavorable cervix w an unfavorable cervix. • Expt Mgmt & ANT vs. IOL • Plan: • Neonatal outcomes • A) IOL now • Maternal outcomes • Cesarean Delivery • B) IOL at 40 wks • C) IOL at 41 wks • What are the R/B/A • D) IOL at 42 wks Elective IOL – Hard Stop Elective IOL – Hard Stop Astoria Seaside St Helens Hermiston Pendleton Hillsboro Gresham The Dalles Enterprise Tillamook Beaverton Cape Lookout Portland La Grande • Why? Condon Regional Hub McMinnville Silverton Satellite Keizer • Right thing to do medically. Salem Baker City Lincoln City Albany Madras Corvallis • IOL costly John Day Prineville Canyon City 5 Redmond Eugene Ontario • Need to do geographically Springfield Bend Florence Vale Reedsport • Facilitates providers to “just say no” Burns North Bend Coos Bay Roseburg Jordan Valley Port Orford Grants Pass Bly Medford Ashland Brookings Klamath Falls Lakeview MILES 020406080 Prevention of Early Term Births Prevention of <39 weeks • HCA - Clark S, et al. – 2010 • Three approaches • Hard stop – not allowed • Soft Stop – MDs agreed not to do • Education Clark et al, Am J Obstet Gynecol, 2010 Elective IOL – Hard Stop Elective IOL – Hard Stop Term births at 37 or 38 weeks’ gestation Ehrenthal et al, Obstet Gynecol, 2011 Ehrenthal et al, Obstet Gynecol, 2011 Elective IOL – Hard Stop Elective IOL – Hard Stop Ehrenthal et al, Obstet Gynecol, 2011 Ehrenthal et al, Obstet Gynecol, 2011 Case #3 – What are R&B? IOL for Macrosomia • 27 yo G1P0 at 39 1/7 requesting IOL • LGA • Based on past evidence: • IOL at 40 weeks GA as compared to ANT • No difference in cesarean rate • No difference in neonatal outcomes Cheng et al, BJOG, 2012 IOL for Macrosomia Cheng et al, BJOG, 2012 Case Presentations Case #1 • 1 – 32 yo G3P2 at 38 0/7 requesting IOL • 32 yo G3P2 at 38 0/7 requesting IOL • Normal Pregnancy • Normal pregnancy • 2 - 34 yo G2P1 at 41 2/7 declining IOL • Elective IOL prior to 39 weeks of • Normal ANT gestation is not consistent with the standard of care or ACOG and should only be offered in experimental • 3 - 27 yo G1P0 at 39 1/7 requesting IOL protocols with written informed • Unfavorable cervix consent Elective IOL – Hard Stop Case #2 Hospitals take 'hard stop' on • 34 yo G2P1 at 41 2/7 declining IOL early elective C-sections, inductions • Normal ANT Oregon is the latest state where some hospitals are refusing to do the procedures before 39 weeks • Expt Mgmt & ANT vs. IOL of pregnancy • Neonatal outcomes • Maternal outcomes • Cesarean Delivery • What is the pt’s understanding of R/B/A Induction of Labor Back to Case #2 • Even w/ unfavorable cvx, @ 41 wks IOL: • 34 yo G2P1 at 41 2/7 declining IOL • Biggest concern is that her pregnancies are • Lower cesarean delivery rate supposed to go longer • Lower meconium-stained fluid • Another concern is labor pain similar to first • Lower perinatal mortality rate (small diff) IOL • Plan: • Extensive counseling re: R&B • Strip membranes • ANTC at 41 4/7 – strip again • Plan IOL at 42 0/7 IOL < 41 wks GA Questions? Contactme • Cochrane DB – Gülmezoglu AM et al, 2006 OHSUPhysicianAdvice&ReferralService • IOL < 41 weeks had lower CS rate •503Ͳ494Ͳ4567 •800Ͳ245Ͳ6478(tollͲfree) • RR 0.58; 95% CI 0.34 to 0.99 Financial Disclosures • None NW Update Induction of Labor DATE: November 14, 2019 Amy C. Hermesch, MD, PhD 2 Outline Choosing a quality project • IOL as a Quality Project • Externally mandated measures/required reporting? • Guideline development • High volume of patients impacted? • Limited evidence review • High cost of disease process or potential for significant cost reduction? • Summary • Variability in practice pattern? • Quality of patient safety concern? • Potential for improved patient or provider satisfaction? • Is there evidence to guide practice? 3 4 OregonMaternalDataCenter(OMDC) Step1:FacilitatedGuidelineDevelopment OHSU Office of Clinical Integration Identify topic for guideline and Evidence-Based Practice development Draft guideline, and Form interprofessional establish outcome • Promoting best practice and reducing guideline content team measures undesirable practice variation.
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