提示: 手机请竖屏浏览!

低危未经产女性中引产与期待治疗的比较
Labor Induction versus Expectant Management in Low-Risk Nulliparous Women


William A. Grobman ... 妇产科和儿科 • 2018.08.09
相关阅读
• 足月择期引产的时代到来了吗

低风险初产妇引产与期待自然分娩,哪一种更有益于母婴健康

 

孙贇†‡,陈子江§¶*

†上海交通大学医学院附属仁济医院生殖医学中心;‡上海市辅助生殖与优生重点实验室;§山东大学附属生殖医院;¶生殖内分泌教育部重点实验室;‖国家辅助生殖与优生工程技术研究中心

*通讯作者

 

妊娠晚期引产需权衡孕产妇及胎儿两者的风险。对于引产时间,美国妇产科学会(ACOG)及中华医学会产科学组指南推荐,正常妊娠已达41周或过期妊娠的孕产妇应予引产,降低围产儿死亡率及不良事件的发生1,2。目前的研究证据提示在孕39周之前进行引产可能会增加新生儿不良事件的发生3。但在孕39周至40周6日,尤其是在初产妇人群中,尚无明确证据显示在此期间进行引产对胎儿有益4,5,考虑到可能存在增加剖宫产率以及孕产妇不良结局的风险,通常不建议进行选择性引产。

查看更多

摘要


背景

在低危未经产女性中,39周引产的围生期和产妇结局尚不确定。

 

方法

在这项多中心试验中,我们将在妊娠38周0日至38周6日的低危未经产女性随机分组,分别在妊娠39周0日至39周4日时接受引产或接受期待治疗(expectant management)。主要结局为由围生期死亡或重度新生儿并发症组成的复合结局;首要的次要结局为剖宫产。

 

结果

共3,062名女性被分配接受引产,3,044名被分配接受期待治疗。在引产组和期待治疗组新生儿中,主要结局的发生率分别为4.3%和5.4%(相对危险度,0.80;95%置信区间[CI],0.64~1.00)。引产组的剖宫产率显著低于期待治疗组(18.6% vs. 22.2%;相对危险度,0.84;95% CI,0.76~0.93)。

 

结论

低危未经产女性39周时引产未显著降低围生期复合不良结局的发生率,但显著降低了剖宫产率(由尤尼斯·肯尼迪·施莱佛国立儿童健康与人类发展研究所[Eunice Kennedy Shriver National Institute of Child Health and Human Development]资助;ARRIVE在ClinicalTrials.gov注册号为NCT01990612)。





作者信息

William A. Grobman, M.D., Madeline M. Rice, Ph.D., Uma M. Reddy, M.D., M.P.H., Alan T.N. Tita, M.D., Ph.D., Robert M. Silver, M.D., Gail Mallett, R.N., M.S., C.C.R.C., Kim Hill, R.N., B.S.N., Elizabeth A. Thom, Ph.D., Yasser Y. El-Sayed, M.D., Annette Perez-Delboy, M.D., Dwight J. Rouse, M.D., George R. Saade, M.D., Kim A. Boggess, M.D., Suneet P. Chauhan, M.D., Jay D. Iams, M.D., Edward K. Chien, M.D., Brian M. Casey, M.D., Ronald S. Gibbs, M.D., Sindhu K. Srinivas, M.D., M.S.C.E., Geeta K. Swamy, M.D., Hyagriv N. Simhan, M.D., and George A. Macones, M.D., M.S.C.E. for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network*
From the Department of Obstetrics and Gynecology, Northwestern University, Chicago (W.A.G., G.M.); University of Alabama at Birmingham, Birmingham (A.T.N.T.); University of Utah Health Sciences Center, Salt Lake City (R.M.S., K.H.); Stanford University, Stanford, CA (Y.Y.E.-S.); Columbia University, New York (A.P.-D.); Brown University, Providence, RI (D.J.R.); University of Texas Medical Branch, Galveston (G.R.S.), University of Texas Health Science Center at Houston, Children’s Memorial Hermann Hospital, Houston (S.P.C.), and University of Texas Southwestern Medical Center, Dallas (B.M.C.) — all in Texas; University of North Carolina at Chapel Hill, Chapel Hill (K.A.B.), and Duke University, Durham (G.K.S.) — both in North Carolina; Ohio State University, Columbus (J.D.I.), and MetroHealth Medical Center, Case Western Reserve University, Cleveland (E.K.C.) — both in Ohio; University of Colorado School of Medicine, Anschutz Medical Campus, Aurora (R.S.G.); University of Pennsylvania, Philadelphia (S.K.S.); University of Pittsburgh, Pittsburgh (H.N.S.) — both in Pennsylvania; Washington University, St. Louis (G.A.M.); the George Washington University Biostatistics Center, Washington, DC (M.M.R., E.A.T.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (U.M.R.). Address reprint requests to Dr. Grobman at the Department of Obstetrics and Gynecology, Northwestern University, 250 E. Superior St., Suite 05-2175, Chicago, IL 60611, or at w-grobman@northwestern.edu. *A list of other members of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Parikh LI, Reddy UM, Männistö T, et al. Neonatal outcomes in early term birth. Am J Obstet Gynecol 2014;211(3):265.e1-265.e11.

2. American College of Obstetricians and Gynecologists. Practice bulletin no. 146: management of late-term and postterm pregnancies. Obstet Gynecol 2014;124:390-396.

3. ACOG Committee on Practice Bulletins — Obstetrics. ACOG practice bulletin no. 107: induction of labor. Obstet Gynecol 2009;114:386-397.

4. Vardo JH, Thornburg LL, Glantz JC. Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor. J Reprod Med 2011;56:25-30.

5. Dunne C, Da Silva O, Schmidt G, Natale R. Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can 2009;31:1124-1130.

6. Guerra GV, Cecatti JG, Souza JP, et al. Elective induction versus spontaneous labour in Latin America. Bull World Health Organ 2011;89:657-665.

7. Osmundson S, Ou-Yang RJ, Grobman WA. Elective induction compared with expectant management in nulliparous women with an unfavorable cervix. Obstet Gynecol 2011;117:583-587.

8. Gibson KS, Waters TP, Bailit JL. Maternal and neonatal outcomes in electively induced low-risk term pregnancies. Am J Obstet Gynecol 2014;211(3):249.e1-249.e16.

9. Stock SJ, Ferguson E, Duffy A, Ford I, Chalmers J, Norman JE. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ 2012;344:e2838-e2838.

10. Cheng YW, Kaimal AJ, Snowden JM, Nicholson JM, Caughey AB. Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes. Am J Obstet Gynecol 2012;207(6):502.e1-502.e8.

11. Darney BG, Snowden JM, Cheng YW, et al. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol 2013;122:761-769.

12. Walker KF, Bugg GJ, Macpherson M, et al. Randomized trial of labor induction in women 35 years of age or older. N Engl J Med 2016;374:813-822.

13. Rosenberger W, Lachin JM. Randomization in clinical trials. New York: Wiley, 2002.

14. Lange AP, Secher NJ, Westergaard JG, Skovgård I. Prelabor evaluation of inducibility. Obstet Gynecol 1982;60:137-147.

15. Ludington E, Dexter F. Statistical analysis of total labor pain using the visual analog scale and application to studies of analgesic effectiveness during childbirth. Anesth Analg 1998;87:723-727.

16. Hodnett ED, Simmons-Tropea DA. The Labour Agentry Scale: psychometric properties of an instrument measuring control during childbirth. Res Nurs Health 1987;10(5):301-310.

17. Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 2005;353:1574-1584.

18. Bailit JL, Grobman WA, Rice MM, et al. Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals. Am J Obstet Gynecol 2013;209(5):446.e1-446.e30.

19. Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc [B] 1995;57:289-300.

20. Caughey AB, Sundaram V, Kaimal AJ, et al. Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess (Full Rep) 2009;176:1-257.

21. Caughey AB, Sundaram V, Kaimal AJ, et al. Systematic review: elective induction of labor versus expectant management of pregnancy. Ann Intern Med 2009;151:252-263, W53-W63.

22. Kawakita T, Iqbal SN, Huang CC, Reddy UM. Nonmedically indicated induction in morbidly obese women is not associated with an increased risk of cesarean delivery. Am J Obstet Gynecol 2017;217(4):451.e1-451.e8.

23. Gibson KS, Waters TP, Bailit JL. A risk of waiting: the weekly incidence of hypertensive disorders and associated maternal and neonatal morbidity in low-risk term pregnancies. Am J Obstet Gynecol 2016;214(3):389.e1-389.e12.

24. Sparks TN, Yeaton-Massey A, Granados JM, Handler SJ, Meyer M, Caughey AB. How do maternal views of delivery outcomes vary by demographics and preferred mode of delivery? Am J Perinatol 2015;32:741-746.

25. Schwarz C, Gross MM, Heusser P, Berger B. Women’s perceptions of induction of labour outcomes: results of an online-survey in Germany. Midwifery 2016;35:3-10.

26. Moore JE, Low LK, Titler MG, Dalton VK, Sampselle CM. Moving toward patient-centered care: women’s decisions, perceptions, and experiences of the induction of labor process. Birth 2014;41:138-146.

27. Yee LM, Kaimal AJ, Houston KA, et al. Mode of delivery preferences in a diverse population of pregnant women. Am J Obstet Gynecol 2015;212(3):377.e1-377.e24.

服务条款 | 隐私政策 | 联系我们