Corina Schoen

Intracervical Foley Catheter With and Without Oxytocin for Labor Induction: A Randomized Controlled Trial

OBJECTIVE To evaluate whether adding oxytocin to preinduction cervical ripening with a Foley catheter increases the rate of delivery within 24 hours. METHODS This was a randomized, multicenter, parallel trial of women with a singleton pregnancy at 24 weeks of gestation or greater undergoing labor induction. Women were randomly allocated to an intracervical Foley catheter followed by oxytocin or Foley with concurrent oxytocin infusion. Nulliparous and multiparous women were randomized and analyzed separately based on parallel design. The primary outcome was Foley placement to delivery at 24 hours or less. A sample size of 100 nulliparous women and 75 multiparous women per group would be required to detect a 20% increase in baseline 24-hour delivery rate with 80% power for each parity group. RESULTS From January 2015 through July 2016, 323 patients were enrolled: 184 nulliparous women and 139 multiparous women. Nulliparous women who received concurrent Foley and oxytocin delivered more frequently within 24 hours of Foley placement than did the Foley followed by oxytocin group (64% compared with 43%, P=.003, relative risk 1.51, 95% confidence interval [CI] 1.14-2.00). Multiparous women who received concurrent Foley and oxytocin delivered more frequently within 24 hours than the Foley followed by oxytocin group (87% compared with 72%, relative risk 1.22, 95% CI 1.02-1.45). Median time to delivery was shorter in both nulliparous women (20.9 compared with 26.1 hours, P<.001) and in multiparous women, (14.9 compared with 18.6 hours, P=.01) who received concurrent Foley and oxytocin compared with Foley followed by oxytocin. There were no significant differences in the rates of cesarean delivery, postpartum hemorrhage, chorioamnionitis, or neonatal intensive care unit admission between the randomization groups. CONCLUSION Induction with concurrent oxytocin infusion added to Foley significantly increases the rate of delivery within 24 hours in both nulliparous and multiparous compared with Foley followed by oxytocin. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02273115.

Anaphylaxis to buccal misoprostol for labor induction.

BACKGROUND: Misoprostol is a commonly used agent for induction of labor. Anaphylactic reactions are infrequent but possible complications of drugs administered to the pregnant patient. Although antibiotics, latex, and anesthetic agents are more common triggers for anaphylaxis, induction agents are also a rare cause. CASE: A 21-year-old woman received buccal misoprostol as a ripening agent for postdate labor induction and experienced anaphylaxis and tachysystole. Prompt administration of epinephrine and emergent cesarean delivery allowed for the safe delivery of the neonate and minimal maternal morbidity. CONCLUSION: When inducing labor, prompt identification and treatment of anaphylaxis and hypersensitivity reactions are necessary to prevent maternal and neonatal morbidity and mortality. Health care providers must be aware of uncommon reactions to medications used to induce labor.

Failed induction of labor

Induction of labor will affect almost a quarter of all pregnancies, but historically there has been no generally accepted definition of failed induction of labor. Only recently have studies analyzed the lengths of latent labor that are associated with successful labor induction ending in a vaginal delivery, and recommendations for uniformity in the diagnosis of failed induction have largely resulted from this data. This review assesses the most recent and inclusive definition for failed induction, risk factors associated with failure, complications, and special populations that may be at risk for a failed induction.

Increased single‐balloon Foley catheter volume for induction of labor and time to delivery: a systematic review and meta‐analysis

Induction of labor is a common intervention. The objective was to investigate whether larger Foley catheter volumes for labor induction decrease the total time from induction to delivery.

Impact of ACOG Guideline Regarding Low Dose Aspirin for Prevention of Superimposed Preeclampsia [27O]

INTRODUCTION:In July 2016, an American College of Obstetricians and Gynecologists (ACOG) guideline recommended that pregnant women with chronic hypertension (CHTN) be offered low dose aspirin to prevent superimposed preeclampsia (SIP). This study aimed to evaluate the incidence of SIP in women with

Cervical Ripening Using Foley Balloon with or without Oxytocin: A Systematic Review and Meta-Analysis

Objective To assess available evidence regarding the use of oxytocin in conjunction with Foley balloon (FB) for cervical ripening. Methods Databases from MEDLINE (U.S. National Library of Medicine, 1980—May 12, 2017), MEDLINE (Ovid, 1980—June 30, 2017), the Cochrane Library Controlled Trials Register, ClinicalTrials.gov, and Web of Science were queried for studies on FB cervical ripening with or without oxytocin in pregnant women. Search terms included: “balloon dilatation” OR “mechanical methods” OR “mechanical method” OR “mechanical dilation” OR “mechanical dilatation” OR “mechanical dilations” OR “mechanical dilatations” OR “balloon” OR “Foley” AND “Pitocin” OR “oxytocin.” All relevant references were reviewed. Literature for inclusion and methodological quality were reviewed based on the Preferred Reporting Items for Systematic Review and Meta‐Analysis guidelines. Results Out of 344 citations, six randomized clinical trials (1,133 patients) fulfilled our inclusion criteria. The pooled estimate showed that the cesarean delivery (CD) rate did not differ (relative risk [RR]: 0.91 (95% confidence interval [CI] [0.76‐1.10]; p = 0.23) between patients who underwent preinduction cervical ripening with FB alone versus those who received oxytocin in addition to FB. Heterogeneity was not significant among studies (I2 0.0%; p = 0.64). Furthermore, no differences in other outcomes such as composite and maternal outcomes were detected between these two groups. Compared with simultaneous use of oxytocin with FB, the Foley alone cervical ripening group had a longer induction to delivery time, and lower deliveries within 12 and 24 hours. Subgroup analysis showed that only multiparous women in the Foley alone group had lower rate of vaginal delivery within 24 hours (RR: 0.74, 95% CI [0.61‐0.89], p = 0.002) along with a trend toward higher CD rates. Conclusion Adding oxytocin to FB at the time of preinduction cervical ripening does not reduce cesarean rates nor improve maternal or neonatal outcomes. Multiparous women who received FB alone seem to have lower rates of vaginal deliveries within 24 hours, but these results should be interpreted with caution.

Outcome Differences Between Women With Superimposed Preeclampsia With and Without Severe Features [28Q]

INTRODUCTION: The Hypertension in Pregnancy Task Force (2013) divided the diagnosis of superimposed preeclampsia into two categories: with and without severe features. This study compares obstetric outcomes in women with superimposed preeclampsia with and without severe features based on this new diagnostic criteria. METHODS: Women with singletons and chronic hypertension with superimposed preeclampsia with and without severe features who delivered between January 2008 and July 2015 at a university hospital were identified based on diagnostic criteria in the Hypertension in Pregnancy Task Force (2013). Primary outcome assessed was composite maternal morbidity, including placental abruption, maternal ICU admission, eclampsia, HELLP syndrome and death. Secondary outcomes included gestational age (GA) at delivery, GA at diagnosis, small for GA, birth weight, 5-minute Apgar less than 7, NICU admission, and IUFD. Chi-square and student t test were used as appropriate. RESULTS: 135 pregnancies with severe features and 66 without severe features were identified. Both groups were similar in maternal demographics. There was no difference in the composite maternal morbidity (P=1.0). Women with severe features were delivered earlier (P=.004), had smaller neonates (P=.01), shorter latency from diagnosis to delivery (P=.03), and higher incidence of IUFD (P=.03). Women diagnosed with severe features solely by BP criteria had a significantly higher IUFD rate than the non-severe group (P=.009). CONCLUSION: Women with superimposed preeclampsia and severe features have significantly higher risk of perinatal complications, especially for IUFD. These women warrant intense surveillance.

Predictors of Progression of Preterm Preeclampsia Without Severe Features to Severe Disease [26H]

INTRODUCTION: It is unclear which women will progress from preeclampsia without severe features to more severe disease by delivery. The objective of this study was to evaluate potential predictors of progression from preterm gestational hypertension (GHTN) or preeclampsia (PE) without severe features to severe disease. METHODS: At a university hospital between January 2008 and July 2015, women with singleton pregnancies and GHTN or PE without severe features diagnosed prior to 34 0/7 weeks had demographic and obstetric factors retrospectively collected to determine if those factors influence progression to preeclampsia with severe features. RESULTS: 63 women developed GHTN or PE without severe features less than 34 weeks. 38 women remained without severe features (60.3%), and 25 progressed to PE with severe features (39.7%). There was no difference in age, race, or gestational age at diagnosis or delivery. Smoking (OR 4.7, 95% CI 1.08 to 20.22) and a history of preeclampsia (OR 5.7, 95% CI 1.04 to 30.93) were associated with higher odds of developing severe features. IUGR was associated with a lower risk of progressing to severe features (OR 0.1, 95% CI 0.01 to 0.85). All IUGR patients were delivered for abnormal antenatal testing. Women who developed severe features had lower parity (P=.03) than those without severe features. CONCLUSION: Smoking and history of preeclampsia may be predictors of progression to PE with severe features in women who develop preterm GHTN or PE without severe features. IUGR is associated with lower odds of progression to severe features, likely secondary to earlier delivery for fetal indications.