Induction of Labour. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-088, December 2020)

Trial of labor after caesarean section in low risk pregnancies: is it risky?

PURPOSE

To evaluate the influence of a previous caesarean section on adverse composite maternal and perinatal outcome in women who attempted a trial of labor.

METHODS

This historical cohort study analyzed maternal and perinatal outcome in women with otherwise low risk pregnancies at term who underwent a trial of labor after a caesarean section (TOLAC). The primary outcome measure was the adverse composite outcome. Secondary outcome measures were amongst others the caesarean section rate and the mode of vaginal delivery.

RESULTS

The adverse composite outcome was more frequently in the previous caesarean section group compared to women with no previous caesarean Sect. (22.3% vs. 15.6%, p < 0.0001). The percentage of caesarean Sect. (15.4% vs. 8.2%, p < 0,0001), uterine rupture (1.0% vs. 0.02%, p < 0.0001), placental abruption (1.1% vs. 0.3%, p = 0.0014), vaginal operative delivery (16.0% vs. 8.6%, p < 0.0001), pH < 7.10 (3.7% vs. 2.5%, p = 0.0151), base excess < -12 (3.2% vs. 2.2%, p = 0.0297), abnormal cardiotocography (22.5% vs. 13.9%, p < 0,0001) and fetal blood analysis (6.2% vs. 2.6%, p < 0.0001) was significantly higher in women with a previous caesarean section. Taking the parity into account, these differences could only been seen in women without a previous vaginal delivery. In parous women with a previous vaginal delivery and a caesarean section in history, the adverse composite did not differ between the groups. Only the rate of pH < 7.1 was higher in women after a caesarean Sect. (4.5% vs. 1.8%, p = 0.0436).

CONCLUSION

Trial of labor after caesarean in otherwise low risk pregnancies is associated with a higher rate of complications especially if there is no history of vaginal delivery.

PROM at term: when might be the best time to induce labour? A retrospective analysis

PURPOSE

PROM after 37 weeks of gestation occurs in approximately 10% of pregnancies. When spontaneous onset of labour does not follow, induction is recommended to decrease the risk of infection for both mother and child. However, there is no clear consensus on whether induction before 24 h after PROM results in fewer complications compared to induction after > 24 h.

MATERIAL AND METHODS

This retrospective observational study analysed the outcomes of 3174 women with PROM admitted to the delivery room of LMU Women's Hospital between 10/2015 and 09/2020. We evaluated whether timing of labour induction was associated with maternal or newborn postpartum infection rates.

RESULTS

Comparing women with spontaneous onset of labour to those who underwent induction, no significant differences were found in maternal CRP or leukocyte levels, fever, endometritis, or Group B streptococcus colonization. However, intrapartum antibiotic therapy was significantly higher in the induction group. When the induction group was subdivided based on the interval from PROM to induction, no significant differences were observed in maternal infection parameters, need for antibiotics, postpartum length of hospital stay, or endometritis. For newborn infections, a significant difference in CRP levels was found, with higher levels in the groups with "induction < 12 h" and "> 24 h".

CONCLUSION

The presented data suggests that waiting for spontaneous contractions within the first 24 h after PROM was not associated with the risk of infection if no initial signs for infection are present. However, beyond 24 h, the risk of infection increased. These findings support current recommendations regarding the timing of induction after PROM.

[AI-supported decision-making in obstetrics - a feasibility study on the medical accuracy and reliability of ChatGPT]

The aim of this study is to investigate the feasibility of artificial intelligence in the interpretation and application of medical guidelines to support clinical decision-making in obstetrics. ChatGPT was provided with guidelines on specific obstetric issues. Using several clinical scenarios as examples, the AI was then evaluated for its ability to make accurate diagnoses and appropriate clinical decisions. The results varied, with ChatGPT providing predominantly correct answers in some fictional scenarios but performing inadequately in others. Despite ChatGPT's ability to grasp complex medical information, the study revealed limitations in the precision and reliability of its interpretations and recommendations. These discrepancies highlight the need for careful review by healthcare professionals and underscore the importance of clear, unambiguous guideline recommendations. Furthermore, continuous technical development is required to harness artificial intelligence as a supportive tool in clinical practice. Overall, while the use of AI in medicine shows promise, its current suitability primarily lies in controlled scientific settings due to potential error susceptibility and interpretation weaknesses, aiming to safeguard the safety and accuracy of patient care.

Low-dose Oral Misoprostol after Cervical Ripening with a Double-balloon Catheter: 25 µg or 50 µg?

Purpose

Misoprostol is used in low doses for the induction of labor. It is still not clear, however, which of the approved doses (25 µg or 50 µg) is more beneficial. The aim of this study was to investigate whether oral misoprostol at a dose of 25 µg or at a dose of 50 µg should be preferred to induce labor after cervical ripening with a double-balloon catheter.

Material and Methods

This retrospective cohort study analyzed full-term pregnancies (≥ 37 + 0 GW) in which sequential induction of labor was carried out using a double-balloon catheter followed by oral administration of misoprostol. The patients were divided into two groups: Group 1 received 50 µg misoprostol every four hours and Group 2 received 25 µg misoprostol every two hours. The primary target parameter was the rate of caesarean sections. Secondary target parameters included the interval from induction to delivery, the rate of spontaneous births, vaginal operative deliveries, and neonatal outcomes.

Results

967 patients were included in the study: 514 in Group 1 and 453 in Group 2. There was no significant difference in the rate of caesarean sections between the two groups (p = 0.688). However, significantly more women in Group 2 had unsuccessful induction of labor, defined as a vaginal birth after 72 hours (15.8% vs. 8.1%, p = 0.001). But fewer neonates from Group 2 required transfer to the neonatal department (10.6% vs. 18.5%, p < 0.001).

Conclusion

The study found no difference in the rate of caesarean sections for the different doses of misoprostol. However the rate of vaginal deliveries only occurring after 72 hours was higher in the group treated with 25 µg misoprostol, while more neonates required transfer to the neonatal department in the group receiving 50 µg misoprostol.

A comparative analysis of methods of preinduction cervical ripening and induction of labor in Poland and in Germany (Part II): maternal and neonatal outcomes

The benefits and risks of delivery should always be considered before initiating preinduction cervical ripening and labor induction. Understanding the benefits and potential complications is crucial for healthcare professionals to make informed decisions and provide optimal care. The research was conducted retrospectively between January 2019 and July 2022. It involved the analysis of the medical records of 154 pregnant women staying in the Clinic of Obstetrics and Gynecology in the city of Szczecin and 150 pregnant women hospitalized in the Clinic of Obstetrics and Gynecology in the town of Schwedt/Oder in Germany. Inclusion criteria were consent to participate and the implementation of internal written protocols in line with national guidelines for labor induction. The research concerned a group of pregnant women with postdate pregnancy, calculated according to the Naegele's rule and confirmed by the USG examination conducted in the first trimester of the pregnancy, as well as an unfavorable cervix that received less than 6 points in the Bishop score. Moreover, the pregnant patients with a low biophysical profile and an abnormal record of CTG or comorbidities were also included, as these factors determined the classification of the group above. The study did not include patients who had undergone cesarean section. The average change in evaluation of the cervix marked on the Bishop Score was higher in Germany, and it was 2.7 points, whereas in Poland, it was 1.6 points. The largest percentage of the scores on the Apgar Scale in the first, third and fifth minutes after birth was in the norm and indicated a good health condition of infants. They reached 8 to 10 points in both countries. Significantly more infants in Germany received pH from the umbilical cord within the limits of the norm. And it marks the welfare of neonates (7.20-7.45). The duration of hospitalization in Poland was shorter than in Germany. It was 3.8 days in the case when the median equalled 3. The number of days of preinduction cervical ripening and induction was similar in both countries. The levels of haemoglobin were comparable in both countries. The most common postpartum complications in Poland and Germany were first-degree perineal tears, episiotomies and anemia. Among the postpartum complications, cervical tears, revision of the uterine cavity, and episiotomy were significantly more common in Poland. First- and second-degree perineal tears were more frequent in Germany.

Value of Cerebroplacental Ratio in Predicting Adverse Perinatal Outcome in Term Pregnancies Complicated by Obesity

Objectives

To evaluate the performance of cerebroplacental ratio (CPR) in predicting composite adverse perinatal outcome (CAPO) in women with obesity compared to non-obese women at term.

Methods

This is a retrospective cohort study in a single tertiary referral centre over a 3-year period. All singleton pregnancies with CPR measurements ≥ 37 + 0 weeks and estimated fetal weight ≥ 10 th centile and attempted vaginal delivery were included and divided into two groups defined by pre-pregnancy body mass index (BMI)

Results

The study cohort included 1207 pregnancies, of which 112 were women with a BMI ≥ 30 kg/m 2 . In obese women, CAPO occurred in 21 cases (18.8%) compared to 247 (22.6%) cases in women with BMI < 30 kg/m 2 (p = 0.404). In the entire study cohort, CPR MoM was significantly lower in the CAPO and OD for IFC group. ROC analyses revealed a significant predictive value of low CPR MoM for CAPO in obese women (AUC = 0.64, p = 0.024). Furthermore, CPR was predictive for OD for IFC not only in obese (AUC = 0.72, p = 0.023) but also in non-obese (AUC = 0.61, p = 0.003) women.

Conclusions

Low CPR MoM was predictive for CAPO and OD for IFC in obese women without additional risk factors. However, the overall predictive performance of CPR for CAPO in obese women was poor.

Collapse

Key Words

• BMI
• adverse perinatal outcome
• cerebroplacental ratio
• obesity

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Gabriel Eisenkolb Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Anne Karge Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Javier U. Ortiz Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Eva Ostermayer Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Silvia M. Lobmaier Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Bettina Kuschel Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Oliver Graupner Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany

Collapse

Vaginal dinoprostone insert compared with two different oral misoprostol regimens for labor induction in nulliparous and multiparous women

INTRODUCTION

Labor induction exhibits considerable variations in protocols and medication regimens. Limited studies compare vaginal dinoprostone inserts with different oral misoprostol dosages, considering parity influence. This study explores the distinctions among 10 mg vaginal dinoprostone inserts and oral misoprostol 25 μg every 2 and every 4 h for labor induction, stratified by parity.

MATERIAL AND METHODS

This retrospective cohort study involved 607 participants across two hospitals. The primary outcome, time from induction to delivery, and secondary outcomes, including mode of delivery and maternal and fetal safety, were assessed.

RESULTS

Patient characteristics revealed differences in indication for labor induction, with the dinoprostone cohort having fewer post-term and premature rupture of membranes cases but more intrauterine growth restriction/small-for-gestational age. Both oral misoprostol regimens showed a shorter time to delivery interval compared to the dinoprostone cohort (median: 1380 min [IQR 1381.0] and 1127.0 min [IQR 1214.0] vs 1631.5 [IQR 1736.2], p < 0.001 and p = 0.014). Only the difference between oral misoprostol q2h and vaginal dinoprostone remained significant for nulliparous but not multiparous women, losing significance over all the population after adjusting for confounding factors. The proportion of women giving birth within 24 h did not significantly differ between misoprostol q2h and dinoprostone after adjusting for confounders. When comparing misoprostol q4h with dinoprostone after confounder adjustment, an increased time to delivery interval for misoprostol q4h was found (p = 0.001). Both oral misoprostol regimens exhibited fewer meconium-stained liquor (miso q4h: OR 0.44, miso q2h: OR 0.34) and cesarean sections (miso q4h: OR 0.48, miso q2h: OR 0.53) compared to dinoprostone, even after adjustment for confounders.

CONCLUSIONS

Our study suggests that oral misoprostol 25 μg q4h is less effective than 10 mg vaginal dinoprostone for labor induction if parity and indication for induction are adjusted for, particularly in multiparous women. In terms of side effects, oral misoprostol regimens seem superior to vaginal dinoprostone. Our data support the individualized use of different agents for labor induction according to parity, indication for induction, bishop score, and women's preference.

Oxytocin and vaginal dinoprostone in labor induction: A systematic review and meta-analysis

BACKGROUND

The comparison between prostaglandin E2 (PGE2) and oxytocin and for induction of labor (IOL) remains controversial.

OBJECTIVE

The present study aimed to determine the safety and efficacy of these two agents in IOL.

SEARCH STRATEGY

PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov. from the establishment of the database to April 23, 2023.

SELECTION CRITERIA

A search was conducted with keywords "labor, induction, prostaglandin E2/PGE2/dinoprostone, and oxytocin". Only randomized clinical trials comparing oxytocin and vaginal dinoprostone in women who were at least late preterm (gestational age [GA] ≥34 weeks), singleton pregnant, and had intact membranes were enrolled for further meta-analysis.

DATA COLLECTION AND ANALYSIS

We conducted both a descriptive analysis and a meta-analysis. In the meta-analysis, we utilized the Mantel-Haenszel random effects model to analyze dichotomous data, employing the relative risk (RR) as the effect measure along with 95% confidence intervals (CIs). The study quality was evaluated using Cochrane Collaboration's risk of bias assessment tool (RoB 2). A random-effects model was applied for the meta-analysis.

MAIN RESULTS

After screening 3303 articles from five databases, a total of nine randomized controlled studies composed of 1071 patients were included. Our analysis included 534 patients in the PGE2 group and 537 patients in the oxytocin group. The pooled estimate of vaginal deliveries following PGE2 induction stood at 84.2%, while after oxytocin induction, it was 79.8%. The meta-analysis showed no statistical difference between the two groups in terms of the rate of vaginal delivery (pooled RR, 1.05; 95% CI: 0.95-1.16; P value for Q, 0.001; I2, 71.14%), cesarean section (pooled RR, 0.84; 95% CI: 0.52-1.35; P value for Q, 0.007; I2, 61.69%) and induction-delivery interval (pooled standard mean difference, 0.09; 95% CI: -0.67 to 0.85; P value for Q, 0.000; I2, 96.45%). Since the results for fetal distress and uterine hyperstimulation were consistent across all enrolled studies, no further meta-analysis was conducted.

CONCLUSIONS

When amalgamating the available literature, it implies that oxytocin was found to have similar effects as PGE2 on delivery outcomes and safety concerns in pregnant women with GA ≥36 weeks. Although the uterine cervix was unfavorable, both low and high doses of oxytocin were feasible for IOL.

Perinatal Outcome in Pregnant Women With Isolated Oligohydramnios Diagnosed With the Single Deepest Pocket Method

AIM

The aim of this study was to investigate perinatal outcome in singleton pregnancies at term with isolated oligohydramnios, diagnosed by using the single deepest pocket method.

PATIENTS AND METHODS

In this historic cohort study, the perinatal outcomes of 196 women with isolated oligohydramnios at term, diagnosed by using the single deepest pocket method, were compared to 8,676 women with normal amniotic fluid volume. The primary outcome measure was the Cesarean section rate. Further outcome parameters included the rate of induction of labor, abnormal cardiotocography, umbilical cord pH and base excess, Apgar, meconium-stained liquor and admission to neonatal intensive care unit.

RESULTS

In the group with isolated oligohydramnios, there were significantly more Cesarean sections (p=0.0081) and more abnormal cardiotocographies (p=0.0005). Univariate and multivariate analyses showed that this difference was seen particularly in nulliparous women (p=0.0025 for Cesarean section and 0.0368 for abnormal cardiotocography). Peripartal and perinatal outcome parameters were not different between the two groups.

CONCLUSION

In women with isolated oligohydramnios at term, there is no impact on fetal outcome. The influence of isolated oligohydramnios on the rate of cesarean section and abnormal cardiotocography is considered to be less than that of parity.

Maternal and Perinatal Outcome After Induction of Labor Versus Expectant Management in Low-risk Pregnancies Beyond Term

BACKGROUND/AIM

Due to still controversial discussion regarding appropriate termination of low-risk singleton pregnancies beyond term, this retrospective study aimed to evaluate maternal and perinatal outcomes depending on gestational age and obstetric management.

PATIENTS AND METHODS

This is a retrospective cohort analysis including 3.242 low-risk singleton deliveries at the Department of Obstetrics of the University Hospital of Cologne between 2017 and 2022. According to current national guidelines, the cohort was subdivided into three gestational groups, group 1: 40+0-40+6 weeks, group 2: 40+7-40+10 weeks and group 3>40+10 weeks.

RESULTS

In our cohort, advanced gestational age was associated with higher rates of secondary caesarean sections, lower rates of spontaneous vaginal deliveries, higher rates of meconium-stained amniotic fluid and depressed neonates with APGAR < 7 after 5 min. Analyzing obstetric management, induction of labor significantly increased the rate of secondary sections and reduced the rate of spontaneous deliveries, while the percentage of assistant vaginal deliveries was independent from obstetric management and gestational age. Induction of labor also significantly enhanced the need for tocolytic subpartu and epidural anesthesia and caused higher rates of abnormalities in cardiotocography (CTG), which also resulted in more frequent fetal scalp blood testing; however, the rate of fetal acidosis was independent of both obstetric management and gestational age.

CONCLUSION

Our study supports expectant management of low-risk pregnancies beyond term, as induction of labor increased the rate of secondary sections and did not improve perinatal outcome.

Induction of Labour with a Double Balloon Catheter - Comparison of Effectiveness of Six Versus Twelve Hours Insertion Time: a Prospective Case Control Study

Introduction

Induction of labour is a common obstetric procedure to initiate or augment contractions when labour is delayed or uncertain. The double balloon catheter is a safe and effective mechanical method for cervical ripening during induction of labour. This study evaluates the effectiveness of reducing double balloon catheter insertion time from 12 to 6 hours.

Methods

248 women undergoing induction with a double balloon catheter at term were divided into two groups: catheter placed for 12 hours at 8 pm in the first half of 2021 (P12) and catheter placed for 6 hours at 7 am in the second half of 2021 (P6). T-tests, chi-squared tests, and Wilcoxon signed rank test were used for statistical analysis. Primary and secondary endpoints included induction to delivery interval, prostaglandin to delivery interval, mode of delivery, and maternal and neonatal outcomes.

Results

The P6 group had a significantly reduced induction to delivery interval of 558 min (P6: 1348 min, P12: 1906 min, p < 0.01, 95% CI: 376-710) within demographically comparable groups. Multiparous women also showed a significant reduction in prostaglandin to delivery interval of 260 min (P6: 590 min, P12: 850 min, p = 0.038, 95% CI: 9-299). There were no significant differences in mode of delivery, maternal blood loss, or neonatal outcome.

Conclusion

Reducing double balloon catheter placement time from 12 to 6 hours resulted in almost 9 hours less induction to delivery interval without adverse effects on maternal and neonatal outcome.

Gestörte Frühgravidität

Eine Schwangerschaft kann intrauterin, ektop oder an einem unklaren Ort liegen und entwicklungsphysiologisch vital oder gestört sein. Die transvaginale Sonographie ermöglicht die Darstellung einer intrauterinen Schwangerschaft ab einem Schwellenwert des humanen Choriongonadotropins (hCG) von 1000 IU/l in der etwa sechsten Schwangerschaftswoche (SSW). Ektope Schwangerschaften sind abhängig von der SSW gegebenenfalls erschwert sonographisch erkennbar. Der Verlauf des hCG-Werts kann hilfreich dabei sein, eine physiologische von einer gestörten Frühschwangerschaft zu unterscheiden, muss aber immer in Zusammenschau mit der Klinik und dem Ultraschallbefund interpretiert werden. Bei einem frühen Abort kann abhängig von der Klinik exspektativ oder medikamentös vorgegangen werden. Die Indikation zur Kürettage sollte insgesamt zurückhaltend gestellt werden. Bei einer ektopen Schwangerschaft sollte abhängig von SSW und Klinik eine operative Therapie oder eine Methotrexattherapie durchgeführt werden.

Vaginal Birth at Term - Part 2. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. The second part of this guideline presents recommendations and statements on care during the dilation and expulsion stages as well as during the placental/postnatal stage. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in individual cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions where necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline, and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Intrahepatic Cholestasis of Pregnancy: A Case Report of Third-Trimester Onset of the Disease

Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus and an elevation in serum bile acid concentrations, typically developing in the late second and/or the third trimester and rapidly resolving after delivery. ICP is a rare condition that most often presents in the late second or early third trimesters of pregnancy. Physicians should be aware of this unusual presentation of ICP and screen their patients appropriately during prenatal consultations by monitoring symptom severity and laboratory tests, including bile acids and liver enzyme levels, in addition to monitoring the fetal condition to start treatment modality including maternal treatment and determine the time of delivery to avoid fetal complications. This is a case of severe ICP diagnosed in the late second trimester and went into labor at 33 weeks of gestational age.

Role of the cerebro-placental-uterine ratio in predicting adverse perinatal outcome in low-risk pregnancies at term

PURPOSE

The cerebroplacental ratio (CPR) is associated with adverse perinatal outcome (APO) in low-risk pregnancies near term. A Doppler parameter, which also includes information from the uterine vessels could potentially improve detection of subclinical placental dysfunction. The aim of this study is to investigate the performance of cerebro-placental-uterine ratio (CPUR) related to APO prediction in low-risk term pregnancies in > 40 + 0 weeks.

METHODS

This is a retrospective cohort study. All low-risk pregnancies in which feto-maternal Doppler was examined from 40 + 0 weeks and an appropriate for gestational age fetus was present were included. ROC (receiver operating characteristic curves) analyses were performed to assess the predictive value of CPUR. The presence of at least one of the following outcome parameters was defined as composite APO (CAPO): operative delivery (OD) due to intrapartum fetal compromise (IFC), admission to the neonatal intensive care unit, umbilical cord arterial pH ≤ 7.15, 5 min APGAR ≤ 7.

RESULTS

A total of n = 114 cases were included. Mean gestational age at examination and delivery were 40 + 3 weeks and 40 + 6 weeks, respectively. Overall, CAPO occurred in 38 of 114 cases (33.3%). ROC analyses showed a significant association of CPUR (AUC = 0.67, p = 0.004) and CPR (AUC = 0.68, p = 0.002) with CAPO. Additionally, CPUR (AUC = 0.64, p = 0.040) showed a predictive value for OD due to IFC.

CONCLUSION

The CPUR in > 40 + 0 weeks showed a predictive value for CAPO and OD due to IFC in low-risk pregnancies. However, the extent to which CPUR can be used to optimize delivery management warrants further investigations in prospective interventional studies.

Intrahepatic cholestasis of pregnancy: an evaluation of obstetric management in German maternity units

Purpose

Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse fetal and neonatal outcome. Evidence for improvement by obstetric management is sparse. Common international guidelines recommend induction of labor before term, however, they differ in recommendations of monitoring the disease and time point of active management. So far, an official guideline for treatment and management of ICP in Germany does not exist. This study aims to compile common practice and policy in obstetric management of ICP in German maternity units. The objective is to gather obstetricians’ opinion on management of ICP, and to estimate the need for standardization of current practice in Germany on the background of existing evidence.

Methods

A questionnaire focusing on indications for interventions was developed including fourteen multiple-choice questions comprising the areas of diagnostic criteria, laboratory testing, fetal monitoring, treatment, and delivery timing. The survey was sent to 699 maternity clinics and was distributed to participants of the annual congress hosted by the German society of perinatal medicine (DGPM). Collected data were summarized and evaluated in relation to available evidence and existing guidelines. Descriptive statistics and Fisher's exact test were used.

Results

334 completed questionnaires returned corresponding to a response rate of 48.1%. Coinciding with existing international guidelines, 48.8% of the participants acknowledge bile acid concentrations above 10 µmol/L to be indicative of ICP. 85.0% of obstetricians recommend antenatal testing with cardiotocography, exceeding common standards of maternity policy guidelines; 50.3% execute active management in ICP-affected pregnancies as they generally recommend a delivery between 37 + 0 and 38 + 6 weeks of gestation. Although recent studies evinced a risk of stillbirth in ICP-affected pregnancies not until a bile acid concentration of > 100 µmol/L, 22.2% of the respondents recommend delivery before 37 + 0 weeks of gestation due to raised bile acids of 40–99 µmol/L.

Conclusions

Opinions on the management of ICP in German maternity units differ widely and partly deviate by large from international standards. Reasons for this may be the lack of a national guideline and the low awareness due to the rarity of the disease on the one hand and the very slow dynamics in evidence generation and thus the uncertainty about the actual risks and optimal management on the other. The present data highlight the need for further research and clinical guidelines to standardize and optimize treatment based on the best available evidence.

Induction of Labor at Term with Oral Misoprostol or as a Vaginal Insert and Dinoprostone Vaginal Insert – A Multicenter Prospective Cohort Study

Introduction The efficacy, safety, and perinatal outcome of oral misoprostol (OM), a misoprostol vaginal insert (MVI), and a dinoprostone vaginal insert (DVI) for induction of labor at term was examined in a prospective multicenter cohort study (ethics committee vote 4154–07/14). The primary aims of the study were the induction-birth interval (IBI), the cumulative delivery rates after 12 h, 24 h, and 48 h as well as the mode of delivery.

Method 322 pregnant women were included in four German tertiary perinatal centers (MVI 110, DVI 64, OM 148). They did not vary in age or BMI. Statistical analysis was carried out using a multivariate linear regression analysis and binary logistic regression analysis.

Results With regards to the median IBI, MVI and OM were equally effective and superior to the DVI (MVI 823 min [202, 5587]; DVI 1226 min [209, 4909]; OM 847 min [105, 5201]; p = 0.006). Within 24 hours, 64% were able to deliver with DVI, 85.5% with MVI and 87.5% with OM (p < 0.01). The rates of secondary Caesarean sections (MVI 24.5%; DVI 26.6%; OM 18.9%) did not differ significantly. Uterine tachysystole was found in 20% with MVI, 4.7% with DVI and 1.4% with OM (p < 0.001). A uterine rupture did not occur in any of the cases. Perinatal acidosis occurred (umbilical cord arterial pH < 7.10) in 8.3% with MVI, 4.7 with DVI and 1% with OM (p = 0.32). Neonatal condition was only impaired in three cases (5-minute Apgar score < 5).

Summary Induction of labor at term using the prostaglandins misoprostol and dinoprostone is an effective intervention that is safe for the mother and child. Oral application of misoprostol demonstrated the highest efficacy while maintaining a favorable safety profile.

New Markers for Placental Dysfunction at Term - Potential for More

The remaining placental reserve capacity at term plays a decisive role in the perinatal morbidity of mother and child. Considering advances made in the field of fetal monitoring, the routine examination methods currently used at term or late term may be insufficient to detect subclinical placental dysfunction (PD). The aim of this study is to offer an up-to-date, narrative review of the literature in the context of detecting PD at term using complementary ultrasound markers and biomarkers. Parameters of fetomaternal Doppler ultrasound and fetal cardiac function, as well as (anti-)angiogenic factors in maternal serum are potential PD markers. These may help identify patients that may benefit from an elective, early induction of labor at term, thereby potentially reducing morbidity and mortality. However, their value in terms of the optimal date of delivery must first be determined in randomized controlled trials on a large number of cases.

Mechanical Methods for the Induction of Labour After Previous Caesarean Section – An Updated, Evidence-based Review

There are currently no up-to-date evidence-based recommendations on the preferred method to induce labour after previous Caesarean section, especially for patients with unripe cervix, as randomised controlled studies are lacking. Intravenous oxytocin and misoprostol are contraindicated in these women because of the high risk of uterine rupture. In women with ripe cervix (Bishop Score > 6), intravenous administration of oxytocin is an effective procedure with comparable rates of uterine rupture to those with spontaneous onset of labour. Vaginal prostaglandin E ₂ (PGE ₂ ) and mechanical methods (balloon catheters, hygroscopic cervical dilators) are effective methods to induce labour in pregnant women with unripe cervix and previous Caesarean section. According to current guidelines, the administration of PGE ₂ is associated with a higher rate of uterine rupture compared to balloon catheters. Balloon catheters are therefore a suitable alternative to PGE ₂ to induce labour after previous Caesarean section, even though this is an off-label use. In addition to two meta-analyses published in 2016, 12 mostly retrospective cohort/observational studies with low to moderate levels of evidence have been published on mechanical methods of cervical ripening after previous Caesarean section. But because of the significant heterogeneity of the studies, substantial differences in study design, and insufficient numbers of pregnant women included in the studies, it is not possible to make any evidence-based recommendations based on these studies. According to a recent meta-analysis, the average rate using balloon catheters is approximately 53% and the average rate after spontaneous onset of labour is 72%. The uterine rupture rate was 0.2–0.9% for vaginal PGE ₂ and 0.56–0.94% for balloon catheters and is therefore comparable to the uterine rupture rate associated with spontaneous onset of labour. According to the product informations, hygroscopic cervical dilators (Dilapan-S) are currently the only method which is not contraindicated for cervical ripening/induction of labour in women with previous Caesarean section, although data are insufficient. Well-designed, randomised, controlled studies with sufficient case numbers comparing balloon catheters and hygroscopic cervical dilators with mechanical methods and vaginal prostaglandin E ₂ /oral misoprostol are therefore necessary to allow proper decision-making.

Labour Induction with Misoprostol in German Obstetric Clinics: What Are the Facts on Such Use?

Subject While the synthetic prostaglandin E1 analogue misoprostol is the most effect labour induction agent, its use is off-label for the most part. For this reason, and in view of its potential adverse effects and varying approaches to its administration, the drug has recently once again become a focus of critical attention. The objective of this survey was thus to establish a record of labour induction with misoprostol in German clinics and determine the impact of the negative reporting on everyday obstetric practice. Material and Methods In this cross-sectional study, 635 obstetrics and gynaecology departments in Germany were requested by email to participate in our survey in February/March 2020. Online responses to 19 questions were requested regarding the clinic, use of misoprostol before and after the critical reporting, use of misoprostol (sourcing, method of administration, dosage, monitoring) and other labour induction methods. Results A total of 262 (41.3%) of the clinics solicited for the survey completed the questionnaire. There were no differences regarding the care level (Perinatal Centre Level I, Perinatal Centre Level II, Clinic with Perinatal Focus or Obstetric/Private Clinic; p = 0.2104) or birth counts (p = 0.1845). In most cases, misoprostol was prepared in the clinic's own pharmacy (54%) or imported from another country (46%) and administered orally in tablet form (95%). Misoprostol dosage levels varied (25 µg [48%], 50 µg [83%], 75 µg [6%], 100 µg [47%] and > 100 µg [5%]). Most of the clinics used premanufactured tablets/capsules (59%), although Cytotec tablets were also divided (35%) or dissolved in water (5%). Misoprostol administration intervals were mainly every 4 hours (64%) or every 6 hours (30%). CTG checks were run in most cases before and after administration of a dose of misoprostol (78% and 76%) and before and after administration of a dose of prostaglandin E2 (both 88%). Presence of contractions led to no misoprostol (59%) or no prostaglandin E2 (64%) being administered in most cases. The critical reporting resulted in discontinuation of use of misoprostol in 17% of the clinics - mainly smaller obstetric/private clinics with fewer than 1000 births. Labour cocktails were used mainly in obstetric and private clinics (61%). Conclusion Misoprostol is an established agent for labour induction in German clinics. The dosing schemes used vary. Improvements of currently common management practices are required, especially in the area of labour induction (CTG checks before and after administration of labour-inducing medication, no administration of prostaglandin if contractions are ongoing). The discussion of use of misoprostol in the media resulted in stoppage of its use mainly in smaller clinics.