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Kehl S. Obesity at term: What to consider? How to deliver? Arch Gynecol Obstet 2024; 309:1725-1733. [PMID: 38326633 DOI: 10.1007/s00404-023-07354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynaecology, Erlangen University Hospital, Universitätsstr. 21-23, 91054, Erlangen, Germany.
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Hosoya S, Maeda Y, Ogawa K, Umehara N, Ozawa N, Sago H. Predictive factors for vaginal delivery by induction of labor in uncomplicated pregnancies at 40-41 gestational weeks: A Japanese prospective single-center cohort study. J Obstet Gynaecol Res 2023; 49:920-929. [PMID: 36594583 DOI: 10.1111/jog.15536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 12/16/2022] [Indexed: 01/04/2023]
Abstract
AIM We investigated cervical parameters predictive of vaginal delivery in elective labor induction among women at 40-41 gestational weeks. METHODS This Japanese prospective single-center cohort study was conducted between July 2019 and June 2020. We enrolled women with an uncomplicated singleton pregnancy who underwent labor induction at 40-41 gestational weeks. We analyzed background characteristics and cervical parameters, including Bishop score, cervical length, posterior cervical angle, and changes in cervical parameters before and after cervical dilatation. The endpoint was the rate of vaginal delivery. RESULTS Of 142 eligible participants, all 24 multiparous women underwent vaginal delivery. Among the nulliparous women (n = 118), the following categories showed significantly higher rates of vaginal delivery: Bishop scores of ≥6 before and after dilatation, compared with Bishop score <6 (adjusted prevalence ratio (aPR) [95% confidence interval (CI)]; 1.58 [1.17-2.13] and 1.56 [1.13-2.14], respectively) and cervical length of <10 and 10-20 mm before dilation, compared with cervical length of >30 mm (aPR [95% CI]; 1.47 [1.00-2.15] and 2.13 [1.42-3.18], respectively). The posterior cervical angle and other background characteristics showed no significant associations. Furthermore, women with cervical lengths of ≥20 mm before and <20 mm after dilatation showed a higher rate of vaginal delivery, compared to cervical length of ≥20 mm even after dilatation (aPR [95% CI]; 1.95 [1.19-3.20]). CONCLUSIONS High Bishop score, short cervical length, and changes in cervical length with dilatation are potential independent predictors of vaginal delivery following elective labor induction in nulliparous women at 40-41 gestational weeks.
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Affiliation(s)
- Satoshi Hosoya
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Japan
| | - Yuto Maeda
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Japan
| | - Kohei Ogawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Japan
| | - Nagayoshi Umehara
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Japan
| | - Nobuaki Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Japan
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Ashraf R, Maxwell C, D'Souza R. Induction of labour in pregnant individuals with obesity. Best Pract Res Clin Obstet Gynaecol 2021; 79:70-80. [PMID: 35031244 DOI: 10.1016/j.bpobgyn.2021.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022]
Abstract
People with obesity may require induction of labour (IoL) due to a higher incidence of pre-existing comorbidities and pregnancy complications, as well as to prevent post-term pregnancies and late-term stillbirths. IoL at 39-40 weeks is associated with fewer caesarean births and lower morbidity for the pregnant person and neonate when compared with expectant management. Ensuring the success and safety of IoL in people with obesity requires adherence to evidence-based protocols for the management of labour induction and augmentation. Cervical ripening as well as the latent and active phases of labour in people with obesity may be considerably prolonged, requiring higher cumulative doses of oxytocin. This should be guided by intrauterine pressure catheters and early provision of neuraxial analgesia, where possible. There is insufficient evidence to recommend one method of IoL over another. The need for higher doses of prostaglandins and concurrent agents for cervical ripening should be studied in prospective studies.
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Affiliation(s)
- Rizwana Ashraf
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Cynthia Maxwell
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada; Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada; Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
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Amikam U, Hiersch L, Barrett J, Melamed N. Labour induction in twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2021; 79:55-69. [PMID: 34844886 DOI: 10.1016/j.bpobgyn.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 01/21/2023]
Abstract
Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jon Barrett
- Departments of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
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Is Misoprostol Vaginal Insert Safe for the Induction of Labor in High-Risk Pregnancy Obese Women? Healthcare (Basel) 2021; 9:healthcare9040464. [PMID: 33919898 PMCID: PMC8070889 DOI: 10.3390/healthcare9040464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/21/2022] Open
Abstract
Induction of labor (IOL) is an event that occurs in up to 25% of pregnancies. In Europe, the misoprostol vaginal insert (MVI—Misodel®) was approved for labor induction in 2013. Studies on the outcomes and safety of IOL in obese pregnant women are scarce; no data are available on MVI IOL in high-risk pregnancy obese women (HRPO—late-term, hypertension, diabetes). As the obesity rates are growing steadily in pregnant women, we aimed to evaluate the failure rate for induction and the safety of a 200 μg MVI in obese (body mass index (BMI) >30 kg/m2) HRPO compared to that for obese non-high-risk pregnancies (non-HRPO). For this purpose, we conducted a cross-sectional study in “Filantropia” Clinical Hospital, Bucharest, Romania, from June 2017—the date of the initiation of the MVI IOL protocol in our clinic—to September 2019. The primary outcomes were the failure rate, measured by cesarean section (CS) ratio, and secondarily, the safety profile of MVI, analyzed by one-way ANOVA. Out of a total of 11,096 registered live births, IOL was performed on 206 obese patients. Of these, 74 obese pregnant women had their labor induced with MVI (HRPO, n = 57, and non-HRPO, n = 17). The average maternal age was 29.9 ± 4.8 years (19–44 years). Across the groups, the rate of CS was 29.8% (n = 17) in the HRPO group compared to 23.5% (n = 4) in the non-HRPO group (p = non significant). In the vaginally birth subgroups, the median time from drug administration to delivery was shorter in the HRPO group compared to the non-HRPO group (16.9 ± 6.0 h 95% confidence interval (CI) 15.0–18.8 vs. 19.4 ± 9.2 h 95% CI 13.8–25.0, p = 0.03). No significant differences were found regarding the maternal outcomes among the studied groups; in terms of perinatal outcomes of safety, 5.4% (n = 4) of the cases of vaginal delivery for HRPO were associated with neonatal intensive care unit (NICU) admissions. The MVI seems to be an efficient labor induction agent in high-risk pregnancy obese women with good maternal outcomes and low perinatologic complications.
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Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity. Obstet Gynecol 2020; 135:542-549. [PMID: 32028494 DOI: 10.1097/aog.0000000000003703] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. METHODS This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. RESULTS There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). CONCLUSIONS In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.
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Demsky AN, Stafford SM, Birch D, Sharma AM, Schulz JA, Steed H. The Edmonton Obesity Staging System Predicts Mode of Delivery After Labour Induction. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:284-292. [PMID: 31864914 DOI: 10.1016/j.jogc.2019.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study sought to evaluate the use of the Edmonton Obesity Staging System (EOSS) in predicting cesarean delivery among term, nulliparous, singleton pregnancies in women with overweight or obesity who are undergoing an induction of labour. METHODS A prospective cohort study was performed in Edmonton, Alberta. Women undergoing an induction of labour at term were recruited to either a sample cohort, including women with a body mass index of ≥25 kg/m2 at first antenatal visit, or a control cohort with a body mass index of 18.5 to 24.9 kg/m2. Participating women provided a self-reported health history and consented to review of their medical records allowing allocation into EOSS categories. The primary outcome was the rate of cesarean delivery based on EOSS category. Secondary outcomes consisted of a summary score of adverse maternal, delivery, and neonatal events (Canadian Task Force Classification II-2). RESULTS Overall, 345 women were recruited, with a participation rate of 93.7%. The sample cohort consisted of 276 women with overweight or obesity, whereas the control cohort included 69 normal-weight women. The overall rate of cesarean delivery was 30.4% for the control cohort and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS category 0, 1, 2, and 3, respectively (P < 0.001). A summary score was not indicative of overall rate of adverse maternal, delivery, and neonatal events (P = 0.22). CONCLUSION The EOSS may help predict the chance of cesarean delivery in a high-risk group of nulliparous women with overweight or obesity who are undergoing an induction of labour at term.
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Affiliation(s)
- Ashley Nicole Demsky
- Department of Obstetrics and Gynecology, Lois Hole Hospital for Women, University of Alberta, Edmonton, AB.
| | - Shawna Marie Stafford
- Department of Obstetrics and Gynecology, Lois Hole Hospital for Women, University of Alberta, Edmonton, AB
| | - Daniel Birch
- Department of Surgery and Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, University of Alberta, Edmonton, AB
| | - Arya M Sharma
- Department of Medicine, University of Alberta, Edmonton, AB
| | - Jane Ann Schulz
- Department of Obstetrics and Gynecology, Lois Hole Hospital for Women, University of Alberta, Edmonton, AB
| | - Helen Steed
- Department of Obstetrics and Gynecology, Lois Hole Hospital for Women, University of Alberta, Edmonton, AB
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Shenouda C, Wijesooriya A, Toufeili A, Miller MR, Penava D, de Vrijer B. Labour Progression in Obese Women: Are Women With Increased Body Mass Index Having Unnecessary Cesarean Sections? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:293-300. [PMID: 31324481 DOI: 10.1016/j.jogc.2019.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study sought to determine whether obese pregnant women undergo cesarean sections without an adequate trial of labour. This may affect future birth and pregnancy outcomes. METHODS A retrospective analysis was done on 526 parturients at Victoria Hospital in London, Ontario. Women were categorized according to parity and pre-pregnancy body mass index (BMI; normal weight, BMI 18.5-24.9 kg/m2; obese class II, BMI 35.0-39.9 kg/m2; obese class III, BMI ≥40 kg/m2). Patient charts and partograms were reviewed for labour progression (time at cervical dilation), demographics, and infant outcomes (Canadian Task Force Classification II-2). RESULTS Obese class II and III primiparous women required an additional 1.62 and 2.67 hours (P = 0.012), respectively, to reach a dilation of 10 cm compared with their normal weight counterparts; obese class II and III multiparous women required an additional 1.25 and 2.05 hours (P = 0.003), respectively. A higher BMI was associated with increased oxytocin use and infant birth weight in primiparous women. Obese women had less gestational weight gain and required more cervical examinations. Cesarean section rates were low for obese parturients (primiparous, 19%; multiparous, 0.8%) and not significantly different among BMI categories. CONCLUSION This study confirmed published results that labour progresses more slowly as maternal BMI increases. The study was performed in a centre with a specialized BMI pregnancy clinic; thus weight gain adherence, awareness of labour differences, and patient counselling may have contributed to low cesarean section rates. Obstetric care providers should consider differences in maternal BMI in labour progression before undertaking a potentially premature cesarean birth, especially in primiparous women.
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Affiliation(s)
- Caroline Shenouda
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, Western University, London, ON
| | | | | | - Michael R Miller
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON; Children's Health Research Institute, London, ON
| | - Debbie Penava
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, Western University, London, ON; Children's Health Research Institute, London, ON
| | - Barbra de Vrijer
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, Western University, London, ON; Children's Health Research Institute, London, ON.
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Dammer U, Bogner R, Weiss C, Faschingbauer F, Pretscher J, Beckmann MW, Sütterlin M, Kehl S. Influence of body mass index on induction of labor: A historical cohort study. J Obstet Gynaecol Res 2018; 44:697-707. [DOI: 10.1111/jog.13561] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 10/21/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Ulf Dammer
- Department of Obstetrics and Gynaecology; Erlangen University Hospital; Erlangen Germany
| | - Roswitha Bogner
- Department of Obstetrics and Gynaecology; Erlangen University Hospital; Erlangen Germany
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics; University Medical Centre Mannheim, Heidelberg University; Heidelberg Germany
| | - Florian Faschingbauer
- Department of Obstetrics and Gynaecology; Erlangen University Hospital; Erlangen Germany
| | - Jutta Pretscher
- Department of Obstetrics and Gynaecology; Erlangen University Hospital; Erlangen Germany
| | - Matthias W. Beckmann
- Department of Obstetrics and Gynaecology; Erlangen University Hospital; Erlangen Germany
| | - Marc Sütterlin
- Department of Obstetrics and Gynaecology; University Medical Centre Mannheim, Heidelberg University; Heidelberg Germany
| | - Sven Kehl
- Department of Obstetrics and Gynaecology; Erlangen University Hospital; Erlangen Germany
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