Induction of labour for suspected macrosomia at term in non-diabetic women: a systematic review and meta-analysis of randomized controlled trials

A model to predict delivery time following induction of labor at term with a dinoprostone vaginal insert: a retrospective study

BACKGROUND

Dinoprostone vaginal insert is the most common pharmacological method for induction of labor (IOL); however, studies on assessing the time to vaginal delivery (DT) following dinoprostone administration are limited.

AIMS

We sought to identify the primary factors influencing DT in women from central China, at or beyond term, who underwent IOL with dinoprostone vaginal inserts.

METHODS

In this retrospective observational study, we analyzed the data of 1562 women at 37 weeks 0 days to 41 weeks 6 days of gestation who underwent dinoprostone-induced labor between January 1st, 2019, and December 31st, 2021. The outcomes of interest were vaginal or cesarean delivery and factors influencing DT, including maternal complications and neonatal characteristics.

RESULTS

Among the enrolled women, 71% (1109/1562) delivered vaginally, with median DT of 740.50 min (interquartile range 443.25 to 1264.50 min). Of the remaining 29% (453/1562), who delivered by cesarean section, 11.9% (54/453) were multiparous. Multiple linear regression analysis showed that multiparity, advanced maternal age, fetal macrosomia, premature rupture of membranes (PROM), and daytime insertion of dinoprostone were the factors that significantly influenced DT. Time to vaginal delivery increased with advanced maternal age and fetal macrosomia and decreased with multiparity, PROM, and daytime insertion of dinoprostone. A mathematical model was developed to integrate these factors for predicting DT: Y = 804.478 - 125.284 × multiparity + 765.637 × advanced maternal age + 411.511 × fetal macrosomia-593.358 × daytime insertion of dinoprostone - 125.284 × PROM.

CONCLUSIONS

Our findings may help obstetricians estimate the DT before placing a dinoprostone insert, which may improve patient management in busy maternity wards and minimize potential risks.

Maternal Diabetes Mellitus and Neonatal Outcomes in Bisha: A Retrospective Cohort Study

BACKGROUND

Maternal diabetes mellitus (MDM) is associated with increased risks for adverse neonatal outcomes. However, the impact of MDM on neonatal outcomes in Bisha, a city in Saudi Arabia, is not well documented. This study aims to investigate the impact of MDM on neonatal outcomes in the Maternity and Children's Hospital (MCH), Bisha, Saudi Arabia.

METHODS

A retrospective cohort study was conducted on 181 pregnant women with diabetes and their neonates who were diagnosed at the Maternity and Children's Hospital (MCH), Bisha, Saudi Arabia, between 5 October 2020 and 5 November 2022. The primary outcome was a composite of adverse neonatal outcomes, including stillbirth, neonatal death, macrosomia, preterm birth, respiratory distress syndrome, hypoglycemia, and congenital anomalies. Logistic regression analyses were used to adjust for potential confounders.

RESULTS

The total sample size was 181. The average age of patients was 34 years (SD = 6.45). The majority of the patients were diagnosed with GDM, 147 (81.2%), and pre-GDM, 34 (18.8%). Neonates born to mothers with MDM had a higher risk of adverse neonatal outcomes compared to those born to mothers without MDM (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI]: 1.25-1.70). The risks of macrosomia (aOR = 1.74, 95% CI: 1.38-2.19), LBW (aOR = 1.32, 95% CI: 1.06-1.66), and RDS (aOR = 1.57, 95% CI: 1.28-1.93) were significantly higher among neonates born to mothers with MDM. The types of DM were statistically significant in terms of their correlation with the following neonatal outcomes: hypoglycemia (p-value = 0.017), macrosomia (p-value = 0.050), and neonatal death (p-value = 0.017).

CONCLUSIONS

MDM is associated with an increased risk of adverse neonatal outcomes in Bisha. The early identification and management of MDM may improve neonatal outcomes and reduce the burden of neonatal morbidity and mortality in this population.

Intracervical Foley catheter plus intravaginal misoprostol compared to intravaginal misoprostol-only for cervical ripening: A systematic review and meta-analysis

To compare the combination of intracervical Foley catheter and intravaginal misoprostol administration versus intravaginal misoprostol administration-only for cervical ripening. The Medline, EMBASE, ClinicalTrials.gov, PROSPERO, Scopus, and Cochrane Collaboration databases were searched systematically. Randomized controlled trials that included patients with a singleton viable fetus who underwent induction of labor that required cervical ripening with an unfavorable cervix (Bishop ≤ 6) were eligible for inclusion. Primary outcomes was time to delivery and rate of cesarean delivery. Thirteen trials with 2978 subjects met the inclusion criteria. There was no difference in the incidence of cesarean delivery between the two groups (RR, 0.90; 95 % CI, 0.72-1.14; I² = 69 %). The combination group resulted in comparable time to delivery (MD -2.50 h; 95 % CI 0.38, -5.38; I² = 97 %), shorter time to vaginal delivery (MD -3.49 h; 95 % CI -4.89, -2.09; I² = 81 %), lower risk of neonatal intensive care unit (NICU) admission (RR 0.72, 95 % CI 0.58-0.90, I² = 0 %), meconium-stained fluid (RR 0.48, 95 % CI 0.31-0.73, I² = 28 %), and tachysystole with fetal heart trace changes (RR 0.49, 95 % CI 0.27-0.86, I² = 43 %), compared with intravaginal misoprostol-only group. There was no statistical difference in rates of terbutaline use, endometritis or chorioamnionitis between the two groups. The combination of intravaginal misoprostol with intracervical Foley catheter for cervical ripening is not associated with shorter time to delivery. However, the combination group shows significant difference in shorter time to vaginal delivery, NICU admission, meconium-stained fluid, and tachysystole with fetal heart trace changes.

Guideline No. 432a: Cervical Ripening and Induction of Labour - General Information

OBJECTIVE

This guideline presents evidence and recommendations for cervical ripening and induction of labour. It aims to provide information to birth attendants and pregnant individuals on optimal perinatal care while avoiding unnecessary obstetrical intervention.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Consistent interprofessional use of the guideline, appropriate equipment, and trained professional staff enhance safe intrapartum care. Pregnant individuals and their support person(s) should be informed of the benefits and risks of induction of labour.

EVIDENCE

Literature published to March 2022 was reviewed. PubMed, CINAHL, and the Cochrane Library were used to search for systematic reviews, randomized controlled trials, and observational studies on cervical ripening and induction of labour. Grey (unpublished) literature was identified by searching the websites of health technology assessment and health technology related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All providers of obstetrical care.

RECOMMANDATIONS

Directive clinique no 432a : Maturation cervicale et déclenchement artificiel du travail - Information générale

OBJECTIF

Présenter des données probantes et des recommandations sur la maturation cervicale et le déclenchement artificiel du travail. Fournir de l'information aux professionnels accoucheurs et aux personnes enceintes sur les soins périnataux optimaux et la prévention des interventions obstétricales inutiles.

POPULATION CIBLE

Toutes les patientes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en application interprofessionnelle et cohérente de la présente directive, l'équipement adéquat et le personnel compétent améliorent la sécurité des soins per partum. Les personnes enceintes et leurs personnes de soutien doivent être informées des risques et bénéfices du déclenchement artificiel du travail. DONNéES PROBANTES: La littérature publiée jusqu'en mars 2022 a été passée en revue. Une recherche a été effectuée dans les bases de données PubMed, CINAHL et Cochrane Library pour répertorier des revues systématiques, des essais cliniques randomisés et des études observationnelles sur la maturation cervicale et le déclenchement artificiel du travail. La littérature grise (non publiée) a été obtenue à l'aide de recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins obstétricaux.

RECOMMANDATIONS

Induction of labour for predicted macrosomia: study protocol for the 'Big Baby' randomised controlled trial

INTRODUCTION

Large-for-gestational age (LGA) fetuses have an increased risk of shoulder dystocia. This can lead to adverse neonatal outcomes and death. Early induction of labour in women with a fetus suspected to be macrosomic may mitigate the risk of shoulder dystocia. The Big Baby Trial aims to find if induction of labour at 38⁺⁰-38⁺⁴ weeks' gestation, in pregnancies with suspected LGA fetuses, reduces the incidence of shoulder dystocia.

METHODS AND ANALYSIS

The Big Baby Trial is a multicentre, prospective, individually randomised controlled trial of induction of labour at 38⁺⁰ to 38⁺⁴ weeks' gestation vs standard care as per each hospital trust (median gestation of delivery 39⁺⁴) among women whose fetuses have an estimated fetal weight >90th customised centile according to ultrasound scan at 35⁺⁰ to 38⁺⁰ weeks' gestation. There is a parallel cohort study for women who decline randomisation because they opt for induction, expectant management or caesarean section. Up to 4000 women will be recruited and randomised to induction of labour or to standard care. The primary outcome is the incidence of shoulder dystocia; assessed by an independent expert group, blind to treatment allocation, from delivery records. Secondary outcomes include birth trauma, fractures, haemorrhage, caesarean section rate and length of inpatient stay. The main trial is ongoing, following an internal pilot study. A qualitative reporting, health economic evaluation and parallel process evaluation are included.

ETHICS AND DISSEMINATION

The study received a favourable opinion from the South West-Cornwall and Plymouth Health Research Authority on 23/03/2018 (IRAS project ID 229163). Study results will be reported in the National Institute for Health Research journal library and published in an open access peer-reviewed journal. We will plan dissemination events for key stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN18229892.

Establishing the Optimal Time for Induction of Labor in Women with Diet-Controlled Gestational Diabetes Mellitus: A Single-Center Observational Study

To determine the optimal week for labor induction in women with diet-controlled gestational diabetes mellitus by comparing differences in perinatal and neonatal outcomes of labor induction to expectant management at different gestational weeks. Methods: This was a retrospective analysis of a prospectively recruited cohort of 797 singleton pregnancies complicated by diet-controlled gestational diabetes mellitus that were diagnosed, treated, and delivered after 37 weeks in a tertiary, university-affiliated perinatal center between January 2016 and December 2021. Results: The incidence of neonatal complications was highest when delivery occurred at 37 weeks, whereas fetal macrosomia occurred mostly at 41 weeks (20.7%); the frequency of large for gestational age infants did not differ between the groups. Conversely, the best neonatal outcomes were observed at 40 weeks due to the lowest number of neonates requiring phototherapy for neonatal jaundice (1.7%) and the smallest proportion of neonates experiencing composite adverse neonatal outcomes defined as neonatal hypoglycemia, phototherapy, clavicle fracture, or umbilical artery pH < 7.15 (10.4%). Compared with expectant management, the risk for neonatal hypoglycemia was increased for induction at 39 weeks (adjusted odds ratio 12.29, 95% confidence interval 1.35−111.75, p = 0.026) and that for fetal macrosomia was decreased for induction at 40 weeks (adjusted odds ratio 0.11, 95% confidence interval 0.01−0.92, p = 0.041), after adjusting for maternal pre-pregnancy body mass index, nulliparity, and mean pregnancy A1c. Conclusions: The lowest rate of neonatal complications was observed at 40 weeks. Labor induction at 40 weeks prevented fetal macrosomia.

Perinatal mortality and neonatal and maternal outcome per gestational week in term pregnancies: A registry-based study

INTRODUCTION

Human pregnancy is considered term from 37+0/7 to 41+6/7 weeks. Within this range, both maternal, fetal and neonatal risks may vary considerably. This study investigates how gestational age per week is related to the components of perinatal mortality and parameters of adverse neonatal and maternal outcome at term.

MATERIAL AND METHODS

A registry-based study was made of all singleton term pregnancies in the Netherlands from January 2014 to December 2017. Stillbirth and early neonatal mortality, as components of perinatal mortality, were defined as primary outcomes; adverse neonatal and maternal events as secondary outcomes. Neonatal adverse outcomes included birth trauma, 5-minute Apgar score ≤3, asphyxia, respiratory insufficiency, neonatal intensive care unit admission and composite neonatal outcome. Maternal adverse outcomes included instrumental vaginal birth, emergency cesarean section, obstetric anal sphincter injury, postpartum hemorrhage, hypertensive disorders of pregnancy and composite maternal outcome. The primary outcomes were evaluated by comparing weekly prospective risks of stillbirth and neonatal death using a fetuses-at-risk approach. Secondly, odds ratios (OR) for perinatal mortality, adverse neonatal and maternal outcome using a births-based approach were compared for each gestational week with all births occurring after that week.

RESULTS

Data of 581 443 births were analyzed. At 37, 38, 39, 40, 41 and 42 weeks, the respective weekly prospective risks of stillbirth were 0.015%, 0.022%, 0.031%, 0.036%, 0.069% and 0.081%; the respective weekly prospective risks of early neonatal death were 0.051%, 0.047%, 0.032%, 0.031%, 0.039% and 0.035%. The OR for adverse neonatal outcomes were the lowest at 39 and 40 weeks. The OR for adverse maternal outcomes, including operative birth, continuously increased with each gestational week.

CONCLUSIONS

The prospective risk of early neonatal death for babies born at 39 weeks is lower than the risk of stillbirth in pregnancies continuing beyond 39+6/7 weeks. Birth at 39 weeks was associated with the best combined neonatal and maternal outcome, fewer operative births and fewer maternal and neonatal adverse outcomes compared with pregnancies continuing beyond 39 weeks. This information with appropriate perspectives should be included when counseling term pregnant women.

A Systematic Review to Compare Adverse Pregnancy Outcomes in Women with Pregestational Diabetes and Gestational Diabetes

Pregestational type 1 (T1DM) and type 2 (T2DM) diabetes mellitus and gestational diabetes mellitus (GDM) are associated with increased rates of adverse maternal and neonatal outcomes. Adverse outcomes are more common in women with pregestational diabetes compared to GDM; although, conflicting results have been reported. This systematic review aims to summarise and synthesise studies that have compared adverse pregnancy outcomes in pregnancies complicated by pregestational diabetes and GDM. Three databases, Pubmed, EBSCOhost and Scopus were searched to identify studies that compared adverse outcomes in pregnancies complicated by pregestational T1DM and T2DM, and GDM. A total of 20 studies met the inclusion criteria and are included in this systematic review. Thirteen pregnancy outcomes including caesarean section, preterm birth, congenital anomalies, pre-eclampsia, neonatal hypoglycaemia, macrosomia, neonatal intensive care unit admission, stillbirth, Apgar score, large for gestational age, induction of labour, respiratory distress syndrome and miscarriages were compared. Findings from this review confirm that pregestational diabetes is associated with more frequent pregnancy complications than GDM. Taken together, this review highlights the risks posed by all types of maternal diabetes and the need to improve care and educate women on the importance of maintaining optimal glycaemic control to mitigate these risks.

Non-diabetic fetal macrosomia: outcomes of elective delivery versus expectant management

Background

Macrosomia in the absence of diabetes can be associated with increased neonatal and maternal morbidity. Management is usually undertaken on a case-by-case basis.

Aims

In order to inform local practice, this study aimed to evaluate the outcomes of the management of non-diabetic macrosomia in an Irish tertiary center.

Methods

A retrospective observational study was performed on all women with estimated fetal weight over 4000 g after 37 weeks’ gestation. Maternal demographics and obstetric and neonatal outcomes were recorded using the hospital information system. Women with diabetes, previous caesarean section, non-cephalic presentation, or any other complicating condition were excluded. Women were divided into two groups:

Active management: Elective delivery for macrosomia—between 38 + 0 and 40 + 6 weeks’ gestation

Expectant management: with induction of labour offered after 41 weeks' gestation

Results

There were 397 women included, 188 with active and 209 with expectant management. There was no difference in adverse neonatal outcomes, major maternal morbidity, or mode of delivery, after exclusion of pre-labor caesarean section. Women with expectant management were more likely to go into spontaneous labor (46.9 vs 1.6%, p < 0.001) and to have a favorable cervix at the onset of induction of labor if nulliparous (86.1 vs 70.0%, p = 0.021), but have higher rates of episiotomy (28.6 vs 18.2%, p = 0.021). With active management, nulliparas with an unfavorable cervix had increased risk of anal sphincter injury (6.5 vs 0.0%, p = 0.007) and postpartum hemorrhage (59.0 vs 35.5%, p = 0.003).

Conclusions

Overall, there was no difference in major maternal or neonatal outcomes between management options for fetal macrosomia. However, inducing nulliparas with an unfavorable cervix for non-diabetic macrosomia was associated with obstetric anal sphincter injury and postpartum hemorrhage.

Incidence changes in risk factors associated with the decreasing number of birth-related clavicle fractures in Finland: A nationwide retrospective birth cohort from 2004 to 2017

BACKGROUND

A clavicle fracture is one of the most common birth injuries. The objective of this study was to examine whether the decreased incidence of birth-related clavicle fractures in Finland is because of temporal changes in their predisposing factors.

METHODS

For this nationwide population-based study, we used the Finnish Medical Birth Register and the Care Register for Health Care databases. The study population included all singleton, live-born newborn born spontaneously or by vacuum-assisted delivery, in cephalic presentation ≥37⁺⁰ weeks of gestation. The incidences of clavicle fractures, pregnancy characteristics, and risk assessments for fracture were calculated and compared between two time periods: 2004-2010 and 2011-2017.

RESULTS

A total of 629 457 newborn were born vaginally between 2004 and 2017. The clavicle fracture incidence decreased from 17.6/1000 to 6.2/1000 live births. Shoulder dystocia, diabetes, and birthweight ≥4000 g were the strongest predisposing factors. The incidence of birthweight ≥4000 g decreased, meanwhile type 1 diabetes and shoulder dystocia remained stable and gestational diabetes, type 2 diabetes, and maternal obesity increased in the later study period. The incidence of clavicle fractures without known predisposing factors declined. Simultaneously, the cesarean birth rate remained stable (13.2%-13.1%), although the rate of vacuum-assisted deliveries increased (8.5%-9.5%).

DISCUSSION

The incidence of clavicle fractures decreased, even though the incidence of most risk factors remained stable or increased, and the cesarean birth rate remained stable. This decline may be related to the reduction of fracture incidence among deliveries without known risk factors, and the decrease in birthweight ≥4000 g.

Monofilament vs multifilament suture for uterine closure at the time of cesarean delivery: a randomized clinical trial

BACKGROUND

Different factors may influence the closure of the uterine wall, including suture material. Suture materials may indeed influence tissue healing and therefore the development of scar defects.

OBJECTIVE

To test whether uterine closure using synthetic absorbable monofilament sutures at the time of cesarean delivery would reduce the rate of cesarean scar defects compared with uterine closure using synthetic absorbable multifilament sutures.

STUDY DESIGN

Parallel-group, nonblinded, randomized clinical trial of women with singleton pregnancies undergoing cesarean delivery at term in a single center in Italy. The inclusion criteria were singleton pregnancy, first or second cesarean delivery, scheduled and emergent or urgent cesarean deliveries, and gestational age between 37 0/7 and 42 0/7 weeks. Eligible participants were randomly allocated in a 1:1 ratio to either the monofilament group (polyglytone 6211 [Caprosyn]; Covidien, Dublin, Ireland) or the multifilament suture group (coated polyglactin 910 suture with Triclosan [Vicryl Plus]; Ethicon, Inc, Raritan, NJ). The primary outcome was the incidence of cesarean scar defect at ultrasound at the 6-month follow-up visit. The secondary outcomes were residual myometrial thickness and symptoms.

RESULTS

Overall, 300 women were included in the trial. Of the randomized women, 151 were randomized to the monofilament group and 149 to the multifilament group. However, 27 women were lost to follow-up: 15 in the monofilament group and 12 in the multifilament group. Of note, 6 months after delivery, the incidence rates of cesarean scar defect were 18.4% (25 of 136 patients) in the monofilament group and 23.4% (32 of 137 patients) in the multifilament group (relative risk, 0.79; 95% confidence interval, 0.41-1.25; P=.31). The mean residual myometrial thicknesses were 7.6 mm in the monofilament group and 7.2 mm in the multifilament group (mean difference, +0.40 mm; 95% confidence interval, -0.23 to 1.03). There was no between-group substantial difference found in the incidence of symptoms, including pelvic pain, painful periods, and dyspareunia.

CONCLUSION

In singleton pregnancies undergoing primary or second cesarean delivery, the use of synthetic absorbable monofilament sutures at the time of uterine wall closure was not associated with a reduction in the rate of cesarean scar defect 6 months after delivery compared with the use of synthetic absorbable multifilament sutures.

Fetal magnetic resonance imaging at 36 weeks predicts neonatal macrosomia: the PREMACRO study

BACKGROUND

Large-for-gestational-age fetuses are at increased risk of perinatal morbidity and mortality. Magnetic resonance imaging seems to be more accurate than ultrasound in the prediction of macrosomia; however, there is no well-powered study comparing magnetic resonance imaging with ultrasound in routine pregnancies.

OBJECTIVE

This study aimed to prospectively compare estimates of fetal weight based on 2-dimensional ultrasound and magnetic resonance imaging with actual birthweights in routine pregnancies.

STUDY DESIGN

From May 2016 to February 2019, women received counseling at the 36-week clinic. Written informed consent was obtained for this Ethics Committee-approved study. In this prospective, single-center, blinded study, pregnant women with singleton pregnancies between 36 0/7 and 36 6/7 weeks' gestation underwent both standard evaluation of estimated fetal weight with ultrasound according to Hadlock et al and magnetic resonance imaging according to the formula developed by Baker et al, based on the measurement of the fetal body volume. Participants and clinicians were aware of the results of the ultrasound but blinded to the magnetic resonance imaging estimates. Birthweight percentile was considered as the gold standard for the ultrasound and magnetic resonance imaging-derived percentiles. The primary outcome was the area under the receiver operating characteristic curve for the prediction of large-for-gestation-age neonates with birthweights of ≥95th percentile. Secondary outcomes included the comparative prediction of large-for-gestation-age neonates with birthweights of ≥90th, 97th, and 99th percentiles and small-for-gestational-age neonates with birthweights of ≤10th, 5th, and 3rd percentiles for gestational age and maternal and perinatal complications.

RESULTS

Of 2914 women who were initially approached, results from 2378 were available for analysis. Total fetal body volume measurements were possible for all fetuses, and the time required to perform the planimetric measurements by magnetic resonance imaging was 3.0 minutes (range, 1.3-5.6). The area under the receiver operating characteristic curve for the prediction of a birthweight of ≥95th percentile was 0.985 using prenatal magnetic resonance imaging and 0.900 using ultrasound (difference=0.085, P<.001; standard error, 0.020). For a fixed false-positive rate of 5%, magnetic resonance imaging for the estimation of fetal weight detected 80.0% (71.1-87.2) of birthweight of ≥95th percentile, whereas ultrasound for the estimation of fetal weight detected 59.1% (49.0-68.5) of birthweight of ≥95th percentile. The positive predictive value was 42.6% (37.8-47.7) for the estimation of fetal weight using magnetic resonance imaging and 35.4% (30.1-41.1) for the estimation of fetal weight using ultrasound, and the negative predictive value was 99.0% (98.6-99.3) for the estimation of fetal weight using magnetic resonance imaging and 98.0% (97.6-98.4) for the estimation of fetal weight using ultrasound. For a fixed false-positive rate of 10%, magnetic resonance imaging for the estimation of fetal weight detected 92.4% (85.5-96.7) of birthweight of ≥95th percentile, whereas ultrasound for the estimation of fetal weight detected 76.2% (66.9-84.0) of birthweight of ≥95th percentile. The positive predictive value was 29.9% (27.2-32.8) for the estimation of fetal weight using magnetic resonance imaging and 26.2% (23.2-29.4) for the estimation of fetal weight using ultrasound, and the negative predictive value was 99.6 (99.2-99.8) for the estimation of fetal weight using magnetic resonance imaging and 98.8 (98.4-99.2) for the estimation of fetal weight using ultrasound. The area under the receiver operating characteristic curves for the prediction of large-for-gestational-age neonates with birthweights of ≥90th, 97th, and 99th percentiles and small-for-gestational-age neonates with birthweights of ≤10th, 5th, and 3rd percentiles was significantly larger in prenatal magnetic resonance imaging than in ultrasound (P<.05 for all).

CONCLUSION

At 36 weeks' gestation, magnetic resonance imaging for the estimation of fetal weight performed significantly better than ultrasound for the estimation of fetal weight in the prediction of large-for-gestational-age neonates with birthweights of ≥95th percentile for gestational age and all other recognized cutoffs for large-for-gestational-age and small-for-gestational-age neonates (P<.05 for all).

Induction of labor for a suspected large-for-gestational-age/macrosomic fetus

Fetal macrosomia is defined as a birth weight of >4000 g, while the term large for gestational age (LGA) is defined as an estimated fetal weight >90th centile for gestational age. Current data indicate that a significant proportion of the babies are LGA. Pregnancies involving LGA babies are associated with increased maternal and perinatal morbidity including caesarean section, postpartum hemorrhage, shoulder dystocia, and birth trauma. To reduce these complications, labor induction has been suggested as a possible solution. However, despite some high-quality evidence in favor of labor induction for suspected macrosomia/LGA, existing guidelines do not support routine induction of labor in this population. The aim of this paper is to critically appraise the available evidence and clinical practice recommendations and highlight the importance of shared decision making and individualized care based on clear counselling regarding the lack of a sensitive diagnostic tool for estimating fetal weight in the third trimester.

Fetal nondiabetic-macrosomia: risk factors for pregnancy adverse outcome and comparison of two growth curves in the prediction of cesarean section

BACKGROUND

Randomized trials reported no difference whether induction or expectant management is performed in non-diabetic women with large for gestational age babies but no tool has been validated for the prediction of high risk cases.

AIM

Assessing the performance of different growth curves in the prediction of complications.

METHODS

Data from 1066 consecutive non-diabetic women who delivered babies ≥4000 g were collected. Logistic regression analysis was used to analyze the impact of the maternal variables on: instrumental delivery, shoulder dystocia (SD), perineal tears, cesarean section (CS), and postpartum hemorrhage. Intergrowth21 curves and customized Gardosi's curves were compared in terms of prediction of adverse outcomes.

FINDINGS

Induction of labor was performed in 23.1% cases. The rate of CS was 17%. Hemorrhage, fetal distress, and SD occurred in 2%, 1.3%, and 2.7% of cases, respectively. Induction was significantly associated with instrumental delivery (p < .001), CS (p = .001), third and fourth degree perineal tears (p = .031), and post-partum hemorrhage (p = .02). The cutoff of 90th percentile according to Intergrowth21 did not show significant performance in predicting CS, while the same cutoff according to the Gardosi curves showed an OR 1.92 (CI 1.30-2.84) (p = .0009).

DISCUSSION

Gardosi curves showed a better performance in predicting the risk of CS versus Intergrowth curves. Induction is significantly associated with adverse outcome in non-diabetic women with LGA babies.

Macrosomic Newborns Delivered at Term after Labor among Nondiabetic Women: Maternal and Neonatal Morbidities

OBJECTIVE

This study aimed to compare morbidities among nonmacrosomic versus macrosomic singleton live births of nondiabetic women who labored.

STUDY DESIGN

This retrospective study utilized the 2003 revision of U.S. birth certificate data of singleton live births (2011-2013) at 37 to 41 weeks who labored. The primary outcomes were composite maternal and neonatal morbidities (CMM and CNM, respectively). We compared these outcomes by birth weight, 2,500 to 3,999 g (group 1; reference), 4,000 to 4,449 g (group 2), and 4,500 to 5,999 g (group 3). We used multivariable Poisson regression analyses to examine the association between birth weight groups and the outcomes.

RESULTS

Among 6,691,338 live births, 92.0% were in group 1, 7.1% in group 2, and 0.9% in group 3. The overall CMM and CNM rates were 4.4 and 6.8 per 1,000 live births, respectively. Compared with group 1, the risk of CMM was significantly higher in group 2 (adjusted risk ratio [aRR] = 1.50; 95% confidence interval [CI]: 1.44-1.56) and group 3 (aRR = 2.00; 95% CI: 1.82-2.19). Likewise, the risk of CNM was significantly higher in group 2 (aRR = 1.38; 95% CI: 1.33-1.43) and group 3 (aRR = 2.57; 95% CI: 2.40-2.75) than in group 1.

CONCLUSION

Nondiabetic women who labor with a macrosomic newborns have a significantly higher rate of adverse outcomes than nonmacrosomic.

Maternal cardiovascular function and risk of intrapartum fetal compromise in women undergoing induction of labor: pilot study

OBJECTIVE

Identification of the fetus at risk of intrapartum compromise has many benefits. Impaired maternal cardiovascular function is associated with placental hypoperfusion predisposing to intrapartum fetal distress. The aim of this study was to assess the predictive accuracy of maternal hemodynamics for the risk of operative delivery due to presumed fetal compromise in women undergoing induction of labor (IOL).

METHODS

In this prospective cohort study, patients were recruited between November 2018 and January 2019. Women undergoing IOL were invited to participate in the study. A non-invasive ultrasonic cardiac output monitor (USCOM-1A®) was used for cardiovascular assessment. The study outcome was operative delivery due to presumed fetal compromise, which included Cesarean or instrumental delivery for abnormal fetal heart monitoring. Regression analysis was used to test the association between cardiovascular markers, as well as the maternal characteristics, and the risk of operative delivery due to presumed fetal compromise. Receiver-operating-characteristics-curve analysis was used to assess the predictive accuracy of the cardiovascular markers for the risk of operative delivery for presumed fetal compromise.

RESULTS

A total of 99 women were recruited, however four women were later excluded from the analysis due to semi-elective Cesarean section (n = 2) and failed IOL (n = 2). The rate of operative delivery due to presumed fetal compromise was 28.4% (27/95). Women who delivered without suspected fetal compromise (controls) were more likely to be parous, compared to those who had operative delivery due to fetal compromise (52.9% vs 18.5%; P = 0.002). Women who underwent operative delivery due to presumed fetal compromise had a significantly lower cardiac index (median, 2.50 vs 2.60 L/min/m² ; P = 0.039) and a higher systemic vascular resistance (SVR) (median, 1480 vs 1325 dynes × s/cm⁵ , P = 0.044) compared to controls. The baseline model (being parous only) showed poor predictive accuracy, with an area under the curve of 0.67 (95% CI, 0.58-0.77). The addition of stroke volume index (SVI) < 36 mL/m² , SVR > 7.2 logs or SVR index (SVRI) > 7.7 logs improved significantly the predictive accuracy of the baseline model (P = 0.012, P = 0.026 and P = 0.012, respectively).

CONCLUSION

In this pilot study, we demonstrated that prelabor maternal cardiovascular assessment in women undergoing IOL could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SVI, SVR or SVRI improved significantly the predictive accuracy of the baseline antenatal model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Evidence-based labor management: induction of labor (part 2)

Induction of labor is indicated for many obstetrical, maternal, and fetal indications. Induction can be offered for pregnancy at 39 weeks' gestation. No prediction method is considered sensitive or specific enough to determine the incidence of cesarean delivery after induction. A combination of 60- to 80-mL single-balloon Foley catheter for 12 hours and either 25-μg oral misoprostol initially, followed by 25 μg every 2-4 hours, or 50 μg every 4-6 hours (if no more than 3 contractions per 10 minutes or previous uterine surgery), or oxytocin infusion should be recommended for induction of labor. Adding membrane stripping at the beginning of induction should be considered. Once 5-6 cm of cervical dilation is achieved during the induction of labor, consideration can be given to discontinue oxytocin infusion if in use at that time and adequate contractions are present. Induction with oxytocin immediately (as soon as feasible) or up to 12 hours of term prelabor rupture of membranes if labor is not evident is recommended. Outpatient Foley ripening can be considered for low-risk women. Cesarean delivery should not be performed before 15 hours of oxytocin infusion and amniotomy if feasible and ideally after 18-24 hours of oxytocin infusion.

Risk factors for neonatal brachial plexus palsy: a systematic review and meta-analysis

AIM

To provide a comprehensive update on the most prevalent, significant risk factors for neonatal brachial plexus palsy (NBPP).

METHOD

Cochrane CENTRAL, MEDLINE, Web of Science, Embase, and ClinicalTrials.gov were searched for relevant publications up to March 2019. Studies assessing risk factors of NBPP in relation to typically developing comparison individuals were included. Meta-analysis was performed for the five most significant risk factors, on the basis of the PRISMA statement and MOOSE guidelines. Pooled odds ratios (ORs), 95% confidence intervals (CIs), and across-study heterogeneity (I² ) were reported. Reporting bias and quality of evidence was rated. In addition, we assessed the incidence of NBPP.

RESULTS

Twenty-two observational studies with a total sample size of 29 419 037 live births were selected. Significant risk factors included shoulder dystocia (OR 115.27; 95% CI 81.35-163.35; I² =92%), macrosomia (OR 9.75; 95% CI 8.29-11.46; I² =70%), (gestational) diabetes (OR 5.33; 95% CI 3.77-7.55; I² =59%), instrumental delivery (OR 3.8; 95% CI 2.77-5.23; I² =77%), and breech delivery (OR 2.49; 95% CI 1.67-3.7; I² =70%). Caesarean section appeared as a protective factor (OR 0.13; 95% CI 0.11-0.16; I² =41%). The pooled overall incidence of NBPP was 1.74 per 1000 live births. It has decreased in recent years.

INTERPRETATION

The incidence of NBPP is decreasing. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are risk factors for NBPP. Caesarean section appears as a protective factor.

WHAT THIS PAPER ADDS

The overall incidence of neonatal brachial plexus palsy is 1.74 per 1000 live births. The incidence has declined significantly. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are the main risk factors. Prevention is difficult owing to unpredictability and often labour-related risk.

Induction of labor versus expectant management among women with macrosomic neonates: a retrospective study

Background: The macrosomic fetus predisposes a variety of adverse maternal and perinatal outcomes. Although older studies have shown no benefit in inducing women of suspected macrosomic fetuses, more updated studies show different information.Objectives: The aim of our study was to compare induction of labor versus expectant management among women with macrosomic neonates weighing more than 4000 g at term (between 37°/7 and 416/7 weeks' gestation).Study design: This was a retrospective cohort study of all live-born singleton pregnancies with macrosomic newborns who were delivered at our institution between 1 January 2000 and 1 June 2015. We compared the outcomes of induction of labor, at each gestational age (GA), between 37 and 41 weeks (study group) with ongoing pregnancy. The primary outcome was cesarean section (CS) rate. Secondary outcomes were composite maternal and neonatal outcome and birth injuries.Results: Overall, out of 3095 patients with macrosomic newborns who were included in the study, 795 women (25.7%) underwent induction of labor. The cesarean section rate was not found to be significantly different between the groups at all gestational ages, nor was the vaginal delivery rate. After adjusting for confounders, induction of labor at 40 and 41 weeks' gestation was associated with composite maternal outcome (adjusted odds ratio (aOR) 1.6, 95% confidence interval (CI): 1.3-2.1; aOR 1.7, 95% CI: 1.3-2.2, respectively) and composite neonatal outcome (aOR 1.6, 95% CI: 1.1-2.4; aOR 1.8, 95% CI: 1.1-2.9). Induction of labor at 40 weeks' gestation was also associated with increased risk of birth injuries (aOR 2.9, 95% CI: 1.4-6).Conclusions: Compared with ongoing pregnancy, induction of labor of women with macrosomic neonates between 37 and 41 weeks of gestation does not reduce the CS rate, nor does it increase the vaginal delivery rate. Moreover, induction of labor of those women beyond 39 weeks' gestation is associated with composite adverse maternal/neonatal outcome, specifically birth injuries.

Identification of newborns with birthweight ≥ 4,500g: Ultrasound within one- vs. two weeks of delivery

OBJECTIVE

Our objective was to compare the diagnostic characteristics of sonographic estimated fetal weight (SEFW) done within 7 versus 8-14 days before delivery for detection of fetal macrosomia (birthweight ≥ 4500 g).

STUDY DESIGN

We performed a multicenter, retrospective cohort study of all non-anomalous singletons with SEFW ≥ 4000 g by Registered Diagnostic Medical Sonographers conducted within 14 days of delivery. Cohorts were grouped by time interval between ultrasound and delivery: 0-7 days versus 8-14 days. The detection rate (DR) and false positive rate (FPR) for detection of birthweight (BW) ≥ 4500 g were compared between groups with subgroup analysis for diabetic women. Area under the receiver operator curve (AUC) was calculated to analyze all possible SEFW cutoffs within our cohort.

RESULTS

A total of 330 patients met inclusion criteria with 250 (75.8 %) having SEFW within 7 days and 80 (24.2 %) with SEFW 8-14 days prior to delivery. The rate of macrosomia was 15.1 % (N = 51). The DR for macrosomia was significantly higher when SEFW was performed within 7 days of delivery compared to 8-14 days among non-diabetic (73.0 % vs 7.1 %; p < 0.001) and diabetic women (76.5 % vs 16.7 %; p = 0.02). There was no significant change in FPR in either group. The AUC for detection of macrosomia was significantly higher when SEFW was performed within 7 days versus 8-14 days (0.89 vs 0.63; p < 0.01).

CONCLUSION

With SEFW ≥ 4000 g, the detection of BW ≥ 4500 g is significantly higher when the sonographic examination is within 7 days of birth irrespective of maternal diabetes.

Early amniotomy after cervical ripening for induction of labor: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE DATA

Timing of artificial rupture of membranes (ie, amniotomy) in induction of labor is controversial, because it has been associated not only with shorter labors, but also with fetal nonreassuring testing, at times necessitating cesarean delivery. The aim of this systematic review and metaanalysis of randomized trials was to evaluate the effectiveness of early amniotomy vs late amniotomy or spontaneous rupture of membranes after cervical ripening.

STUDY

The search was conducted with the use of electronic databases from inception of each database through February 2019. Review of articles included the abstracts of all references that were retrieved from the search.

STUDY APPRAISAL AND SYNTHESIS METHODS

Selection criteria included randomized clinical trials that compared early amniotomy vs control (ie, late amniotomy or spontaneous rupture of membranes) after cervical ripening with either Foley catheter or prostaglandins at any dose. The primary outcome was the incidence of cesarean delivery. The summary measures were reported as summary relative risk with 95% of confidence interval with the use of the random effects model of DerSimonian and Laird.

RESULTS

Four trials that included 1273 women who underwent cervical ripening with either Foley catheter or prostaglandins and then were assigned randomly to either early amniotomy, late amniotomy, or spontaneous rupture of membranes (control subjects) were included in the review. Women who were assigned randomly to early amniotomy had a similar risk of cesarean delivery (31.1% vs 30.9%; relative risk, 1.05; 95% confidence interval, 0.71-1.56) compared with control subjects and had a shorter interval from induction to delivery of approximately 5 hours (mean difference, -4.95 hours; 95% confidence interval, -8.12 to -1.78). Spontaneous vaginal delivery was also reduced in the early amniotomy group, but only 1 of the included trials reported this outcome (67.5% vs 69.1%; relative risk, 0.78; 95% confidence interval, 0.66-0.93). No between-group differences were reported in the other obstetrics or perinatal outcomes.

CONCLUSION

After cervical ripening, routine early amniotomy does not increase the risk of cesarean delivery and reduces the interval from induction to delivery.

Reliability of strain elastography using in vivo compression in the assessment of the uterine cervix during pregnancy

Objective To determine the reproducibility of the mean strain value in various cervical areas and new elastographic parameters for measuring cervical stiffness evaluated by strain elastography using in vivo compression generated by internal organ movement. Methods A prospective observational study (140 singleton pregnant women; 15-33 weeks of gestation) was performed at two tertiary centers. Cervical strain was evaluated using E-cervix™ elastography. The mean strain levels of various cervical areas [internal os (IOS), external os (EOS) and endocervical area] and several new parameters [i.e. the ratio of the strain level of IOS and EOS, elasticity contrast index (ECI), and hardness ratio] were assessed twice by two independent examiners. The inter-observer and intra-observer variances were calculated using the intraclass correlation coefficient (ICC) with a 95% confidence interval (CI). Bland-Altman (B-A) analysis was also performed. Results The median gestational age was 24.0 weeks, and the mean cervical length (CL) was 3.8 cm. The intra-observer and inter-observer ICCs of the mean strain levels of the specified cervical area and new elastographic parameters were statistically significant (P < 0.001, all); the intra-observer ICC was 0.639-0.725, and the inter-observer ICC was 0.538-0.718. Conclusion The reproducibility of elastographic parameter measurements using in vivo compression is improvable.

Intracervical Foley Catheter Plus Intravaginal Misoprostol vs Intravaginal Misoprostol Alone for Cervical Ripening: A Meta-Analysis

Currently, there is no meta-analysis comparing intravaginal misoprostol plus intracervical Foley catheter versus intravaginal misoprostol alone for term pregnancy without identifying risk factors. Therefore, the purpose of this study is to conduct a systematic review and meta-analysis of randomized control trials (RCTs) comparing concurrent intravaginal misoprostol and intracervical Foley catheter versus intravaginal misoprostol alone for cervical ripening. We systematically searched Embase, Pubmed, and Cochrane Collaboration databases for randomized controlled trials (RCTs) comparing intracervical Foley catheter plus intravaginal misoprostol and intravaginal misoprostol alone using the search terms "Foley", "misoprostol", "cervical ripening", and "induction" up to 29 January 2019. Data were extracted and analyzed by two independent reviewers including study characteristics, induction time, cesarean section (C/S), clinical suspicion of chorioamnionitis, uterine tachysystole, meconium stain, and neonatal intensive care unit (NICU) admissions. Data was pooled using random effects modeling and calculated with risk ratio (RR) and 95% confidence interval (CI). Pooled analysis from eight studies, including 1110 women, showed that labor induction using a combination of intracervical Foley catheter and intravaginal misoprostol decreased induction time by 2.71 h (95% CI -4.33 to -1.08, p = 0.001), as well as the risk of uterine tachysystole and meconium staining (RR 0.54, 95% CI 0.30-0.99 and RR 0.48, 95% CI 0.32-0.73, respectively) significantly compared to those using intravaginal misoprostol alone. However, there was no difference in C/S rate (RR 0.93, 95% CI 0.78-1.11) or clinical suspicion of chorioamnionitis rate (RR 1.22, CI 0.58-2.57) between the two groups. Labor induction with a combination of intracervical Foley catheter and intravaginal misoprostol may be a better choice based on advantages in shortening induction time and reducing the risk of uterine tachysystole and meconium staining compared to intravaginal misoprostol alone.

Maternal and Neonatal Morbidity Associated With Early Term Delivery of Large-for-Gestational-Age But Nonmacrosomic Neonates

OBJECTIVE

To evaluate whether, at 37-39 weeks of gestation, delivery of a neonate with a birth weight that is 90% or greater for gestational age but less than 4,000 g is associated with increased composite maternal and neonatal morbidity.

METHODS

This retrospective cohort study used U.S. Vital Statistics datasets for the years 2011-2013. Inclusion criteria were singleton pregnancies delivered at 37-39 weeks of gestation after labor in which the neonates were nonanomalous, and either appropriate for gestational age or large for gestational age (LGA) neonates with birth weights of less than 4,000 g (our threshold for macrosomia). The coprimary outcomes were composite maternal morbidity (any of the following: maternal transfusion, ruptured uterus, unplanned hysterectomy, admission to intensive care unit, or unplanned procedure) and composite neonatal morbidity (any of the following: Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure or serious neurologic dysfunction, significant birth injury or neonatal mortality). Multivariable Poisson regression models were used to calculate adjusted relative risk (aRR) and 95% CI.

RESULTS

Among the 3.9 million women who met inclusion criteria, 1.3% delivered neonates who were LGA but nonmacrosomic. The rate of composite maternal morbidity was 53% higher women who delivered nonmacrosomic LGA neonate (6.27 vs 4.09/1,000 live births; aRR 1.40, 95% CI 1.25-1.56). This increased risk of composite maternal morbidity persisted in analyses stratified by diabetes. The rate of composite neonatal morbidity was 83% higher for nonmacrosomic LGA neonates (11.09 vs 6.07/1,000 live births; aRR 1.47, 95% CI 1.35-1.60) and persisted in analyses stratified by diabetes.

CONCLUSION

At 37-39 weeks of gestation, delivery of a neonate with a birth weight that is 90% or greater for gestational age but less than 4,000 g is associated with increased composite maternal and neonatal morbidity.

A systematic scoping review of clinical indications for induction of labour

BACKGROUND

The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist.

METHODS

A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool.

RESULTS

68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence.

CONCLUSIONS

While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.

Management of pregestational diabetes mellitus: a comparison of guidelines

Background: Pregestational diabetes is associated with adverse maternal and neonatal outcomes. The aim of this study was to summarize and compare evidence-based recommendations on pregestational diabetes and to focus especially on issues related to the management of this entity.Materials and methods: A descriptive review of three recently published national guidelines on pregestational diabetes was conducted: the American Diabetes Association on "Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2019," the National Institute for Health and Care Excellence on "Diabetes in pregnancy: management from preconception to the postnatal period" and the American College of Obstetricians and Gynecologists on "Pregestational Diabetes Mellitus." These guidelines were compared according to recommendations on management, during the preconception, antenatal, intrapartum and postpartum period.Results: There were many similar recommendations regarding the preconception counseling, the antepartum assessment by specialists, the glycemic control target levels, the pharmacologic treatment and the postpartum period among the three guidelines. On the other hand, the American Diabetes Association makes no recommendations regarding fetal monitoring and obstetric management during pregnancy and the intrapartum period, while there are several similarities between the other two guidelines.Conclusions: The adoption of an international consensus based on evidence - based guidelines will increase the awareness of the healthcare professionals on the management of pregestational diabetes, leading that way to more favorable perinatal outcomes.

Maternal and neonatal complications of fetal macrosomia: systematic review and meta-analysis

OBJECTIVE

To determine accurate estimates of risks of maternal and neonatal complications in pregnancies with fetal macrosomia by performing a systematic review of the literature and meta-analysis.

METHODS

A search of MEDLINE, EMBASE, CINAHL and The Cochrane Library was performed to identify relevant studies reporting on maternal and/or neonatal complications in pregnancies with macrosomia having a birth weight (BW) > 4000 g and/or those with birth weight > 4500 g. Prospective and retrospective cohort and population-based studies that provided data regarding both cases and controls were included. Maternal outcomes assessed were emergency Cesarean section (CS), postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS). Neonatal outcomes assessed were shoulder dystocia, obstetric brachial plexus injury (OBPI) and birth fractures. Meta-analysis using a random-effects model was used to estimate weighted pooled estimates of summary statistics (odds ratio (OR) and 95% CI) for each complication, according to birth weight. Heterogeneity between studies was estimated using Cochran's Q, I2 statistic and funnel plots.

RESULTS

Seventeen studies reporting data on maternal and/or neonatal complications in pregnancy with macrosomia were included. In pregnancies with macrosomia having a BW > 4000 g, there was an increased risk of the maternal complications: emergency CS, PPH and OASIS, which had OR (95% CI) of 1.98 (1.80-2.18), 2.05 (1.90-2.22) and 1.91 (1.56-2.33), respectively. The corresponding values for pregnancies with BW > 4500 g were: 2.55 (2.33-2.78), 3.15 (2.14-4.63) and 2.56 (1.97-3.32). Similarly, in pregnancies with a BW > 4000 g, there was an increased risk of the neonatal complications: shoulder dystocia, OBPI and birth fractures, which had OR (95% CI) of 9.54 (6.76-13.46), 11.03 (7.06-17.23) and 6.43 (3.67-11.28), respectively. The corresponding values for pregnancies with a BW > 4500 g were: 15.64 (11.31-21.64), 19.87 (12.19-32.40) and 8.16 (2.75-24.23).

CONCLUSION

Macrosomia is associated with serious maternal and neonatal adverse outcomes. This study provides accurate estimates of these risks, which can be used for decisions on pregnancy management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Protocol for the prospective observational clinical study: estimation of fetal weight by MRI to PREdict neonatal MACROsomia (PREMACRO study) and small-for-gestational age neonates

INTRODUCTION

Macrosomia refers to growth beyond a specific threshold, regardless of gestational age. These fetuses are also frequently referred to as large for gestational age (LGA). Various cut-offs have been used but for research purposes, a cut-off above the 95th centile for birth weight is often preferred because it defines 90% of the population as normal weight. The use of centiles, rather than estimated weights, also accommodates preterm macrosomic infants, although most of the complications, maternal and fetal, arise during the delivery of large babies at term. This means that accurate identification of LGA fetuses (≥95th centile) may play an important role in guiding obstetric interventions, such as induction of labour or caesarean section. Traditionally, identification of fetuses suspected of macrosomia has been based on biometric measurements using two-dimensional (2D) ultrasound (US), yet this method is rather sub-optimal. We present a protocol (V.2.1, date 19 May 2016) for the estimation of fetal weight (EFW) by MRI to PREdict neonatal MACROsomia (PREMACRO study), which is a prospective observational clinical study designed to determine whether MRI at 36 + 0 to 36 + 6 weeks of gestation, as compared with 2D US, can improve the identification of LGA neonates ≥95th centile.

METHODS AND ANALYSIS

All eligible women attending the 36-week clinic will be invited to participate in the screening study for LGA fetuses ≥95th centile and will undergo US-EFW and MRI-EFW within minutes of each other. From these estimations, a centile will be derived which will be compared with the centile of birth weight used as the gold standard. Besides birth weight, other pregnancy and neonatal outcomes will be collected and analysed. The first enrolment for the study was in May 2016. As of September 2018, 2004 women have been screened and recruited to the study. The study is due to end in April 2019.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the International Conference on Harmonisation for good clinical practice and the appropriate regulatory requirement(s). A favourable ethical opinion was obtained from the Ethics Committee of the University Hospital Brugmann, reference number CE2016/44. Results will be published in peer-reviewed journals and disseminated at international conferences.

TRIAL REGISTRATION NUMBER

NCT02713568.

The Epidemiology of Brachial Plexus Birth Palsy in the United States: Declining Incidence and Evolving Risk Factors

BACKGROUND

The epidemiology of brachial plexus birth palsy (BPBP) in the United States may be changing over time due to population-level changes in obstetric care.

METHODS

The Kids' Inpatient Database from 1997 to 2012 was analyzed. Annual estimates of BPBP incidence and disease determinant distribution were calculated for the general population and the study population with BPBP. Long-term trends were analyzed. A multivariate logistic regression model was used to quantify the risk associated with each determinant.

RESULTS

The database yielded a combined total of 5,564,628 sample births extrapolated to 23,385,597 population births. The population incidence of BPBP dropped 47.1% over the 16-year study period, from 1.7 to 0.9 cases per 1000 live births (P<0.001). Female, black, and Hispanic subgroups had moderately increased risks of BPBP. Among children with BPBP, 55.0% had no identifiable risk factor. Shoulder dystocia was the strongest risk factor for BPBP in the regression model [odds ratio (OR), 113.2; P<0.001], although the risk of sustaining a BPBP in the setting of shoulder dystocia decreased from 10.7% in 1997 to 8.3% in 2012 (P=0.006). Birth hypoxia was independently associated with BPBP (OR, 3.1; P<0.001). Cesarean delivery (OR, 0.16; P<0.001) and multiple gestation birth (OR, 0.45; P<0.001) were associated with lower incidence of BPBP. Notably, the rate of cesarean delivery increased by 62.8% during the study period, from 20.9% in 1997 to 34.0% in 2012 (P<0.001).

CONCLUSIONS

Over a 16-year period, the incidence of BPBP fell dramatically, paralleled by a significant increase in the rate of cesarean delivery. Systemic changes in obstetric practice may have contributed to these trends. As more than half of BPBP cases have no identifiable risk factor, prospective investigation of established risk factors and characterization of new disease determinants are needed to more reliably identify infants at greatest risk. Racial and geographic inequalities in disease burden should be investigated to identify interventional targets.

LEVEL OF EVIDENCE

Level III-case series.

External validation and clinical usefulness of first-trimester prediction models for small- and large-for-gestational-age infants: a prospective cohort study

Objective

To assess the external validity of all published first‐trimester prediction models based on routinely collected maternal predictors for the risk of small‐ and large‐for‐gestational‐age (SGA and LGA) infants. Furthermore, the clinical potential of the best‐performing models was evaluated.

Design

Multicentre prospective cohort.

Setting

Thirty‐six midwifery practices and six hospitals (in the Netherlands).

Population

Pregnant women were recruited at <16 weeks of gestation between 1 July 2013 and 31 December 2015.

Methods

Prediction models were systematically selected from the literature. Information on predictors was obtained by a web‐based questionnaire. Birthweight centiles were corrected for gestational age, parity, fetal sex, and ethnicity.

Main outcome measures

Predictive performance was assessed by means of discrimination (C‐statistic) and calibration.

Results

The validation cohort consisted of 2582 pregnant women. The outcomes of SGA <10th percentile and LGA >90th percentile occurred in 203 and 224 women, respectively. The C‐statistics of the included models ranged from 0.52 to 0.64 for SGA (n = 6), and from 0.60 to 0.69 for LGA (n = 6). All models yielded higher C‐statistics for more severe cases of SGA (<5th percentile) and LGA (>95th percentile). Initial calibration showed poor‐to‐moderate agreement between the predicted probabilities and the observed outcomes, but this improved substantially after recalibration.

Conclusion

The clinical relevance of the models is limited because of their moderate predictive performance, and because the definitions of SGA and LGA do not exclude constitutionally small or large infants. As most clinically relevant fetal growth deviations are related to ‘vascular’ or ‘metabolic’ factors, models predicting hypertensive disorders and gestational diabetes are likely to be more specific.

Tweetable abstract

The clinical relevance of prediction models for the risk of small‐ and large‐for‐gestational‐age is limited.

The clinical relevance of prediction models for the risk of small‐ and large‐for‐gestational‐age is limited.

Antenatal intervention for congenital fetal lower urinary tract obstruction (LUTO): a systematic review and meta-analysis

Objective: To evaluate the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction (LUTO) in improving perinatal survival and postnatal renal function.Methods: Electronic databases were searched from their inception until May 2018. Selection criteria included randomized controlled trials and nonrandomized studies including fetuses with ultrasound evidence of LUTO evaluating antenatal intervention for improving perinatal outcomes. Any type of antenatal bladder drainage technique was analyzed. The primary outcome was perinatal survival. The secondary outcome was postnatal survival with normal renal function. The summary measures were reported as summary odds ratio (OR) with 95% of confidence interval (CI).Results: Ten articles with a total of 355 fetuses were included in the meta-analysis. Inclusion criteria of the selected studies were singleton pregnancy with severe LUTO confirmed on detailed fetal ultrasound examination. Nine studies analyzed the efficacy of vesico-amniotic shunt performed in the second trimester. The overall estimate survival was higher in the vesico-amniotic shunt group compared to the conservative group (OR: 2.54, 95% CI: 1.14-5.67). 64/112 fetuses (57.1%) survived in the vesico-amniotic shunt group compared to 52/134 (38.8%) in the control group. Five studies reported on postnatal renal function between 6 months and 2 years. Rate of good postnatal renal function was higher in the vesico-amniotic shunt group compared to the conservative group (OR: 2.09, 95% CI: 0.74-5.9). Fetal cystoscopy was performed in only two included studies. Overall, 45 fetuses underwent fetal cystoscopy. The perinatal survival was higher in the cystoscopy group compared to the conservative management group (OR: 2.63, 95% CI: 1.07-6.47). Normal renal function was noted in 13/34 fetuses in the cystoscopy group versus 12/61 in the conservative management group at 6 months follow-up (OR: 1.75, 95% CI: 1.05-2.92)Conclusions: Antenatal bladder drainage appears to improve perinatal survival in cases of LUTO.

Childhood health and education outcomes following early term induction for large-for-gestational age: A population-based record linkage study

INTRODUCTION

There is debate about optimal management of pregnancies with a large-for-gestational age baby. A recent randomized controlled trial reported that early term induction of labor reduced cesarean section rates and infant morbidity. However, long term childhood outcomes have not been assessed. The aim of this study was to assess maternal, neonatal and child health and education outcomes for large-for-gestational age babies induced at 37-38 weeks' gestation.

MATERIAL AND METHODS

Population-based record linkage study of term (37+ weeks), cephalic-presenting singleton pregnancies with a large-for-gestational age baby in New South Wales, Australia, 2002-2006. Linked birth, hospital, mortality and education data were used with at least 9 years follow up from birth. Exposure was induction of labor at 37-38 weeks, compared to expectant management (spontaneous birth at ≥37 weeks and planned births at ≥39 weeks). Relative risks and 95% confidence intervals were estimated using Modified Poisson regression with robust variance.

RESULTS

Among 10 174 eligible pregnancies, 412 (4.0%) had an induction at 37-38 weeks. Women in the induction group were less likely to have a cesarean section (RR: 0.65, 95% CI: 0.51-0.82). Infants had higher rates of: low Apgar scores, birth trauma, neonatal jaundice and phototherapy use, and admission to special care nursery or neonatal intensive care than their expectantly managed counterparts. As children, they had higher rates of hospital admission (RR: 1.16, 95% CI: 1.04-1.30) and special needs (RR: 1.98, 95% CI: 1.12-3.50). However, by age 8 there was no difference in overall literacy and numeracy achievement.

CONCLUSIONS

Although women who had an early term labor induction with large-for-gestational age were less likely to have a cesarean section, the increased risk of neonatal morbidities and additional healthcare utilization suggests the need for caution in early induction of large-for-gestational age babies before 39 weeks' gestation.

Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials

Background: Different techniques have been analyzed to reduce the risk of perineal trauma during labor.Objective: To evaluate whether perineal massage techniques during vaginal delivery decreases the risk of perineal trauma.Search strategy: Electronic databases (Medline, Prospero, Scopus, ClinicalTrials.gov, Embase, ScienceDirect, the Cochrane Library, SciELO) were searched from their inception until February 2018. No restrictions for language or geographic location were applied.Selection criteria: We included all randomized controlled trials (RCTs) comparing the use of perineal massage during labor (i.e. intervention group) with a control group (i.e. no perineal massage) in women with singleton gestation and cephalic presentation at ≥36 weeks. Perineal massage was defined as massage of the posterior perineum by the clinician's fingers (with or without lubricant). Trials on perineal massage during antenatal care, before the onset of labor, or only in the early part of the first stage, were not included.Data collection and analysis: All analyses were done using an intention-to-treat approach. The primary outcome was severe perineal trauma, defined as third and fourth degree perineal lacerations. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of either a relative risk (RR) with 95% confidence interval (CI).Main results: Nine trials including 3374 women were analyzed. All studies included women with singleton pregnancy in cephalic presentation at ≥36 weeks undergoing spontaneous vaginal delivery. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant. Women randomized to receive perineal massage during labor had a significantly lower incidence of severe perineal trauma, compared to those who did not (RR 0.49, 95% CI 0.25-0.94). All the secondary outcomes were not significant, except for the incidence of intact perineum, which was significantly higher in the perineal massage group (RR 1.40, 95% 1.01-1.93), and for the incidence of episiotomy, which was significantly lower in the perineal massage group (RR 0.56, 95% CI 0.38-0.82).Conclusions: Perineal massage during labor is associated with significant lower risk of severe perineal trauma, such as third and fourth degree lacerations. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant.

Use of lubricant gel to shorten the second stage of labor during vaginal delivery

Background: Vaginal application of lubricant during labor has been studied to shorten the length of the second stage of labor.Objective: To evaluate whether vaginal application of lubricant shortens the second stage of labor.Data sources: Electronic databases were searched from their inception until February 2018. No restrictions for language or geographic location were applied.Study eligibility criteria: Randomized controlled trials (RCTs) comparing the use of lubricant of the vaginal canal (i.e. intervention group) with a control group (i.e. no lubricant) in pregnant women with singleton gestation and cephalic presentation undergoing spontaneous vaginal delivery at term. Trials on other interventions that might impact second stage of labor (pushing methods, perineal massage, Ritgen's maneuver, etc.) were not included.Study appraisal and synthesis methods: All analyses were done using an intention-to-treat approach. The primary outcome was the length of the second stage of labor. Pooled analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of mean difference (MD) with 95% confidence interval (CI).Tabulation, integration, and results: Three RCTs including 512 women evaluating the effect of lubricant application during labor were included in the meta-analysis. All trials included pregnant women with singleton gestations in cephalic presentation at term undergoing spontaneous vaginal delivery. One trial included only nulliparous women, while the other two included both nulliparous and multiparous women. Lubricant application started in the first stage before the active phase of labor, and was done intermittently by the midwife or the physician. A sterile gel was applied into the vaginal canal manually or with an applicator. All trials used water-soluble gel. The quantity of gel used was about 2-5 ml for each vaginal examination. There were no statistically significant differences, comparing women who received lubricant gel during labor with those who did not, in the lengths of second stage of labor (MD -7.11 min, 95% CI -15.60 to 1.38), of the first stage of labor, or of the active phase of the first stage of labor. No between-group differences were noticed in the risk of perineal lacerations, mode of delivery, and in the neonatal outcomes.Conclusion: Vaginal application of lubricant during labor does not reduce the length of the second stage of labor in pregnant women with singleton gestations undergoing an attempt at spontaneous vaginal delivery at term.

Discontinuing Oxytocin Infusion in the Active Phase of Labor: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the benefits and harms of discontinuation of oxytocin after the active phase of labor is reached.

DATA SOURCES

Electronic databases (ie, MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, ScienceDirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) were searched from their inception until April 2017.

METHODS OF STUDY SELECTION

We included all randomized controlled trials comparing discontinuation (ie, intervention group) and continuation (ie, control group) of oxytocin infusion after the active phase of labor is reached, either after induction or augmentation of labor. Discontinuation of oxytocin infusion was defined as discontinuing oxytocin infusion when the active phase of labor was achieved. Continuation of oxytocin infusion was defined as continuing oxytocin infusion until delivery. Only trials in singleton gestations with vertex presentation at term were included. The primary outcome was the incidence of cesarean delivery.

TABULATION, INTEGRATION, AND RESULTS

Nine randomized controlled trials, including 1,538 singleton gestations, were identified as relevant and included in the meta-analysis. All nine trials included only women undergoing induction of labor. In the discontinuation group, if arrest of labor occurred, usually defined as no cervical dilation in 2 hours or inadequate uterine contractions for 2 hours or more, oxytocin infusion was restarted. Women in the control group had oxytocin continued until delivery usually at the same dose used at the time the active phase was reached. Women who were randomized to have discontinuation of oxytocin infusion after the active phase of labor was reached had a significantly lower risk of cesarean delivery (9.3% compared with 14.7%; relative risk 0.64, 95% CI 0.48-0.87) and of uterine tachysystole (6.2% compared with 13.1%; relative risk 0.53, 95% CI 0.33-0.84) compared with those who were randomized to have continuation of oxytocin infusion until delivery. Discontinuation of oxytocin infusion was associated with an increase in the duration of the active phase of labor (mean difference 27.65 minutes, 95% CI 3.94-51.36).

CONCLUSION

In singleton gestations with cephalic presentation at term undergoing induction, discontinuation of oxytocin infusion after the active phase of labor at approximately 5 cm is reached reduces the risk of cesarean delivery and of uterine tachysystole compared with continuous oxytocin infusion. Given this evidence, discontinuation of oxytocin infusion once the active stage of labor is established in women being induced should be considered as an alternative management plan.

Impact of shoulder dystocia, stratified by type of manoeuvre, on severe neonatal outcome and maternal morbidity

BACKGROUND

Shoulder dystocia is an uncommon and unpredictable obstetric emergency. It is associated with significant neonatal, maternal and medico-legal consequences.

AIM

To ascertain the impact shoulder dystocia has on severe neonatal and maternal outcomes specific to the type of manoeuvre.

MATERIALS AND METHODS

This was a retrospective study of 48 021 term singleton vaginal deliveries the Mater Mothers' Hospital in Brisbane between 2007 and 2015. Maternal and neonatal outcomes were compared between deliveries complicated by shoulder dystocia and those uncomplicated.

RESULTS

Deliveries complicated by shoulder dystocia are associated with low Apgar scores (≤3) at five minutes (odds ratio (OR) 5.25, 95% CI 3.23-8.56, P < 0.001), acidosis (OR 3.10, 95% CI 2.76-3.50, P < 0.001), postpartum haemorrhage (OR 2.28, 95% CI 1.90-2.75, P < 0.001) and perineal trauma (OR 1.92, 95% CI 1.54-2.39, P < 0.001). Compared to McRoberts' manoeuvre and suprapubic pressure alone, the odds of serious neonatal outcome are increased with internal rotational manoeuvres (OR 3.82, 95% CI 2.54-5.74, P < 0.001) and delivery of the posterior arm (OR 4.49, 95% CI 3.54-5.69, P < 0.001). The OR of maternal injury is 2.07 (95% CI 1.77-2.45, P < 0.001), 2.26 (95% CI 1.21-4.21, P < 0.001) and 2.29 (95% CI 1.58-3.32, P < 0.001) with McRoberts'/suprapubic pressure, internal rotation and posterior arm delivery, respectively. Brachial plexus injuries and fractures complicate 1.4 and 0.9% of deliveries, with the risk of injury increasing when greater than one manoeuvre is required.

CONCLUSION

The risk of neonatal and maternal trauma is strongly associated with the number and types of manoeuvres. Given the associated implications, adequate antenatal counselling, simulation training and enhanced labour surveillance are essential.

Interventions for treating hyperemesis gravidarum: a Cochrane systematic review and meta-analysis

INTRODUCTION

While nausea and vomiting in early pregnancy are very common, affecting approximately 80% of the pregnancies, hyperemesis gravidarum is a severe form affecting 0.3-1.0% of the pregnancies. Although hyperemesis gravidarum is rarely a source of mortality, it is a significant source of morbidity. It is one of the most common indications for hospitalization in pregnancy. Beyond the maternal and fetal consequences of malnutrition, the severity of hyperemesis symptoms causes a major psychosocial burden leading to depression, anxiety, and even pregnancy termination. The aim of this meta-analysis was to examine all randomized controlled trials of interventions specifically for hyperemesis gravidarum and evaluate them based on both subjective and objective measures of efficacy, maternal and fetal/neonatal safety, and economic costs.

MATERIAL AND METHODS

Randomized controlled trials were identified by searching electronic databases. We included all randomized controlled trials for the treatment of hyperemesis gravidarum. The primary outcome was intervention efficacy as defined by severity, reduction, or cessation in nausea/vomiting; number of episodes of emesis; and days of hospital admission. Secondary outcomes included other measures of intervention efficacy, adverse maternal/fetal/neonatal outcomes, quality of life measures, and economic costs.

RESULTS

Twenty-five trials (2052 women) met the inclusion criteria but the majority of 18 different comparisons described in the review include data from single studies with small numbers of participants. Selected comparisons reported below: No primary outcome data were available when acupuncture was compared with placebo. There was insufficient evidence to identify clear differences between acupuncture and metoclopramide in a study with 81 participants regarding reduction/cessation in nausea or vomiting (risk ratio (RR) 1.40, 95% CI 0.79-2.49 and RR 1.51, 95% CI 0.92-2.48, respectively). Midwife-led outpatient care was associated with fewer hours of hospital admission than routine inpatient admission (mean difference (MD) - 33.20, 95% CI -46.91 to -19.49) with no difference in pregnancy-unique quantification of emesis and nausea (PUQE) score, decision to terminate the pregnancy, miscarriage, small-for-gestational age infants, or time off work when compared with routine care. Women taking vitamin B6 had a slightly longer hospital stay compared with placebo (MD 0.80 days, 95% CI 0.08-1.52). There was insufficient evidence to demonstrate a difference in other outcomes including mean number of episodes of emesis (MD 0.50, 95% CI -0.40-1.40) or side effects. A comparison between metoclopramide and ondansetron identified no clear difference in the severity of nausea or vomiting (MD 1.70, 95% CI -0.15-3.55, and MD -0.10, 95% CI -1.63-1.43; one study, 83 women, respectively). However, more women taking metoclopramide complained of drowsiness and dry mouth (RR 2.40, 95% CI 1.23-4.69, and RR 2.38, 95% CI 1.10-5.11, respectively). There were no clear differences between groups for other side effects. In a single study with 146 participants comparing metoclopramide with promethazine, more women taking promethazine reported drowsiness, dizziness, and dystonia (risk ratio (RR) 0.70, 95% CI 0.56-0.87, RR 0.48, 95% CI 0.34-0.69, and RR 0.31, 95% CI 0.11-0.90, respectively). There were no clear differences between groups for other important outcomes including quality of life and other side effects. In a single trial with 30 women, those receiving ondansetron had no difference in duration of hospital admission compared to those receiving promethazine (mean difference (MD) 0.00, 95% CI -1.39-1.39), although there was increased sedation with promethazine (RR 0.06, 95% CI 0.00-0.94). Regarding corticosteroids, in a study with 110 participants there was no difference in days of hospital admission compared to placebo (MD -0.30, 95% CI -0.70-0.10), but there was a decreased readmission rate (RR 0.69, 95% CI 0.50-0.94; 4 studies, 269 women). For hydrocortisone compared with metoclopramide, no data were available for primary outcomes and there was no difference in the readmission rate (RR 0.08, 95% CI 0.00-1.28; one study, 40 women). In a study with 80 women, compared to promethazine, those receiving prednisolone had increased nausea at 48 h (RR 2.00, 95% CI 1.08-3.72), but not at 17 days (RR 0.81, 95% CI 0.58-1.15). There was no clear difference in the number of episodes of emesis or subjective improvement in nausea/vomiting.

CONCLUSIONS

While there were a wide range of interventions studied, both pharmaceutical and otherwise, there were a limited number of placebo controlled trials. In comparing the efficacy of the commonly used antiemetics, metoclopramide, ondansetron, and promethazine, the results of this review do not support the clear superiority of one over the other in symptomatic relief. Other factors such as side effect profile medication safety and healthcare costs should also be considered when selecting an intervention.