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Bruinsma A, Keulen JKJ, Kortekaas JC, van Dillen J, Duijnhoven RG, Bossuyt PMM, van Kaam AH, van der Post JAM, Mol BW, de Miranda E. Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial. Eur J Obstet Gynecol Reprod Biol X 2022; 16:100165. [PMID: 36262791 PMCID: PMC9574420 DOI: 10.1016/j.eurox.2022.100165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/21/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy. Design Multicentre prospective cohort study alongside RCT. Setting 90 midwifery practices and 12 hospitals in the Netherlands. Population 3642 low-risk women with uncomplicated singleton late-term pregnancy. Main outcome measures Composite adverse outcome (perinatal death, Apgar score 5′ < 7, NICU admission, meconium aspiration syndrome), composite severe adverse perinatal outcome (all above with Apgar score 5′ < 4 instead of < 7) and caesarean section. Results From 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096). Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84). A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (11/1039) (adjRR 0.54; 95 % CI 0.07–24.19). One maternal death due to amniotic fluid embolism occurred after elective induction at 41 weeks + 6 days. Conclusion In this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable. No stillbirths in late-term pregnancy (IOL or EM) of 3642 women in INDEX-cohort. Less adverse perinatal outcomes in INDEX-cohort than in trial with comparable risk difference. More women approaching late-term pregnancy prefer EM, not elective induction.
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Affiliation(s)
- Aafke Bruinsma
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands,Rotterdam University of Applied Sciences, School of Midwifery, Rochussenstraat 198, Rotterdam, the Netherlands,Corresponding author at: Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Judit KJ Keulen
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands,Zuyd University, Research Center for Midwifery Science, Faculty Midwifery Education & Studies Maastricht, Universiteitssingel 60, Maastricht, the Netherlands
| | - Joep C Kortekaas
- Elkerliek Medical Center, Department of Obstetrics & Gynaecology, Wesselmanlaan 25, Helmond, the Netherlands
| | - Jeroen van Dillen
- Radboud University Medical Center, Department of Obstetrics & Gynaecology, Geert Grooteplein Zuid 10, Nijmegen, the Netherlands
| | - Ruben G Duijnhoven
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands
| | - Patrick MM Bossuyt
- Amsterdam UMC, University of Amsterdam, Department of Epidemiology & Data Science, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anton H van Kaam
- Amsterdam UMC, University of Amsterdam, Emma, Children’s hospital, Department of Neonatology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Joris AM van der Post
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands
| | - Ben W Mol
- Monash University, Department of Obstetrics and Gynaecology, 246 Clayton Road, Clayton, Victoria, Australia,University of Aberdeen, Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, AB24 3FX Aberdeen, UK
| | - Esteriek de Miranda
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, Amsterdam, the Netherlands
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Kortekaas JC, Kazemier BM, Keulen JKJ, Bruinsma A, Mol BW, Vandenbussche F, Van Dillen J, De Miranda E. Risk of adverse pregnancy outcomes of late- and postterm pregnancies in advanced maternal age: A national cohort study. Acta Obstet Gynecol Scand 2020; 99:1022-1030. [PMID: 32072610 PMCID: PMC7496606 DOI: 10.1111/aogs.13828] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/14/2022]
Abstract
Introduction There is an increase in women delivering ≥35 years of age. We analyzed the association between advanced maternal age and pregnancy outcomes in late‐ and postterm pregnancies. Material and methods A national cohort study was performed on obstetrical low‐risk women using data from the Netherlands Perinatal Registry from 1999 to 2010. We included women ≥18 years of age with a singleton pregnancy at term. Women with a pregnancy complicated by congenital anomalies, hypertensive disorders or diabetes mellitus were excluded. Composite adverse perinatal outcome was defined as stillbirth, neonatal death, meconium aspiration syndrome, 5‐minute Apgar score <7, neonatal intensive care unit admittance and sepsis. Composite adverse maternal outcome was defined as maternal death, placental abruption and postpartum hemorrhage of >1000 mL. Results We stratified the women into three age groups: 18‐34 (n = 1 321 366 [reference]); 35‐39 (n = 286 717) and ≥40 (n = 40 909). Composite adverse perinatal outcome occurred in 1.6% in women aged 18‐34, 1.7% in women aged 35‐39 (relative risk [RR] 1.06, 95% confidence interval [95% CI] 1.03‐1.08) and 2.2% in women aged ≥40 (RR 1.38, 95% CI 1.29‐1.47), with 5‐minute Apgar score <7 as the factor contributing most to the outcome. Composite adverse maternal outcome occurred in 4.6% in women aged 18‐34, 5.0% in women aged 35‐39 (RR 1.08, 95% CI 1.06‐1.10) and 5.2% in women aged ≥40 (RR 1.14, 95% CI 1.09‐1.19), with postpartum hemorrhage >1000 mL as the factor contributing most to the outcome. In all age categories, the risk of adverse pregnancy outcomes was higher for nulliparous than for multiparous women. The risk of adverse outcomes increased in both nulliparous and parous women with advancing gestational age. When adjusted for parity, onset of labor and gestational age, advanced maternal age is associated with an increase in both composite adverse perinatal and maternal outcomes. Conclusions The risk of adverse pregnancy outcome increases with advancing maternal age. Women aged ≥40 have an increased risk of adverse perinatal and maternal outcome when pregnancy goes beyond 41 weeks.
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Affiliation(s)
- Joep C Kortekaas
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Brenda M Kazemier
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Judit K J Keulen
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aafke Bruinsma
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Frank Vandenbussche
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Van Dillen
- Department of Obstetrics & Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esteriek De Miranda
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Kortekaas JC, Bruinsma A, Keulen JKJ, Vandenbussche FP, van Dillen J, de Miranda E. Management of late-term pregnancy in midwifery- and obstetrician-led care. BMC Pregnancy Childbirth 2019; 19:181. [PMID: 31117985 PMCID: PMC6532173 DOI: 10.1186/s12884-019-2294-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/12/2019] [Indexed: 11/24/2022] Open
Abstract
Management of late-term pregnancy in midwifery- and obstetrician-led care. BACKGROUND Since there is no consensus regarding the optimal management in late-term pregnancies (≥41.0 weeks), we explored the variety of management strategies in late-term pregnancy in the Netherlands to identify the magnitude of this variety and the attitude towards late-term pregnancy. METHODS Two nationwide surveys amongst all midwifery practices (midwifery-led care) and all hospitals with an obstetric unit (obstetrician-led care) were performed with questions on timing, frequency and content of consultations/surveillance in late-term pregnancy and on timing of induction. Propositions about late-term pregnancy were assessed using Likert scale questions. RESULTS The response rate was 40% (203/511) in midwifery-led care and 92% (80/87) in obstetrician-led care. All obstetric units made regional protocols with their collaborating midwifery practices about management in late-term pregnancy. Most midwifery-led care practices (93%) refer low-risk women at least once for consultation in obstetrician-led care in late-term pregnancy. The content of consultations varies among hospitals. Membrane sweeping is performed more in midwifery-led care compared to obstetrician-led care (90% vs 31%, p < 0.001). Consultation at 41 weeks should be standard care according to 47% of midwifery-led care practices and 83% of obstetrician-led care units (p < 0.001). Induction of labour at 41.0 weeks is offered less often to women in midwifery-led care in comparison to obstetrician-led care (3% vs 21%, p < 0.001). CONCLUSIONS Substantial practice variation exists within and between midwifery-and obstetrician-led care in the Netherlands regarding timing, frequency and content of antenatal monitoring in late-term pregnancy and timing of labour induction. An evidence based interdisciplinary guideline will contribute to a higher level of uniformity in the management in late- term pregnancies.
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Affiliation(s)
- Joep C. Kortekaas
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Aafke Bruinsma
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Judit K. J. Keulen
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Frank P.H.A. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
| | - Esteriek de Miranda
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Keulen JK, Bruinsma A, Kortekaas JC, van Dillen J, Bossuyt PM, Oudijk MA, Duijnhoven RG, van Kaam AH, Vandenbussche FP, van der Post JA, Mol BW, de Miranda E. Induction of labour at 41 weeks versus expectant management until 42 weeks (INDEX): multicentre, randomised non-inferiority trial. BMJ 2019; 364:l344. [PMID: 30786997 PMCID: PMC6598648 DOI: 10.1136/bmj.l344] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To compare induction of labour at 41 weeks with expectant management until 42 weeks in low risk women. DESIGN Open label, randomised controlled non-inferiority trial. SETTING 123 primary care midwifery practices and 45 hospitals (secondary care) in the Netherlands, 2012-16. PARTICIPANTS 1801 low risk women with an uncomplicated singleton pregnancy: randomised to induction (n=900) or to expectant management until 42 weeks (n=901). INTERVENTIONS Induction at 41 weeks or expectant management until 42 weeks with induction if necessary. PRIMARY OUTCOME MEASURES Primary outcome was a composite of perinatal mortality and neonatal morbidity (Apgar score <7 at five minutes, arterial pH <7.05, meconium aspiration syndrome, plexus brachialis injury, intracranial haemorrhage, and admission to a neonatal intensive care unit (NICU). Secondary outcomes included maternal outcomes and mode of delivery. The null hypothesis that expectant management is inferior to induction was tested with a non-inferiority margin of 2%. RESULTS Median gestational age at delivery was 41 weeks+0 days (interquartile range 41 weeks+0 days-41 weeks+1 day) for the induction group and 41 weeks+2 days (41 weeks+0 days-41 weeks+5 days) for the expectant management group. The primary outcome was analysed for both the intention-to-treat population and the per protocol population. In the induction group, 15/900 (1.7%) women had an adverse perinatal outcome versus 28/901 (3.1%) in the expectant management group (absolute risk difference -1.4%, 95% confidence interval -2.9% to 0.0%, P=0.22 for non-inferiority). 11 (1.2%) infants in the induction group and 23 (2.6%) in the expectant management group had an Apgar score <7 at five minutes (relative risk (RR) 0.48, 95% CI 0.23 to 0.98). No infants in the induction group and three (0.3%) in the expectant management group had an Apgar score <4 at five minutes. One fetal death (0.1%) occurred in the induction group and two (0.2%) in the expectant management group. No neonatal deaths occurred. 3 (0.3%) neonates in the induction group versus 8 (0.9%) in the expectant management group were admitted to an NICU (RR 0.38, 95% CI 0.10 to 1.41). No significant difference was found in composite adverse maternal outcomes (induction n=122 (13.6%) v expectant management n=102 (11.3%)) or in caesarean section rate (both groups n=97 (10.8%)). CONCLUSIONS This study could not show non-inferiority of expectant management compared with induction of labour in women with uncomplicated pregnancies at 41 weeks; instead a significant difference of 1.4% was found for risk of adverse perinatal outcomes in favour of induction, although the chances of a good perinatal outcome were high with both strategies and the incidence of perinatal mortality, Apgar score <4 at five minutes, and NICU admission low. TRIAL REGISTRATION Netherlands Trial Register NTR3431.
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Affiliation(s)
- Judit Kj Keulen
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Aafke Bruinsma
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Joep C Kortekaas
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Patrick Mm Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, University Medical Centre, Utrecht, Netherlands
| | - Ruben G Duijnhoven
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Frank Pha Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Joris Am van der Post
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Esteriek de Miranda
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Kortekaas JC, Scheuer AC, de Miranda E, van Dijk AE, Keulen JKJ, Bruinsma A, Mol BWJ, Vandenbussche FPHA, van Dillen J. Perinatal death beyond 41 weeks pregnancy: an evaluation of causes and substandard care factors as identified in perinatal audit in the Netherlands. BMC Pregnancy Childbirth 2018; 18:380. [PMID: 30236080 PMCID: PMC6149052 DOI: 10.1186/s12884-018-1973-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 08/09/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Late- and postterm pregnancy are associated with adverse perinatal outcomes, like perinatal death. We evaluated causes of death and substandard care factors (SSFs) in term and postterm perinatal death. METHODS We used data from the Perinatal Audit Registry of the Netherlands (PARS). Women with a term perinatal death registered in PARS were stratified by gestational age into early-/full-term (37.0-40.6) and late-/postterm (≥41.0 weeks) death. Cause of death and SSFs ≥41 weeks were scored and classified by the local perinatal audit teams. RESULTS During 2010-2012, 947/479,097 (0.21%) term deaths occurred, from which 707 cases (75%) were registered and could be used for analyses. Five hundred ninety-eight early-/full-term and 109 late-/postterm audited deaths were registered in the PARS database. Of all audited cases of perinatal death in the PARS database, 55.2% in the early-/fullterm group occurred antepartum compared to 42.2% in the late-/postterm group, while intrapartum death occurred in 7.2% in the early-/full-term group compared to 19.3% in the late-/postterm group in the audited cases from the PARS database. According to the local perinatal audit, the most relevant causes of perinatal death ≥41 weeks were antepartum asphyxia (7.3%), intrapartum asphyxia (9.2%), neonatal asphyxia (10.1%) and placental insufficiency (10.1%). In the group with perinatal death ≥41 weeks there was ≥1SSF identified in 68.8%. The most frequent SSFs concerned inadequate cardiotocography (CTG) evaluation and/or classification (10.1%), incomplete registration or documentation in medical files (4.6%) or inadequate action on decreased foetal movements (4.6%). CONCLUSIONS In the Netherlands Perinatal Audit Registry, stillbirth occurred relatively less often antepartum and more often intrapartum in pregnancies ≥41 weeks compared to pregnancies at 37.0-40.6 weeks in the audited cases from the PARS database. Foetal, intrapartum and neonatal asphyxia were identified more frequently as cause of death in pregnancies ≥41 weeks. The most identified SSFs related to death in pregnancies ≥41 weeks concerned inadequate CTG monitoring (evaluation, classification, registration or documentation) and inadequate action on decreased foetal movements.
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Affiliation(s)
- Joep C. Kortekaas
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Anke C. Scheuer
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
| | - Esteriek de Miranda
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Judit K. J. Keulen
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Aafke Bruinsma
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ben W. J. Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC Australia
| | - Frank P. H. A. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
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Keulen JKJ, Bruinsma A, Kortekaas JC, van Dillen J, van der Post JAM, de Miranda E. Timing induction of labour at 41 or 42 weeks? A closer look at time frames of comparison: A review. Midwifery 2018; 66:111-118. [PMID: 30170263 DOI: 10.1016/j.midw.2018.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 07/14/2018] [Accepted: 07/22/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postterm pregnancy is associated with increased perinatal risk. The WHO defines postterm pregnancy as a pregnancy at or beyond 42 weeks + 0 days, though currently labour is induced at 41 weeks in many settings. Guidelines on timing of labour induction are frequently based on the Cochrane systematic review 'Induction of labour for improving birth outcomes for women at or beyond term' in which is concluded that a policy of induction of labour is associated with fewer adverse perinatal outcome and fewer Caesarean sections. However, the included trials differed regarding the timing of induction, ranging from 39 to beyond 42 weeks while the upper limit of expectant management exceeded a gestational age of 42 weeks in most studies. OBJECTIVE to evaluate perinatal mortality, meconium aspiration syndrome and Caesarean section rate of trials comparing a policy of elective induction of labour and expectant management according to timeframes of comparison with a focus on studies within the 41-42 weeks' timeframe. DESIGN Review. METHODS The systematic review of Cochrane was used as a starting point for assessing relevant trials and a search was performed for additional recent trials. We evaluated incidence and causes of perinatal mortality, incidence of meconium aspiration syndrome and Caesarean section according to three time frames of comparison. We pooled estimates and heterogeneity was tested. The quality of the included trials was assessed using the Quality Assessment Tool for Quantative Studies (EPHPP). FINDINGS In total 22 trials were included which had all different timeframes of comparison. Only one trial compared induction of labour at 41 weeks + 0-2 days with induction at 42 weeks + 0 days, three other trials compared induction of labour at 41 weeks + 0-6 days with induction at 42 weeks + 0-6 days. In 18 trials the comparison was outside the 41-42 weeks' timeframe: in six trials induction was planned ≤ 40 weeks and in another 12 trials expectant management was beyond 43 weeks. The incidence of potentially gestational age associated perinatal mortality between 41 and 42 weeks was 0/2.444 [0%] (induction) versus 4/2.452 [0.16%] (expectant management), NNT 613; 95%CI 613 - infinite. Two trials in the timeframe of comparison 41-42 weeks were available for evaluation of meconium aspiration syndrome (6/554 (induction) versus 14/554 (expectant management), RR 0.44; 95%CI 0.17-1.16). Three trials in the timeframe 41-42 weeks could be evaluated for Caesarean section, with different inclusion criteria regarding Bishop score. There was no significant difference in the Caesarean section rate 93/629 (induction) versus 106/629 (expectant management), RR 0.88; 95%CI 0.68-1.13. CONCLUSION Evidence is lacking for the recommendation to induce labour at 41 weeks instead of 42 weeks for the improvement of perinatal outcome. More studies comparing both timeframes with an adequate sample size are needed to establish the optimal timing of induction of labour in late-term pregnancies.
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Affiliation(s)
- Judit K J Keulen
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Aafke Bruinsma
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Joep C Kortekaas
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; Department of Obstetrics & Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics & Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - Joris A M van der Post
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Esteriek de Miranda
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Bruinsma A, Keulen J, Kortekaas J, van Dillen J, Oudijk M, Bakker J, van Kaam A, Bossuyt P, Vandenbussche F, van de Post J, Mol BW, de Miranda E. 40: Induction of labor at 41 weeks or expectant management until 42 weeks - preliminary results of the INDEX trial. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bruinsma A, Kampman M, Exterkate CC, Hendriks GJ. [An exploratory study of 'blended' cognitive behavioural therapy (CBT) for patients with a panic disorder: results and patients' experiences]. Tijdschr Psychiatr 2016; 58:361-370. [PMID: 27213635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Digital technology (e-health or 'blended' care), combined with evidence-based face-to-face CBT, is becoming increasingly implemented into mental health care and is expected to result in improved effectiveness and efficiency. AIM To explore the feasibility of blended CBT for patients with a panic disorder. METHOD Nine face-to-face sessions of blended CBT (n = 18), supplemented with the digital support of a tabletcomputer and three e-mail contacts, were compared with 12 weekly sessions of regular CBT (n = 18). Primary outcomes were panic frequency and avoidance behaviour; the secondary outcome was general functioning. Patients' experiences of the treatment were collected in the form of a structured interview. RESULTS The effect sizes found in both the regular and the blended CBT were medium to high (Cohen's d 0.42-1.60). In both types of treatment there was a significant reduction in patients' symptoms. There were no big differences in patient satisfaction regarding the treatment received. The therapists registered 39 face-to-face minutes in the blended treatment but they registered in total 41 fewer face-to-face minutes; this represented a time reduction of 4%. CONCLUSION Blended CBT with help of a tablet computer seems to be a suitable method for treating panic disorder psychologically, although the time saved is only moderate. Much more research is needed to ascertain the feasibility and the cost effectiveness of blended CBT.
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Kortekaas JC, Bruinsma A, Keulen JKJ, van Dillen J, Oudijk MA, Zwart JJ, Bakker JJH, de Bont D, Nieuwenhuijze M, Offerhaus PM, van Kaam AH, Vandenbussche F, Mol BWJ, de Miranda E. Effects of induction of labour versus expectant management in women with impending post-term pregnancies: the 41 week - 42 week dilemma. BMC Pregnancy Childbirth 2014; 14:350. [PMID: 25338555 PMCID: PMC4288619 DOI: 10.1186/1471-2393-14-350] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 07/21/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Post-term pregnancy, a pregnancy exceeding 294 days or 42 completed weeks, is associated with increased perinatal morbidity and mortality and is considered a high-risk condition which requires specialist surveillance and induction of labour. However, there is uncertainty on the policy concerning the timing of induction for post-term pregnancy or impending post-term pregnancy, leading to practice variation between caregivers. Previous studies on induction at or beyond 41 weeks versus expectant management showed different results on perinatal outcome though conclusions in meta-analyses show a preference for induction at 41 weeks. However, interpretation of the results is hampered by the limited sample size of most trials and the heterogeneity in design. Most control groups had a policy of awaiting spontaneous onset of labour that went far beyond 42 weeks, which does not reflect usual care in The Netherlands where induction of labour at 42 weeks is the regular policy. Thus leaving the question unanswered if induction at 41 weeks results in better perinatal outcomes than expectant management until 42 weeks. METHODS/DESIGN In this study we compare a policy of labour induction at 41 + 0/+1 weeks with a policy of expectant management until 42 weeks in obstetrical low risk women without contra-indications for expectant management until 42 weeks and a singleton pregnancy in cephalic position. We will perform a multicenter randomised controlled clinical trial. Our primary outcome will be a composite outcome of perinatal mortality and neonatal morbidity. Secondary outcomes will be maternal outcomes as mode of delivery (operative vaginal delivery and Caesarean section), need for analgesia and postpartum haemorrhage (≥1000 ml). Maternal preferences, satisfaction, wellbeing, pain and anxiety will be assessed alongside the trial. DISCUSSION This study will provide evidence for the management of pregnant women reaching a gestational age of 41 weeks. TRIAL REGISTRATION Dutch Trial Register (Nederlands Trial Register): NTR3431. Registered: 14 May 2012.
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Affiliation(s)
- Joep C Kortekaas
- />Department of Obstetrics & Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
- />Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- />Department of Obstetrics and Gynaecology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Aafke Bruinsma
- />Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Judit KJ Keulen
- />Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen van Dillen
- />Department of Obstetrics & Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martijn A Oudijk
- />Department of Obstetrics and Gynaecology, University Medical Center, Utrecht, the Netherlands
| | - Joost J Zwart
- />Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - Jannet JH Bakker
- />Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Dokie de Bont
- />Midwifery practice ‘het Verloskundig Huys’, Zwolle, the Netherlands
| | - Marianne Nieuwenhuijze
- />Research Center for Midwifery Science, Faculty Midwifery Education & Studies Maastricht, ZUYD University, Heerlen, the Netherlands
| | - Pien M Offerhaus
- />KNOV (Royal Dutch Organisation for Midwives), Utrecht, the Netherlands
| | - Anton H van Kaam
- />Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank Vandenbussche
- />Department of Obstetrics & Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ben Willem J Mol
- />The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, 5000 SA Australia
| | - Esteriek de Miranda
- />Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Bruinsma A, Neumann J, Fahlenkamp H. Einsatz von Data Mining-Methoden zur Prozess- und Instandhaltungsoptimierung von Abfallverbrennungsanlagen. CHEM-ING-TECH 2003. [DOI: 10.1002/cite.200390312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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