Preventing Elective Deliveries Before 39 Weeks John R. Allbert Charlotte, NC

Elective Delivery Adverse outcomes are increased if delivery occurs before 39 weeks Adverse outcomes are increased if delivery occurs before 39 weeks There is a nearly 5 fold and 4 fold increased risk of respiratory morbidity in 37 and 38 week deliveries respectively compared to 39 week elective deliveries (NEMJ Jan ;360:111) There is a nearly 5 fold and 4 fold increased risk of respiratory morbidity in 37 and 38 week deliveries respectively compared to 39 week elective deliveries (NEMJ Jan ;360:111) For every 100 deliveries the cost savings for delaying delivery until 39 weeks is $160,000 and $50,000 compared to delivering at 37 and 38 weeks respectively For every 100 deliveries the cost savings for delaying delivery until 39 weeks is $160,000 and $50,000 compared to delivering at 37 and 38 weeks respectively

Induction of Labor Confirming Gestational Age Ultrasound measurement at less than 20 weeks of gestation supports GA of 39 wks or greater Ultrasound measurement at less than 20 weeks of gestation supports GA of 39 wks or greater Fetal heart tones with doppler ultrasonography documented for 30 wks Fetal heart tones with doppler ultrasonography documented for 30 wks It has been 36 wks since a positive serum or urine hCG pregnancy test It has been 36 wks since a positive serum or urine hCG pregnancy test ACOG Practice Bulletin 107, August 2009

Indications for Induction of Labor Abruptio placentae Abruptio placentae Chorioamnionitis Chorioamnionitis Gestational HTN Gestational HTN Preeclampsia Preeclampsia Maternal medical condition, (DM,cHTN) Maternal medical condition, (DM,cHTN) Fetal compromise, (isoimmunization, IUGR, oligohydramnios) Fetal compromise, (isoimmunization, IUGR, oligohydramnios) ACOG Practice Bulletin 107, August 2009

IUGR SGA is EFW <10% SGA is EFW <10% IUGR is failure of the fetus to achieve its growth potential IUGR is failure of the fetus to achieve its growth potential Induction of labor for of IUGR prior to 39 weeks should some how confirm placental dysfunction Induction of labor for of IUGR prior to 39 weeks should some how confirm placental dysfunction

IUGR Placental Dysfunction Oligohydramnios Oligohydramnios Abnormal doppler of the umbilical artery (>95%) Abnormal doppler of the umbilical artery (>95%) Documented poor fetal growth over a 3 week interval, particularly the abdominal circumference Documented poor fetal growth over a 3 week interval, particularly the abdominal circumference Nonreassuring NST, CST, BPP Nonreassuring NST, CST, BPP

Hypertension Less Morbidity With Induction Induction of labor vs expectant management for gestational hypertention Induction of labor vs expectant management for gestational hypertention Inducing labor at term if DBP >95 mmHg in hypertension and >90 mmHg in preeclampsia vs observation Inducing labor at term if DBP >95 mmHg in hypertension and >90 mmHg in preeclampsia vs observation Lower need for IV antihypertensives and anticonvulsants in the induction group Lower need for IV antihypertensives and anticonvulsants in the induction group Lower C/S rate in primagravidas with induction Lower C/S rate in primagravidas with induction Koopmans CM, Lancet 2009;374:979

Oligohydramnios Estimated with ultrasonography Estimated with ultrasonography AFI < 5 cm AFI < 5 cm Deepest vertical pocket < 2 cm Deepest vertical pocket < 2 cm Ideal measurement for intervention has not been established Ideal measurement for intervention has not been established Delivery should be considered if gestational age is at least 37 weeks but may be individualized Delivery should be considered if gestational age is at least 37 weeks but may be individualized ACOG Practice Bulletin Number 9, Antepartum Fetal Surveillance

Induction What is the commitment If the cervix is unfavorable, reevaluate the clinical criteria If the cervix is unfavorable, reevaluate the clinical criteria If you start the induction, you are not always obligated to have that patient delivered If you start the induction, you are not always obligated to have that patient delivered If the induction is not succeeding, consider discharging the patient and restart the induction in 2-4 days If the induction is not succeeding, consider discharging the patient and restart the induction in 2-4 days

Category A Category B Category C Category D Category E Category F Category G  Eclampsia  HELLP syndrome  PPROM  Placenta previa with active bleeding  Acute placental abruption  Fetal demise  Chorioamnioniti s  IUGR  Oligohydramnios  HIV (at 38 weeks)  Isoimmunization  Fetal hydrops  Multiple gestation  Cholestasis of pregnancy  Third trimester bleeding  Placenta previa without current bleeding  Decreased fetal movement  Chronic placental abruption (symptom-free >7 days)  Venous thromboembolism  Fetal anomaly  Nonreactive NST  BPP<4  Preeclampsia  Pregnancy- induced hypertension  Chronic hypertension  Poorly controlled diabetes  Maternal drug use  Prior classical c-section  Long distance from hospital  Previous myomectomy  Prior precipitous labor  History of prior stillbirth  Nonvertex presentation  Well-controlled diabetes  Genital herpes infection (active or prodromal)  Lupus  SGA with no evidence of placental insufficiency  Coagulation defects  Proteinuric renal disease (isolated)  Advanced cervical dilation  Polyhydramnios  Unstable lie s/p version  Macrosomia  Elective  Repeat LTCS  No indication given  Other (written in on the data collection form)

Other Indications Cholestasis Cholestasis Lupus Lupus Diabetes Diabetes Previous Classical C/S Previous Classical C/S Prior C/S Prior C/S Previa Previa Maternal drug use Maternal drug use HIV HIV