Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients

Alan T.N. Tita; Lindsay Doherty; William A. Grobman; Uma M. Reddy; Robert M. Silver; Gail Mallett; Madeline Murguia Rice; Yasser Y. El-Sayed; Ronald J. Wapner; Dwight J. Rouse; George R. Saade; John M. Thorp; Suneet P. Chauhan; Maged M. Costantine; Edward K. Chien; Brian M. Casey; Sindhu K. Srinivas; Geeta K. Swamy; Hyagriv N. Simhan; George A. Macones

doi:10.1097/AOG.0000000000004230

Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients

Alan T.N. Tita^*, Lindsay Doherty, William A. Grobman, Uma M. Reddy, Robert M. Silver, Gail Mallett, Madeline Murguia Rice, Yasser Y. El-Sayed, Ronald J. Wapner, Dwight J. Rouse, George R. Saade, John M. Thorp, Suneet P. Chauhan, Maged M. Costantine, Edward K. Chien, Brian M. Casey, Sindhu K. Srinivas, Geeta K. Swamy, Hyagriv N. Simhan, George A. Macones

^*Corresponding author for this work

Obstetrics and Gynecology

Research output: Contribution to journal › Article › peer-review

13 Scopus citations

Abstract

OBJECTIVE:To compare risks of maternal and perinatal outcomes by completed week of gestation from 39 weeks in low-risk nulliparous patients undergoing expectant management.METHODS:We conducted a secondary analysis of a multicenter randomized trial of elective induction of labor at 39 weeks of gestation compared with expectant management in low-risk nulliparous patients. Participants with nonanomalous neonates, who were randomized to and underwent expectant management and attained 39 0/7 weeks of gestation, were included. Delivery gestation was categorized by completed week: 39 0/7-39 6/7 (39 weeks), 40 0/7-40 6/7 (40 weeks), and 41 0/7-42 2/7 (41-42 weeks) (none delivered after 42 2/7). The coprimary outcomes were cesarean delivery and a perinatal composite (death, respiratory support, 5-minute Apgar score 3 or less, hypoxic ischemic encephalopathy, seizure, sepsis, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension requiring vasopressor support). Other outcomes included a maternal composite (blood transfusion, surgical intervention for postpartum hemorrhage, or intensive care unit admission), hypertensive disorders of pregnancy, peripartum infection, and neonatal intermediate or intensive care unit admission. For multivariable analysis, P<.0125 was considered to indicate statistical significance for the coprimary outcomes.RESULTS:Of 2,502 participants who underwent expectant management, 964 (38.5%) delivered at 39 weeks of gestation, 1,111 (44.4%) at 40 weeks, and 427 (17.1%) at 41-42 weeks. The prevalence of medically indicated delivery was 37.9% overall and increased from 23.8% at 39 weeks of gestation to 80.3% at 41-42 weeks. The frequency of cesarean delivery (17.3%, 22.0%, 37.5%; P<.001) and the perinatal composite (5.1%, 5.9%, 8.2%; P=.03) increased with 39, 40, and 41-42 weeks of gestation, respectively, and hypertensive disorders of pregnancy decreased (16.4%, 12.1%, 10.8%, P=.001). The adjusted relative risk, 95% CI (39 weeks as referent) was significant for cesarean delivery at 41-42 weeks of gestation (1.93, 1.61-2.32) and for hypertensive disorders of pregnancy at 40 weeks (0.71, 0.58-0.88) and 41-42 weeks (0.61, 0.45-0.82). None of the other outcomes were significant.CONCLUSION:In expectantly managed low-risk nulliparous participants, the frequency of medically indicated induction of labor, and the risks of cesarean delivery but not the perinatal composite outcome, increased significantly from 39 to 42 weeks of gestation.

Original language	English (US)
Pages (from-to)	250-257
Number of pages	8
Journal	Obstetrics and gynecology
Volume	137
Issue number	2
DOIs	https://doi.org/10.1097/AOG.0000000000004230
State	Published - Feb 1 2021

Funding

Financial Disclosure Robert M. Silver disclosed that he is a consultant for Gestvision. Alan T.N. Tita, Edward K. Chien and Hyagriv N. Simhan disclosed that money was paid to his institution for industry research studies for clinical trials. Hyagriv N. Simhan disclosed that he is a cofounder of Naima Health, LLC. Geeta K. Swamy disclosed receiving funding from GlaxoSmithKline and Pfizer. George Saade disclosed that he is a consultant for Medicem. The other authors did not report any potential conflicts of interest. Supported by grants (HD40512, HD36801, HD27869, HD34208, HD68268, HD40485, HD40500, HD53097, HD40560, HD40545, HD27915, HD40544, HD34116, HD68282, HD87192, HD68258, HD87230) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Center for Advancing Translational Sciences (UL1TR001873). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ASJC Scopus subject areas

Obstetrics and Gynecology

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10.1097/AOG.0000000000004230

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Tita, A. T. N., Doherty, L., Grobman, W. A., Reddy, U. M., Silver, R. M., Mallett, G., Rice, M. M., El-Sayed, Y. Y., Wapner, R. J., Rouse, D. J., Saade, G. R., Thorp, J. M., Chauhan, S. P., Costantine, M. M., Chien, E. K., Casey, B. M., Srinivas, S. K., Swamy, G. K., Simhan, H. N., & Macones, G. A. (2021). Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients. Obstetrics and gynecology, 137(2), 250-257. https://doi.org/10.1097/AOG.0000000000004230

@article{80f96a18849442f7b5ffdfcc3b4d9170,

title = "Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients",

abstract = "OBJECTIVE:To compare risks of maternal and perinatal outcomes by completed week of gestation from 39 weeks in low-risk nulliparous patients undergoing expectant management.METHODS:We conducted a secondary analysis of a multicenter randomized trial of elective induction of labor at 39 weeks of gestation compared with expectant management in low-risk nulliparous patients. Participants with nonanomalous neonates, who were randomized to and underwent expectant management and attained 39 0/7 weeks of gestation, were included. Delivery gestation was categorized by completed week: 39 0/7-39 6/7 (39 weeks), 40 0/7-40 6/7 (40 weeks), and 41 0/7-42 2/7 (41-42 weeks) (none delivered after 42 2/7). The coprimary outcomes were cesarean delivery and a perinatal composite (death, respiratory support, 5-minute Apgar score 3 or less, hypoxic ischemic encephalopathy, seizure, sepsis, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension requiring vasopressor support). Other outcomes included a maternal composite (blood transfusion, surgical intervention for postpartum hemorrhage, or intensive care unit admission), hypertensive disorders of pregnancy, peripartum infection, and neonatal intermediate or intensive care unit admission. For multivariable analysis, P<.0125 was considered to indicate statistical significance for the coprimary outcomes.RESULTS:Of 2,502 participants who underwent expectant management, 964 (38.5%) delivered at 39 weeks of gestation, 1,111 (44.4%) at 40 weeks, and 427 (17.1%) at 41-42 weeks. The prevalence of medically indicated delivery was 37.9% overall and increased from 23.8% at 39 weeks of gestation to 80.3% at 41-42 weeks. The frequency of cesarean delivery (17.3%, 22.0%, 37.5%; P<.001) and the perinatal composite (5.1%, 5.9%, 8.2%; P=.03) increased with 39, 40, and 41-42 weeks of gestation, respectively, and hypertensive disorders of pregnancy decreased (16.4%, 12.1%, 10.8%, P=.001). The adjusted relative risk, 95% CI (39 weeks as referent) was significant for cesarean delivery at 41-42 weeks of gestation (1.93, 1.61-2.32) and for hypertensive disorders of pregnancy at 40 weeks (0.71, 0.58-0.88) and 41-42 weeks (0.61, 0.45-0.82). None of the other outcomes were significant.CONCLUSION:In expectantly managed low-risk nulliparous participants, the frequency of medically indicated induction of labor, and the risks of cesarean delivery but not the perinatal composite outcome, increased significantly from 39 to 42 weeks of gestation.",

author = "Tita, {Alan T.N.} and Lindsay Doherty and Grobman, {William A.} and Reddy, {Uma M.} and Silver, {Robert M.} and Gail Mallett and Rice, {Madeline Murguia} and El-Sayed, {Yasser Y.} and Wapner, {Ronald J.} and Rouse, {Dwight J.} and Saade, {George R.} and Thorp, {John M.} and Chauhan, {Suneet P.} and Costantine, {Maged M.} and Chien, {Edward K.} and Casey, {Brian M.} and Srinivas, {Sindhu K.} and Swamy, {Geeta K.} and Simhan, {Hyagriv N.} and Macones, {George A.}",

note = "Funding Information: Financial Disclosure Robert M. Silver disclosed that he is a consultant for Gestvision. Alan T.N. Tita, Edward K. Chien and Hyagriv N. Simhan disclosed that money was paid to his institution for industry research studies for clinical trials. Hyagriv N. Simhan disclosed that he is a cofounder of Naima Health, LLC. Geeta K. Swamy disclosed receiving funding from GlaxoSmithKline and Pfizer. George Saade disclosed that he is a consultant for Medicem. The other authors did not report any potential conflicts of interest. Funding Information: Supported by grants (HD40512, HD36801, HD27869, HD34208, HD68268, HD40485, HD40500, HD53097, HD40560, HD40545, HD27915, HD40544, HD34116, HD68282, HD87192, HD68258, HD87230) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Center for Advancing Translational Sciences (UL1TR001873). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Publisher Copyright: {\textcopyright} 2021 Lippincott Williams and Wilkins. All rights reserved.",

year = "2021",

month = feb,

day = "1",

doi = "10.1097/AOG.0000000000004230",

language = "English (US)",

volume = "137",

pages = "250--257",

journal = "Obstetrics and gynecology",

issn = "0029-7844",

publisher = "Lippincott Williams and Wilkins",

number = "2",

}

Tita, ATN, Doherty, L, Grobman, WA, Reddy, UM, Silver, RM, Mallett, G, Rice, MM, El-Sayed, YY, Wapner, RJ, Rouse, DJ, Saade, GR, Thorp, JM, Chauhan, SP, Costantine, MM, Chien, EK, Casey, BM, Srinivas, SK, Swamy, GK, Simhan, HN & Macones, GA 2021, 'Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients', Obstetrics and gynecology, vol. 137, no. 2, pp. 250-257. https://doi.org/10.1097/AOG.0000000000004230

TY - JOUR

T1 - Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients

AU - Tita, Alan T.N.

AU - Doherty, Lindsay

AU - Grobman, William A.

AU - Reddy, Uma M.

AU - Silver, Robert M.

AU - Mallett, Gail

AU - Rice, Madeline Murguia

AU - El-Sayed, Yasser Y.

AU - Wapner, Ronald J.

AU - Rouse, Dwight J.

AU - Saade, George R.

AU - Thorp, John M.

AU - Chauhan, Suneet P.

AU - Costantine, Maged M.

AU - Chien, Edward K.

AU - Casey, Brian M.

AU - Srinivas, Sindhu K.

AU - Swamy, Geeta K.

AU - Simhan, Hyagriv N.

AU - Macones, George A.

N1 - Funding Information: Financial Disclosure Robert M. Silver disclosed that he is a consultant for Gestvision. Alan T.N. Tita, Edward K. Chien and Hyagriv N. Simhan disclosed that money was paid to his institution for industry research studies for clinical trials. Hyagriv N. Simhan disclosed that he is a cofounder of Naima Health, LLC. Geeta K. Swamy disclosed receiving funding from GlaxoSmithKline and Pfizer. George Saade disclosed that he is a consultant for Medicem. The other authors did not report any potential conflicts of interest. Funding Information: Supported by grants (HD40512, HD36801, HD27869, HD34208, HD68268, HD40485, HD40500, HD53097, HD40560, HD40545, HD27915, HD40544, HD34116, HD68282, HD87192, HD68258, HD87230) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Center for Advancing Translational Sciences (UL1TR001873). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Publisher Copyright: © 2021 Lippincott Williams and Wilkins. All rights reserved.

PY - 2021/2/1

Y1 - 2021/2/1

N2 - OBJECTIVE:To compare risks of maternal and perinatal outcomes by completed week of gestation from 39 weeks in low-risk nulliparous patients undergoing expectant management.METHODS:We conducted a secondary analysis of a multicenter randomized trial of elective induction of labor at 39 weeks of gestation compared with expectant management in low-risk nulliparous patients. Participants with nonanomalous neonates, who were randomized to and underwent expectant management and attained 39 0/7 weeks of gestation, were included. Delivery gestation was categorized by completed week: 39 0/7-39 6/7 (39 weeks), 40 0/7-40 6/7 (40 weeks), and 41 0/7-42 2/7 (41-42 weeks) (none delivered after 42 2/7). The coprimary outcomes were cesarean delivery and a perinatal composite (death, respiratory support, 5-minute Apgar score 3 or less, hypoxic ischemic encephalopathy, seizure, sepsis, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension requiring vasopressor support). Other outcomes included a maternal composite (blood transfusion, surgical intervention for postpartum hemorrhage, or intensive care unit admission), hypertensive disorders of pregnancy, peripartum infection, and neonatal intermediate or intensive care unit admission. For multivariable analysis, P<.0125 was considered to indicate statistical significance for the coprimary outcomes.RESULTS:Of 2,502 participants who underwent expectant management, 964 (38.5%) delivered at 39 weeks of gestation, 1,111 (44.4%) at 40 weeks, and 427 (17.1%) at 41-42 weeks. The prevalence of medically indicated delivery was 37.9% overall and increased from 23.8% at 39 weeks of gestation to 80.3% at 41-42 weeks. The frequency of cesarean delivery (17.3%, 22.0%, 37.5%; P<.001) and the perinatal composite (5.1%, 5.9%, 8.2%; P=.03) increased with 39, 40, and 41-42 weeks of gestation, respectively, and hypertensive disorders of pregnancy decreased (16.4%, 12.1%, 10.8%, P=.001). The adjusted relative risk, 95% CI (39 weeks as referent) was significant for cesarean delivery at 41-42 weeks of gestation (1.93, 1.61-2.32) and for hypertensive disorders of pregnancy at 40 weeks (0.71, 0.58-0.88) and 41-42 weeks (0.61, 0.45-0.82). None of the other outcomes were significant.CONCLUSION:In expectantly managed low-risk nulliparous participants, the frequency of medically indicated induction of labor, and the risks of cesarean delivery but not the perinatal composite outcome, increased significantly from 39 to 42 weeks of gestation.

AB - OBJECTIVE:To compare risks of maternal and perinatal outcomes by completed week of gestation from 39 weeks in low-risk nulliparous patients undergoing expectant management.METHODS:We conducted a secondary analysis of a multicenter randomized trial of elective induction of labor at 39 weeks of gestation compared with expectant management in low-risk nulliparous patients. Participants with nonanomalous neonates, who were randomized to and underwent expectant management and attained 39 0/7 weeks of gestation, were included. Delivery gestation was categorized by completed week: 39 0/7-39 6/7 (39 weeks), 40 0/7-40 6/7 (40 weeks), and 41 0/7-42 2/7 (41-42 weeks) (none delivered after 42 2/7). The coprimary outcomes were cesarean delivery and a perinatal composite (death, respiratory support, 5-minute Apgar score 3 or less, hypoxic ischemic encephalopathy, seizure, sepsis, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension requiring vasopressor support). Other outcomes included a maternal composite (blood transfusion, surgical intervention for postpartum hemorrhage, or intensive care unit admission), hypertensive disorders of pregnancy, peripartum infection, and neonatal intermediate or intensive care unit admission. For multivariable analysis, P<.0125 was considered to indicate statistical significance for the coprimary outcomes.RESULTS:Of 2,502 participants who underwent expectant management, 964 (38.5%) delivered at 39 weeks of gestation, 1,111 (44.4%) at 40 weeks, and 427 (17.1%) at 41-42 weeks. The prevalence of medically indicated delivery was 37.9% overall and increased from 23.8% at 39 weeks of gestation to 80.3% at 41-42 weeks. The frequency of cesarean delivery (17.3%, 22.0%, 37.5%; P<.001) and the perinatal composite (5.1%, 5.9%, 8.2%; P=.03) increased with 39, 40, and 41-42 weeks of gestation, respectively, and hypertensive disorders of pregnancy decreased (16.4%, 12.1%, 10.8%, P=.001). The adjusted relative risk, 95% CI (39 weeks as referent) was significant for cesarean delivery at 41-42 weeks of gestation (1.93, 1.61-2.32) and for hypertensive disorders of pregnancy at 40 weeks (0.71, 0.58-0.88) and 41-42 weeks (0.61, 0.45-0.82). None of the other outcomes were significant.CONCLUSION:In expectantly managed low-risk nulliparous participants, the frequency of medically indicated induction of labor, and the risks of cesarean delivery but not the perinatal composite outcome, increased significantly from 39 to 42 weeks of gestation.

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UR - http://www.scopus.com/inward/citedby.url?scp=85100224880&partnerID=8YFLogxK

U2 - 10.1097/AOG.0000000000004230

DO - 10.1097/AOG.0000000000004230

M3 - Article

C2 - 33416294

AN - SCOPUS:85100224880

SN - 0029-7844

VL - 137

SP - 250

EP - 257

JO - Obstetrics and gynecology

JF - Obstetrics and gynecology

IS - 2

ER -

Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients

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