Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, MedStar Georgetown University Hospital, Washington, DC.
Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, MedStar Washington Hospital Center, Washington, DC.
Am J Obstet Gynecol. 2019 Jan;220(1):100.e1-100.e9. doi: 10.1016/j.ajog.2018.09.027. Epub 2018 Sep 28.
The optimal route of delivery in early-onset preeclampsia before 34 weeks is debated because many clinicians are reluctant to proceed with induction for perceived high risk of failure.
Our objective was to investigate labor induction success rates and compare maternal and neonatal outcomes by intended mode of delivery in women with early preterm preeclampsia.
We identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth, or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n = 460) and planned cesarean delivery (n = 454) and women with successful induction of labor (n = 214) and unsuccessful induction of labor (n = 246). We calculated relative risks and 95% confidence intervals to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birthweight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance, marital status, and steroid use.
Among the 460 women with induction (50%), 47% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7, and 32 to 33 6/7, the induction of labor success rates were 38% (12 of 32), 39% (70 of 180), and 54% (132 of 248), respectively. Induction of labor compared with planned cesarean delivery was less likely to be associated with placental abruption (adjusted relative risk, 0.33; 95% confidence interval, 0.16-0.67), wound infection or separation (adjusted relative risk, 0.23; 95% confidence interval, 0.06-0.85), and neonatal asphyxia (0.12; 95% confidence interval, 0.02-0.78). Women with vaginal delivery compared with those with failed induction of labor had decreased maternal morbidity (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.82) and no difference in neonatal outcomes.
About half of women with preterm preeclampsia who attempted an induction had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high-risk population of women.
在 34 周之前出现的早发性子痫前期的最佳分娩途径存在争议，因为许多临床医生不愿意进行引产，因为他们认为引产的失败风险很高。
我们旨在调查早产子痫前期孕妇引产成功率，并比较不同分娩方式的母婴结局。
我们在“安全分娩联盟”研究中确定了 914 例存在子痫前期的单胎妊娠病例进行分析，这些孕妇的分娩时间在 24 0/7 至 33 6/7 周之间。我们排除了胎儿畸形、产前死胎或自发性早产。比较了行引产（n=460）和计划剖宫产（n=454）、引产成功（n=214）和引产失败（n=246）孕妇的母婴结局。我们使用泊松回归模型和倾向评分调整计算相对风险和 95%置信区间来确定结局。倾向评分的计算考虑了产妇年龄、胎龄、产次、体重指数、吸烟、糖尿病、慢性高血压、医院类型和地点、出生体重、剖宫产史、胎位不正/臀位、简化 Bishop 评分、保险、婚姻状况和类固醇使用等因素。
在 460 例接受引产的孕妇中（50%），47%的分娩方式为阴道分娩。根据胎龄，24-27 6/7、28-31 6/7 和 32-33 6/7 周时，引产成功率分别为 38%（12/32）、39%（70/180）和 54%（132/248）。与计划剖宫产相比，引产不太可能导致胎盘早剥（调整后的相对风险，0.33；95%置信区间，0.16-0.67）、伤口感染或分离（调整后的相对风险，0.23；95%置信区间，0.06-0.85）和新生儿窒息（0.12；95%置信区间，0.02-0.78）。与引产失败的孕妇相比，阴道分娩的孕妇母体发病率降低（调整后的相对风险，0.27；95%置信区间，0.09-0.82），新生儿结局无差异。
约一半尝试引产的早产子痫前期孕妇成功实现了阴道分娩。阴道分娩成功率随胎龄增加而增加。成功的引产可以预防与之前剖宫产相关的母婴并发症，这在后续妊娠中具有重要意义。虽然引产组和计划剖宫产组严重母婴发病率/死亡率的综合发生率没有差异，但引产失败的孕妇母体发病率增加，这突出了在这些高风险孕妇中进行复杂分娩方式咨询的必要性。
