Obstetrical Department, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China (Yi Hu, X Wang, Zhu, Bao, Lu, L Wang, W Wang, Wu, Qi, Y Wang, Li, W Xie, Wu, L Hu, Xia, Lou, D Chen, and Liang); Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA (Yi Hu, Ma, and Liang); Obstetrical Department, Ninghai Maternal and Child Health Hospital, Ninghai, China (B Chen, Guo, and B Xie); Obstetrical Department, The First People's Hospital of Taizhou City, Taizhou, China (X Wang, X Chen, and Yu Han).
Obstetrical Department, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China (Yi Hu, X Wang, Zhu, Bao, Lu, L Wang, W Wang, Wu, Qi, Y Wang, Li, W Xie, Wu, L Hu, Xia, Lou, D Chen, and Liang); Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA (Yi Hu, Ma, and Liang); Obstetrical Department, Ninghai Maternal and Child Health Hospital, Ninghai, China (B Chen, Guo, and B Xie); Obstetrical Department, The First People's Hospital of Taizhou City, Taizhou, China (X Wang, X Chen, and Yu Han).
Am J Obstet Gynecol MFM. 2024 Oct;6(10):101456. doi: 10.1016/j.ajogmf.2024.101456. Epub 2024 Aug 15.
Growing evidence suggests that elective induction of labor at 39 weeks' gestation may lead to more favorable perinatal outcomes than expectant management, however, how to weigh the pros and cons of elective labor induction at 39 weeks, the expectation of spontaneous delivery at 40 or 41 weeks, or delayed labor induction at 40 or 41 weeks on neonatal and maternal outcomes remains a practical challenge in clinical decision-making.
We compared the neonatal and maternal outcomes between elective induction of labor at 39 weeks' gestation and expectant management in a real-world setting. We also divided the expectantly managed group and compared outcomes of the spontaneous delivery at 40 or 41 weeks' gestation group and the induced group at 40 or 41 weeks' gestation with those of the elective induction at 39 weeks' gestation group.
This retrospective cohort study included 21,282 participants who delivered between January 1, 2019, and June 30, 2022. Participants were initially categorized into 3 groups at 39 weeks' gestation, namely elective induction of labor, spontaneous delivery, and expectant management, for the primary analysis in which elective induction was compared with expectant management. Subsequently, the expectant management group at 39 weeks' gestation was divided into 3 groups at 40 weeks, and participants who underwent expectant management at 40 weeks were then divided into 2 groups at 41 weeks' gestation, namely elective induction and spontaneous delivery. In total, 6 groups were compared in the secondary analysis with the elective induction at 39 weeks' gestation group serving as the reference group.
At 39 weeks' gestational age, participants who underwent elective induction of labor had a significantly lower risk for the primary composite outcomes than participants who were managed expectantly (adjusted odds ratio, 0.72; 95% confidence interval, 0.55-0.95), and there was no significant difference in the risk for cesarean delivery between the 2 groups. After further dividing the expectantly managed group and comparing them with participants who underwent elective induction of labor at 39 weeks' gestation, those who underwent spontaneous delivery at 40 weeks' gestation had significantly lower risks for cesarean delivery (0.61; 0.52-0.71) and chorioamnionitis (0.78; 0.61-1.00) but a higher risk for fetal distress (1.39; 1.22-1.57); those with spontaneous delivery at 41 weeks' gestation had a significantly higher risk for fetal distress (1.44; 1.16-1.79), postpartum hemorrhage (1.83; 1.26-2.66), and prolonged or arrested labor (1.61; 1.02-2.54). Moreover, when compared with participants who underwent elective induction of labor at 39 weeks' gestation, participants who were induced later in gestation had significantly higher risks for adverse neonatal and maternal outcomes, especially at 40 weeks' gestation.
Our findings indicate that elective induction of labor at 39 weeks' gestation was significantly associated with lower risks for adverse short-term neonatal and maternal outcomes when compared with expectant management. Moreover, our study highlights the nuanced trade-offs in risks and benefits between elective induction at 39 weeks' gestation and waiting for spontaneous labor or delayed induction at 40 or 41 weeks' gestation, thus providing valuable insights for clinical decision-making in practice.
越来越多的证据表明，在 39 孕周选择性引产可能会带来比期待管理更有利的围产结局，然而，如何权衡 39 孕周选择性引产、40 或 41 孕周期待自然分娩或 40 或 41 孕周延迟引产对新生儿和产妇结局的利弊，在临床决策中仍然是一个实际挑战。
我们比较了在真实环境中 39 孕周选择性引产与期待管理的新生儿和产妇结局。我们还将期待管理组进行了分组，并比较了 40 或 41 孕周自然分娩组和 40 或 41 孕周引产组与 39 孕周选择性引产组的结局。
这是一项回顾性队列研究，纳入了 2019 年 1 月 1 日至 2022 年 6 月 30 日期间分娩的 21282 名参与者。参与者最初在 39 孕周时分为三组，即选择性引产、自然分娩和期待管理，主要分析比较了选择性引产与期待管理。随后，将 39 孕周时的期待管理组分为 40 孕周时的三组，然后将 40 孕周时接受期待管理的参与者分为 41 孕周时的两组，即选择性引产和自然分娩。总共比较了 6 组，以 39 孕周选择性引产组为参照组进行二次分析。
在 39 孕周时，与期待管理组相比，选择性引产组发生主要复合结局的风险显著降低（调整优势比，0.72；95%置信区间，0.55-0.95），两组剖宫产风险无显著差异。进一步将期待管理组分组并与 39 孕周选择性引产组进行比较后发现，40 孕周自然分娩组的剖宫产（0.61；0.52-0.71）和绒毛膜羊膜炎（0.78；0.61-1.00）风险显著降低，但胎儿窘迫（1.39；1.22-1.57）风险较高；41 孕周自然分娩组的胎儿窘迫（1.44；1.16-1.79）、产后出血（1.83；1.26-2.66）和产程延长或停滞（1.61；1.02-2.54）风险显著增加。此外，与 39 孕周选择性引产组相比，孕晚期引产的参与者发生不良新生儿和产妇结局的风险显著增加，尤其是在 40 孕周时。
我们的研究结果表明，与期待管理相比，39 孕周选择性引产与不良短期新生儿和产妇结局的风险显著降低。此外，我们的研究强调了 39 孕周选择性引产与等待自然分娩或延迟至 40 或 41 孕周引产之间的风险和获益之间的细微权衡，从而为临床实践中的决策提供了有价值的见解。
