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Preventing Elective Deliveries Before 39 Weeks

Preventing Elective Deliveries Before 39 Weeks. John R. Allbert Charlotte, NC. Elective Delivery. Adverse outcomes are increased if delivery occurs before 39 weeks

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Preventing Elective Deliveries Before 39 Weeks

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

  2. Elective Delivery • 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 8 2009;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

  3. Induction of LaborConfirming Gestational Age • 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 • It has been 36 wks since a positive serum or urine hCG pregnancy test ACOG Practice Bulletin 107, August 2009

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

  5. IUGR • SGA is EFW <10% • 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

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

  7. HypertensionLess Morbidity With Induction • 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 • Lower need for IV antihypertensives and anticonvulsants in the induction group • Lower C/S rate in primagravidas with induction Koopmans CM, Lancet 2009;374:979

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

  9. InductionWhat is the commitment • 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 the induction is not succeeding, consider discharging the patient and restart the induction in 2-4 days

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

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