Decline in stillbirths and perinatal mortality after implementation of a more aggressive induction policy in post-date pregnancies: a nationwide register study.

INTRODUCTION: In 2011 Danish national guidelines were changed towards a more aggressive induction and fetal surveillance policy from (1) induction of labor at gestational age (GA) of 42+0  weeks and (2) no fetal surveillance after 40+0  weeks to (1) induction of labor between 41+2 and 41+6  weeks, (2) earlier induction at 41+0  weeks in the case of maternal age >40 years or body mass index (BMI) >35 kg/m2 and (3) fetal surveillance at GA 41+0  weeks. MATERIAL AND METHODS: This national cohort study included all pregnancies that reached 41+0  weeks of gestation in 2008-2014 (n = 102 167). Multivariate logistic regression analyses were used to estimate risks in the years after (2012-2014) vs. before (2008-2010) new national guidelines, adjusted for maternal age, BMI, and parity. RESULTS: We observed a decline in stillbirths from 0.9‰ to 0.5‰ [odds ratio (OR)adjusted 0.50, 95% CI 0.29-0.89, p = 0.018]. Furthermore, a decline in perinatal deaths from 1.3‰ to 0.8‰ (ORadjusted 0.62, 95% CI 0.39-0.96, p = 0.033) and vacuum extraction (ORadjusted 0.86, 95% CI 0.82-0.90, p = 0.007) was observed. The risk of cesarean section (ORadjusted 0.98, 95% CI 0.94-1.02, p = 0.251), Apgar score below 7 at five minutes (ORadjusted 0.96, 95% CI 0.81-1.14, p = 0.0.678) and admissions to the neonatal department (ORadjusted 1.04, 95% CI 1.00-1.14, p = 0.064) did not change, whereas induction of labor increased from 28.2 to 42.6% (ORadjusted 1.89, 95% CI 1.84-1.95, p < 0.001). CONCLUSIONS: This study showed a decline in stillbirths and perinatal mortality after implementation of new Danish guidelines for post-date pregnancies. The risk of interventions as cesarean section and vacuum extraction remained stable despite an increase in labor inductions.

Pregnancy-associated plasma protein A levels and neonatal complications in post-date pregnancies.

OBJECTIVES: To assess the association between serum pregnancy-associated plasma protein A (PAPP-A) and free ß-human chorionic gonadotropin (free ß-hCG) in the first trimester and perinatal complications in post-date pregnancies. METHODS: A total of 4948 women, who delivered after 40 gestational weeks, were included. Labour was not induced routinely until 42 weeks. Serum levels of PAPP-A and free ß-hCG were determined at the first-trimester screening for Down syndrome. Neonatal complications were obtained from specific registration forms filled out by senior neonatologists. RESULTS: In post-date pregnancies, PAPP-A < 0.4 multiples of the median was associated with Apgar score of less than 7 at 5 min (ORadj 5.4, 95% CI 2.0-14.3), admission to the neonatal intensive care unit (ORadj 1.5, 95% CI 1.0-2.3) and newborn hypoglycaemia (ORadj 3.4, 95% CI 1.8-6.4). In small for gestation (SGA) neonates, the risk of hypoglycaemia was further increased (OR 14.6, 95% CI 3.4-58.0). Similar analyses were made with free ß-hCG, but no statistically significant associations were found. CONCLUSIONS: Low first-trimester serum PAPP-A was associated with increased neonatal morbidity in post-date pregnancies, particularly in newborns with SGA. Thus, PAPP-A may qualify the timing of induction of labour in these pregnancies.