Maternal and perinatal outcomes of extreme obesity in pregnancy.

OBJECTIVE: To evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m2) in pregnancy on maternal and perinatal outcomes. METHODS: We conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m2). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: A total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs. 4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs. 1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs. 1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs. 25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs. 4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs. 2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs. 2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs. 7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs. 0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs. 41.5%) (aOR 1.57; 95% CI 1.35 to 1.83). CONCLUSION: Women with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.

Objectif : Évaluer les effets de l'obésité extrême (IMC prégrossesse ≥ 50,0 kg/m2) pendant la grossesse sur les issues maternelles et périnatales. Méthodes : Nous avons mené une étude de cohorte en population générale au moyen de la Newfoundland and Labrador Perinatal Database en vue de comparer les issues obstétricales des femmes présentant une obésité extrême à celles des femmes dont l'IMC est normal (IMC prégrossesse allant de 18,50 à 24,99 kg/m2). Nous avons inclus les femmes qui connaissaient une grossesse monofœtale et qui ont accouché entre le 1er janvier 2002 et le 31 décembre 2011. Parmi les issues maternelles d'intérêt, on trouvait l'hypertension gestationnelle, le diabète gestationnel, la césarienne, la dystocie de l'épaule, la durée de l'hospitalisation, l'admission à l'unité maternelle de soins intensifs, l'hémorragie postpartum et la mort. Parmi les issues périnatales, on trouvait le poids de naissance, l'accouchement préterme, l'indice d'Apgar, les anomalies métaboliques néonatales, l'admission à l'UNSI, la mortinaissance et le décès néonatal. Une issue composite en matière de morbidité a été élaborée; on y retrouve au moins un des facteurs suivants : césarienne, hypertension gestationnelle, poids de naissance ≥ 4 000 g, poids de naissance < 2 500 g ou admission à l'UNSI. Des analyses univariées et des analyses de régression logistique multivariée (neutralisant l'effet de l'âge maternel, de la parité, du tabagisme, de l'état quant à la présence ou non d'un partenaire et de l'âge gestationnel) ont été menées, et des rapports de cotes corrigés (RCc) et des intervalles de confiance à 95 % ont été calculés. Résultats : Au total, 5 788 femmes ont été incluses à l'étude : 71 présentant une obésité extrême et 5 717 présentant un IMC normal. Les femmes extrêmement obèses étaient plus susceptibles de connaître ce qui suit : hypertension gestationnelle (19,7 % vs 4,8 %) (RCc 1,56; IC à 95 %, 1,33 - 1,82), diabète gestationnel (21,1 % vs 1,5 %) (RCc 2,04; IC à 95 %, 1,74 - 2,38), dystocie de l'épaule (7,1 % vs 1,4 %) (RCc 1,51; IC à 95 %, 1,05 - 2,19), césarienne (60,6 % vs 25,0 %) (RCc 1,46; IC à 95 %, 1,29 - 1,65), hospitalisation de plus de cinq jours (cas de césarienne exclus) (14,3 % vs 4,7 %) (RCc 1,42; IC à 95 %, 1,07 - 1,89), poids de naissance ≥ 4 000 g (38,0 % vs 11,9 %) (RCc 1,58; IC à 95 %, 1,38 - 1,80), poids de naissance ≥ 4 500 g (16,9 % vs 2,1 %) (RCc 1,87; IC à 95 %, 1,57 - 2,23), anomalie métabolique néonatale (8,5 % vs 2,0 %) (RCc 1,50; IC à 95 %, 1,20 - 1,86), admission à l'UNSI (16,9 % vs 7,8 %) (RCc 1,28; IC à 95 %, 1,07 - 1,52), mortinaissance (1,4 % vs 0,2 %) (RCc 1,68; IC à 95 %, 1,00 - 2,82) et issue indésirable composite (81,7 % vs 41,5 %) (RCc 1,57; IC à 95 %, 1,35 - 1,83). Conclusion : Les femmes qui présentent une obésité extrême sont exposées à des risques accrus de connaître une variété d'issues indésirables maternelles et périnatales. Puisque, au sein de notre population, environ six parturientes sur 1 000 présentent une obésité extrême, il est important de traiter de ces risques avant la conception et d'inciter les patientes à obtenir un IMC plus santé avant de devenir enceintes.

The effect of gestational weight gain by body mass index on maternal and neonatal outcomes.

OBJECTIVE: To evaluate the effects of gestational weight gain on maternal and neonatal outcomes in different body mass index (BMI) classes. METHODS: We compared maternal and neonatal outcomes based on gestational weight gain in underweight, normal weight, overweight, obese, and morbidly obese (BMI>or=40.00) women. The study group was a population-based cohort of women with singleton gestations who delivered between April 1, 2001, and March 31, 2007, drawn from the Newfoundland and Labrador Provincial Perinatal Program Database. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking status, partnered status, and gestational age) were performed and odds ratios (ORs) were calculated. RESULTS: Only 30.6% of women gained the recommended amount of weight during pregnancy; 52.3% of women gained more than recommended, and 17.1% gained less than recommended. In women with normal pre-pregnancy BMI, excess weight gain was associated with increased rates of gestational hypertension (OR 1.27; 95% CI 1.08-1.49), augmentation of labour (OR 1.09; 95% CI 1.01-1.18), and birth weight>or=4000 g (OR 1.21; 95% CI 1.10-1.34). In overweight women, excess weight gain was associated with increased rates of gestational hypertension (OR 1.31; 95% CI 1.10-1.55) and birth weight>or=4000 g (OR 1.30; 95% CI 1.15-1.47). In women who were obese or morbidly obese, excess weight gain was associated with increased rates of birth weight>or=4000 g (OR 1.20; 95% CI 1.07-1.34) and neonatal metabolic abnormality (OR 1.31; 95% CI 1.00-1.70). In morbidly obese women, poor weight gain was associated with less use of epidural analgesia (OR 0.34; 95% CI 0.12-0.95). In women who were of normal weight, overweight, or obese, the rate of adverse outcome (Caesarean section, gestational hypertension, birth weight<2500 g or birth weight>or=4000 g) was lower in women with recommended weight gain than in those with excess weight gain. Adverse outcomes were reduced in nulliparous morbidly obese women who had poor weight gain (OR 0.18; 95% CI 0.04-0.83). CONCLUSION: The effects of gestational weight gain on pregnancy outcome depend on the woman's pre-pregnancy BMI. Pregnancy weight gains of 6.7-11.2 kg (15-25 lb) in overweight and obese women, and less than 6.7 kg (15 lb) in morbidly obese women are associated with a reduction in the risk of adverse outcome.

Randomized trial of oral misoprostol before endometrial biopsy.

OBJECTIVE: To determine if the use of oral misoprostol in women undergoing endometrial biopsy reduces procedural discomfort. METHODS: Women undergoing endometrial biopsy were randomized to receive either 400 microg misoprostol or a vitamin B6 placebo orally 12 hours prior to the procedure, and were stratified based on menopausal status. The primary outcome was procedural discomfort on a visual analogue scale (0-10). Secondary outcomes included the need to dilate the cervix or use a tenaculum, and side effects. Subgroup analyses were planned for premenopausal and postmenopausal women separately. Sample size calculation was based on detecting a 50% reduction in pain, with alpha = 0.05 and beta = 0.10, in the premenopausal group. RESULTS: A total of 72 women (49 premenopausal and 23 postmenopausal) were enrolled; 35 received misoprostol (23 premenopausal and 12 postmenopausal) and 37 received placebo (26 premenopausal and 11 postmenopausal). There were no significant differences in procedural discomfort (misoprostol vs. placebo 5.8 +/- 2.9 vs. 5.5 +/- 3.2, P = 0.77; premenopausal women 4.9 +/- 3.3 vs. 5.1 +/- 3.1, P = 0.85; postmenopausal women 7.1 +/- 1.9 vs. 7.1 +/- 2.3, P = 0.99), need to dilate the cervix (6.1% vs. 5.6%, P = 0.93) or use a tenaculum (44.1% vs. 48.6%, P = 0.70). Significantly more women in the misoprostol group experienced nausea (31.4% vs. 2.7%, P = 0.001), diarrhea (20.0% vs. 2.7%, P = 0.02), abdominal pain (22.9% vs. 5.4%, P = 0.03), menstrual-like cramping (42.9% vs. 2.7%, P < 0.001) and vaginal bleeding (11.4% vs. 0%, P = 0.03). CONCLUSION: The use of 400 microg oral misoprostol 12 hours prior to endometrial biopsy did not reduce procedural discomfort and was associated with more side effects than use of placebo. This finding was noted in all women as well as among subgroups of premenopausal and postmenopausal women.

A randomized trial of oral misoprostol in premenopausal women before hysteroscopy.

OBJECTIVE: To determine if the use of oral misoprostol in premenopausal women undergoing diagnostic hysteroscopy produces a clinically important difference in pre-procedural cervical dilatation. METHODS: At a tertiary care hospital, premenopausal women undergoing diagnostic hysteroscopy were randomized to receive either 400 microg of misoprostol or a vitamin B6 placebo orally 12 hours before the procedure. Patients were stratified on the basis of parity. The primary outcome was the pre-procedural dilatation of the cervix. Secondary outcomes included the need to further dilate the cervix, the time required to further dilate the cervix, and side effects. RESULTS: Sixty-four women (11 nulliparous and 53 parous) undergoing diagnostic hysteroscopy consented to participate in the study. Thirty-three women received misoprostol and 31 received placebo. Baseline demographics showed no difference in age and parity between the two groups. There were no significant differences in pre-procedural dilatation (5.0 mm vs. 4.7 mm, P = 0.52), need to further dilate the cervix (56.7% vs. 63.0%, P = 0.63), and time required to further dilate the cervix (12.7 seconds vs. 25.7 seconds, P = 0.27). Significantly more women in the misoprostol group experienced menstrual-like cramping (24.2% vs. 3.3%, P = 0.03) and vaginal spotting (21.2% vs. 3.3%, P = 0.05). CONCLUSION: In premenopausal women, there is no improvement in pre-procedural cervical dilatation with administration of oral misoprostol 12 hours before diagnostic hysteroscopy. Further research is required in both nulliparous and parous premenopausal women to determine whether oral misoprostol improves cervical dilatation and, if so, the ideal dose, route and timing.

Rectal misoprostol versus oxytocin in the management of the third stage of labour.

OBJECTIVE: To compare the effect of rectal misoprostol with intramuscular oxytocin in the routine management of the third stage in a rural developing country. METHODS: A randomized controlled trial was performed at two district hospitals in Ghana, West Africa. Four hundred fifty women in advanced labour were enrolled. The only exclusion criterion was a known medical contraindication to prostaglandin administration. Women were randomized to receive rectal misoprostol 800 microg or intramuscular oxytocin 10 IU with delivery of the anterior shoulder. The main outcome measure was change in hemoglobin concentration from before to after delivery. Secondary outcomes included the need for additional uterotonics, estimated blood loss, transfusion, and medication side effects. RESULTS: Demographic characteristics were similar in each treatment group. There was no significant difference between treatment groups in change in hemoglobin (misoprostol 1.19 g/dL and oxytocin 1.16 g/dL; relative difference 2.6%; 95% confidence intervals [CI]-16.8% to 19.4%; P = 0.80). The only significant secondary outcome was shivering, which was more common in the misoprostol group (misoprostol 7.5% vs. oxytocin 0.9%; relative risk 8.0; 95% CI 1.86-34.36; P = 0.001). CONCLUSION: Rectal misoprostol 800 microg is as effective as 10 IU intramuscular oxytocin in minimizing blood loss in the third stage of labour. Rectal misoprostol has a lower incidence of side effects than the equivalent oral dose. This confirms the utility of misoprostol as a safe and effective uterotonic for use in the rural and remote areas of developing nations where other pharmacologic agents may be less feasible.

Transvaginal ultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia.

OBJECTIVE: To estimate whether cervical length measured by transvaginal ultrasonography in women having had loop electrosurgical excision procedure (LEEP), cold knife conization, or cryotherapy predicts spontaneous preterm birth. METHODS: Women with a history of LEEP, cold knife conization, or cryotherapy and who were subsequently pregnant with singleton gestations were prospectively compared with both a low-risk control group and women with previous spontaneous preterm birth. A transvaginal ultrasonogram measuring cervical length was performed at 24 to 30 weeks of gestation. Primary outcomes included cervical length and spontaneous preterm birth less than 37 weeks. Secondary outcomes were spontaneous preterm birth less than 34 weeks, low birth weight, and maternal and neonatal outcomes. RESULTS: Women with previous LEEP (N = 75), cold knife conization (N = 21), and cryotherapy (N = 36) had shorter cervical lengths (3.54, 3.69, and 3.75 cm respectively) than the low-risk control group (N = 81, 4.21 cm) (P < .001, P = .03, P = .02 respectively) and similar lengths to women with a previous spontaneous preterm birth (N = 63, 3.78 cm). Loop electrosurgical excision procedure and cold knife conization, but not cryotherapy, were associated with spontaneous preterm birth less than 37 weeks (odds ratio 3.45, 95% confidence interval 1.28-10.00, P = .02; and odds ratio 2.63, 95% confidence interval 1.28-5.56, P = .009, respectively). Using a cutoff of 3.0 cm, transvaginal ultrasonography had a positive predictive value of 53.8% and negative predictive value of 95.2% for spontaneous preterm birth less than 37 weeks in women with LEEP. CONCLUSION: Women with a history of LEEP, cold knife conization, and cryotherapy all independently have shorter cervical lengths than low-risk controls and similar lengths to women with previous spontaneous preterm birth. Loop electrosurgical excision procedure and cold knife conization are associated with spontaneous preterm birth less than 37 weeks, and transvaginal ultrasonography predicts preterm birth in women who have had LEEP. LEVEL OF EVIDENCE: II-2.

Oral misoprostol versus oxytocin in the management of the third stage of labour.

OBJECTIVE: To compare the effects of oral misoprostol 800 mug with intramuscular oxytocin 10 IU in routine management of the third stage of labour. METHODS: This randomized controlled trial was performed in a rural district hospital in Ghana, West Africa, and enrolled women in labour with anticipated vaginal delivery and no known medical contraindication to prostaglandin administration. Women were randomized to receive oral misoprostol 800 mug or intramuscular oxytocin 10 IU. Blood samples were taken to determine hemoglobin concentration before delivery and at 12 hours post partum. Treatment was administered at delivery of the anterior shoulder. The primary outcome was the change in hemoglobin concentration from before to after delivery. Secondary outcomes included other measures of blood loss and presumed medication side effects. RESULTS: In total, 450 women were enrolled in the study. Their baseline characteristics were similar. There was no significant difference between the groups in the change in hemoglobin concentration (misoprostol 1.07 g/dL and oxytocin 1.00 g/dL). The only significant secondary outcomes were shivering (80.7% with misoprostol vs. 3.6% with oxytocin) and pyrexia (11.4% with misoprostol, none with oxytocin). CONCLUSION: Routine use of oral misoprostol 800 microg appears to be as effective as 10 IU parenteral oxytocin in minimizing blood loss during the third stage of labour, as determined by change in hemoglobin concentration. Misoprostol appears to be a safe, inexpensive, and effective uterotonic for use in rural and remote areas, where intravenous oxytocin may be unavailable.

Cervical assessment in women with hysteroscopic uterine septum resection: a retrospective cohort study.

OBJECTIVE: To estimate whether cervical length measured by transvaginal ultrasonography in women with a history of hysteroscopic uterine septum resection predicts spontaneous preterm birth <35 weeks' gestation. METHODS: This retrospective cohort study compared women who had undergone hysteroscopic metroplasty, and were subsequently pregnant with singleton gestations delivered January 2003 to December 2012, to a low-risk control group. Transvaginal ultrasonographic cervical lengths were measured 16-30 weeks' gestation. The primary outcome was spontaneous preterm birth <35 weeks' gestation and the primary exposure variable of interest was cervical length. RESULTS: Women with a uterine septum resected (N = 24) had a shorter cervical length (2.90 cm) than the low-risk control group (N = 141, 4.31 cm, p < 0.0001); and were more likely to have a cervical length <3.0 cm (41.7% versus 1.4%, p < 0.0001), <2.5 cm (33.3% versus 0%, p < 0.0001), <2.0 cm (16.7% versus 0%, p < 0.0001) and <1.5 cm (12.5% versus 0%, p = 0.003). Women with septum resected were more likely to receive corticosteroids (33.3% versus 11.3%, p = 0.010), but were not more likely to have a spontaneous preterm birth <35 weeks (4.2% versus 0.7%, p = 0.27). There were no differences noted in secondary outcomes including neonatal morbidity. CONCLUSION: Pregnant women with a history of a hysteroscopic uterine septum resection have shorter cervical lengths than low-risk controls but may not be at a higher risk of spontaneous preterm birth <35 weeks' gestation. Further research with a larger sample size is needed to evaluate this group of women to determine if transvaginal ultrasonographic cervical length assessment is of benefit.

The maternal benefits of corticosteroids with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome.

OBJECTIVES: To determine the more effective regime in improving hematologic abnormalities associated with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, by comparing two different antenatal dosing protocols for dexamethasone (given primarily for fetal lung maturity). STUDY DESIGN: A retrospective cohort study of 30 women between 24 and 34 weeks' gestation, diagnosed with HELLP syndrome prior to delivery, who received 2 doses of dexa-methasone 12 mg intramuscularly, given either 24 hours apart or 12 hours apart. RESULTS: There was a shorter time from the first corticosteroid dose to the beginning of improvement with the 12-hour regime for platelet count (11 hours [9, 25 hours] versus 69 hours [41, 112 hours], median [quartiles], P = 0.003) and for alkaline phosphatase (25 hours [5, 44 hours] versus 59 hours [31, 69 hours], median [quartiles], P = 0.02). Worsening recurred from 11 hours, for alanine aminotransferase (ALT) and aspartate transaminase (AST), to 32 hours, for uric acid, after initial improvement. Hematologic improvement occurred in 37% (for ALT) to 67% (for alkaline phosphatase) of women overall. CONCLUSION: A temporary improvement in the hematologic parameters of HELLP syndrome can occur with antenatal dexa-methasone administration, with the 12-hour regime having quicker onset to improvement in platelet count and alkaline phosphatase.

Maternal serum screening: practice patterns of physicians in Newfoundland.

OBJECTIVE: To compare the utilization of the second trimester maternal serum screen (MSS) of a-fetoprotein, human chorionic gonadotrophin, and unconjugated estriol, in Newfoundland, by practice location, training, and gender. METHODS: Four hundred eighteen anonymous self-reported questionnaires were mailed out to all practising family physicians, general practitioners, and obstetricians in Newfoundland, who were identified through the provincial medical board. The survey included questions on demographic characteristics, provision of antenatal care, gestational age at which MSS is ordered, reasons for offering or not offering MSS, and the use of routine antenatal ultrasound. Categorical data were analyzed using chi-square and Fisher exact tests, as appropriate. RESULTS: Overall, 63% of physicians responded to the survey. Forty percent of respondents had an urban practice. Female physicians, regardless of specialty, were more likely to offer MSS to their patients (89% vs. 78%; P = 0.04), whereas family physicians and obstetricians were more likely to offer screening than general practitioners (85% vs. 83% vs. 25%; P = 0.02). Among physicians offering MSS, 54% offered it only to women 35 years and older. Practice location did not affect whether a woman was offered MSS (P = 0.41). Twenty-five percent of family physicians offering MSS did not offer it at the appropriate gestational age of 15 to 20 weeks. Ninety-four percent of pregnant women were routinely offered an ultrasound during pregnancy. CONCLUSION: The utilization of MSS in Newfoundland is affected by physician training and gender, but not by practice location. Further education of physicians is required to ensure appropriate use and timing of this screening test.

Transvaginal ultrasonography to predict preterm birth in women with bicornuate or didelphus uterus.

OBJECTIVE: To estimate whether cervical length measured by transvaginal ultrasonography (TVUS) in women with uterine anomalies predicts spontaneous preterm birth (SPTB). METHODS: This retrospective cohort study compared women with a uterine anomaly who were pregnant with singleton gestations and delivered August 2000 to April 2008 to a low risk control group. Transvaginal ultrasonographic cervical lengths were measured 16-30 weeks gestation. Primary outcome was cervical length and SPTB less than 35 weeks and the primary exposure variable of interest was cervical length. Secondary outcomes were SPTB less than 37 weeks, less than 32 weeks, low birth weight, maternal and neonatal outcomes. Receiver operating characteristic curves were generated to identify the best cervical length cutoff. RESULTS: Women with a bicornuate uterus (N = 35) had shorter cervical length (3.46 cm) than the low risk control group (N = 122, 4.32 cm, p < 0.0001). Women with a bicornuate or didelphus uterus, compared with low risk women, had higher rates of SPTB less than 35 weeks (8.6% and 30.8% versus 0.8%, p = 0.0007), neonatal intensive care unit admission more than 24 h (26.5% and 41.7% versus 7.5%, p = 0.0021) and composite perinatal morbidity (32.4% and 69.2% versus 8.3%, p < 0.0001). Using a cutoff of 3.0 cm, TVUS cervical length in women with a bicornuate uterus predicted SPTB less than 35 weeks (positive predictive value [PPV] = 37.5% and negative predictive value [NPV] = 100%), birth weight less than 2500 g (PPV = 50.0% and NPV = 96.3%) and respiratory distress syndrome (PPV = 37.5% and NPV = 100%). CONCLUSION Women with a bicornuate uterus have shorter cervical lengths than low risk controls, and are at higher risk of SPTB less than 35 weeks. Transvaginal ultrasonographic cervical length predicts SPTB less than 35 weeks, low birth weight and perinatal morbidity in these women.

Oral misoprostol for premature rupture of membranes at term.

OBJECTIVE: The study was undertaken to compare the efficacy, safety, and maternal satisfaction of oral misoprostol and intravenous oxytocin for labor induction in women with premature rupture of membranes at term. STUDY DESIGN: One hundred five women were stratified by parity and randomly assigned to oral misoprostol 75 microg every 4 hours as needed to establish labor or to intravenous oxytocin. RESULTS: The induction to vaginal delivery time with oral misoprostol was 737 (+/-426) minutes compared with 573 (+/-318) minutes with oxytocin (P=.04). The incidence of hyperstimulation was lower in the misoprostol group (6.0% vs 27.1%, P=.005). Women were more likely to be very satisfied with their care in the misoprostol group (86.0% vs 63.4%, P=.02). CONCLUSION: In women at term with premature rupture of membranes, oral misoprostol resulted in a longer induction to vaginal delivery interval but increased maternal satisfaction and less hyperstimulation compared with intravenous oxytocin. Further research is needed to assess uncommon neonatal and maternal outcomes.

First trimester ultrasound screening is effective in reducing postterm labor induction rates: a randomized controlled trial.

OBJECTIVE: This study was designed to test the null hypothesis that first trimester ultrasound crown-rump length measurement for gestational age determination will result in no difference in the rate of induction of labor for postterm pregnancy, compared with second trimester biometry alone. STUDY DESIGN: Two hundred eighteen women were randomly assigned to receive either first trimester ultrasound screening or second trimester ultrasound screening to establish the expected date of confinement. Sample size was calculated by using a 2-tailed alpha=.05 and power (1-beta)=80%. Data were analyzed with chi(2) and Fisher exact tests. RESULTS: Of 104 women randomly assigned to the first trimester screening group, 41.3% had their gestational age adjusted on the basis of the crown-rump length measurement. Of 92 women randomly assigned to the second trimester screening group, 10.9% were corrected as a result of biometry (P <.001, relative risk=0.26, 95% CI=0.15-0.46). Five women in the first trimester screening group and 12 women in the second trimester screening group had labor induced for postterm pregnancy (P=0.04, relative risk=0.37, 95% CI=0.14-0.96). CONCLUSION: The application of a program of first trimester ultrasound screening to a low-risk obstetric population results in a significant reduction in the rate of labor induction for postterm pregnancy.