Routine Induction Research Articles

Which level of risk justifies routine induction of labor for healthy women?

Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (and their offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or even uncertain. Characteristics such as an advanced maternal age, a non-native ethnicity, a high Body Mass Index, an artificially assisted conception, and even nulliparity are increasingly considered an indication for induction of labor. Because induction of labor has many disadvantages, a debate is urgently needed on which level of risk justifies routine induction of labor for healthy women, only based on characteristics that are associated with statistically significant small absolute risk differences, compared to others without these characteristics. This commentary contributes to this debate by arguing why induction of labour should not routinely be offered to all women where there is a small increase in absolute risk, and no any other medical risks or complications during pregnancy. To underpin our statement, national data from the Netherlands were used reporting stillbirth rates in groups of women based on their characteristics, for each gestational week from 37 weeks of gestation onwards.

Offering routine induction of labour at 39weeks in low-risk nulliparous women: No need for hasty change.

Offering routine induction of labour at 39weeks in low-risk nulliparous women: No need for hasty change.

Checking mask ventilation before neuromuscular block: A nation‐wide survey of anaesthetists’ attitudes and thinking

The value of checking mask ventilation before administering neuromuscular blocking drugs is still debated. We conducted a survey of the practice of anaesthetists in Sweden, first asking if they use a mask ventilation trial (MVT) as part of routine induction with intubation (not rapid sequence induction or expected difficult airway). We focused on the reasons for or against the MVT, probing the anaesthetists' attitudes in general but also in specific scenarios. The response rate was 54%. We found that 65.1% routinely use a MVT, 21.4% sometimes do and 13.5% never do so. There was no effect for years of experience on the distribution. The most common reason for checking mask ventilation was "to gather information about the airway," while the reason for not using the MVT was mostly "that muscle relaxation often improves mask ventilation." We found several interesting comments about airway management at both practical and theoretical levels. The survey highlights that routinely performing a MVT is a common practice in Sweden in spite of the lack of evidence for increased patient safety. Future airway guidelines may need to address this practice.

Comparison of haemodynamic responses to orotracheal intubation in anaesthetised and paralysed patients with simulated cervical spine injury: Airtraq® video laryngoscope versus Fibreoptic bronchoscope

Background: Endotracheal intubation may produce haemodynamic fluctuations which may be deleterious in patients with cardiovascular and neurological disorders. This is further worsened in patients with difficult airway. This study was conducted to compare haemodynamic fluctuations produced when intubation was done using Airtraq and fibreoptic bronchoscopy which are used in patients with anticipated difficult airway. Methodology: Prospective randomized study. Eighty patients, ASA PS 1 and 2 undergoing elective surgery were randomized into two groups – Group A and Group F. After routine induction and muscle relaxation, orotracheal intubation was done using Airtraq in Group A and fibreoptic bronchoscope in Group F. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded at regular intervals. Duration and number of attempts for intubation were also noted Results: There was no significant difference in the average of variation in HR (p=0.384), SBP (p=0.179), DBP (p=0.746) and MAP (p=0.057) from the baseline between the two groups. Duration of intubation in FOB group (mean value of 56.98 s) was more than Airtraq® video laryngoscope group (mean value of 37.38 s) which was statistically significant. Conclusion: Use of fibreoptic bronchoscope offer no added advantage over Airtraq video laryngoscope in terms of haemodynamic response for intubation in difficult airway situation such as cervical spine injury.

Effects of edaravone combined with flurbiprofen axetil on tumor necrosis factor-α and interleukin-6 of patients under one-lung ventilation

Objective To observe the effects of edaravone combined with flurbiprofen axetil on the levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in patients under one-lung ventilation (OLV). Methods A total of sixty patients undergoing thoracic surgery or radical resection for esophageal cancer were enrolled in this study. They were randomly divided into four groups (n=15): an edaravone group (group E), a flurbiprofen axetil group (group F), an edaravone combined with flurbiprofen axetil group (group E+F) and a normal saline group (group C). Patients underwent routine general anesthesia induction and maintenance. Then, 10 min after insertion of a double lumen endobronchial tube, group E was treated with 0.8 mg/kg edavarone, group F was treated with 1 mg/kg flurbiprofen axetil, group E+F was treated with 0.8 mg/kg edavarone and 1 mg/kg flurbiprofen axetil, and group C received 100 ml normal saline alone. Perioperavtive hemodynamics and blood gas indicators were recorded. The broncho-alveolar lavage fluid (BALF) of the ventilated lung and radial arterial blood samples (5 ml) were collected at two time points: after intubation (T1) and 60 min after OLV (T2). The concentrations of TNF-α in BALF and serum IL-6 were determined by ELISA. Results The partial pressure of oxygen in arterial blood (PaO2) was significantly decreased at T2 in all groups, compare with those at T1 (P<0.05). The TNF-α concentration in BALF was significantly decreased in groups E and E+F (P<0.05), but remarkably increased in group C at T2, compare with those at T1 (P<0.05). Compared with group C, groups E, F and E+F showed remarkably decreased levels of TNF-α at T2 (P<0.05). The concentration of IL-6 in group C at T2 were higher than that at T1 (P<0.05). Compared with group C, groups E, F and E+F showed remarkably decreased levels of IL-6 at T2 (P<0.05). Conclusions OLV can induce lung and systemic inflammatory response. Edaravone and flurbiprofen axetil can decrease the levels of TNF-α in BALF and serum IL-6 to inhibit inflammatory response in patients undergoing surgery with OLV, where no apparent advantage was found in combined use. Key words: Edaravone; Flurbiprofen axetil; One-lung ventilation; Tumor necrosis factor-α; Interleukin-6

Metabolomic Analysis of Serum Glycerophospholipid Levels in Eosinophilic and Neutrophilic Asthma

ObjectiveTo compare the serum glycerophospholipid levels in the inflammatory subtypes of asthma by using targeted metabolomic analysis. MethodsDemographic and clinical data were collected from 51 patients with asthma between January 2015 and December 2015. Routine blood and sputum induction tests were performed. Eosinophilic asthma was defined as induced sputum containing ≥ 3% eosinophils, and neutrophilic asthma, as induced sputum containing ≥ 71% neutrophils. Serum metabolic glycerophospholipid profile was determined by liquid chromatography-mass spectrometry. Differences in glycerophospholipid levels between eosinophilic and non-eosinophilic asthma and between neutrophilic and non-neutrophilic asthma were analyzed using partial least squares discriminant analysis. ResultsThe serum lysophosphatidylglycerol level was significantly higher in the group with ≥ 3% eosinophils in sputum than in the group with < 3% eosinophils in sputum. The area under the receiver-operating characteristic curve was ≥ 70%. There was no significant difference in the serum metabolic glycerophospholipid profile between the group with sputum neutrophils ≥ 71% and the group with sputum neutrophils < 71%. ConclusionSerum lysophosphatidylglycerol is produced abundantly in eosinophilic asthma and may be a biomarker of eosinophilic asthma. This information is helpful for identifying and tailoring treatment for the common asthma subtypes.

Scalp block with bupivacaine and ropivacaine for attenuation of haemodynamic response to head pinning in neurosurgical patients: An observational study

Objective: Present study was performed to compare the effectiveness of bupivacaine and ropivacaine for scalp block on the haemodynamic response during skull-pin insertion. Materials and Method: Ninety patients who underwent elective craniotomy were divided into two equal groups (n=45). After routine induction, patients were intubated. All the patients received scalp blocks with 20 ml of either 0.5% bupivacaine (group B) or 0.5% ropivacaine (group R) approximately 5 minutes before skull-pins insertion. Heart rate (HR) and mean arterial pressure (MAP) were recorded at 60sec, 120 sec and 300 sec following head pin insertion. Results: MAP and HR were stable during and after head pinning in both the groups at all time points. Conclusion: Both bupivacaine and ropivacaine for scalp block are equally effective for blunting hemodynamic responses during head pinning. Ropivacaine being less toxic can be a safe alternative for scalp block. Keywords: Anaesthesia, Local anaesthesia, Scalp block, Bupivacaine, Ropivacaine, Hemodynamic.

Induction of labor at 39 weeks of gestation versus expectant management for low-risk nulliparous women: a cost-effectiveness analysis

A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes. We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States. A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years. In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time. In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.

20: Induction of labor versus expectant management at 39 weeks: a cost-effectiveness analysis

A recent study found that induction of labor at 39 weeks for low-risk women was not associated with an increased risk of adverse neonatal outcomes. We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks versus expectant management. A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks versus expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the US annually that are considered low risk. Outcomes included mode of delivery, preeclampsia, macrosomia, intrauterine fetal demise, permanent brachial plexus injury, cerebral palsy, and neonatal death, in addition to cost and quality-adjusted life years (QALY) for both the woman and neonate. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. In our theoretical cohort of 1.6 million women, induction of labor resulted in 49,449 fewer cesarean deliveries and 79,152 fewer cases of preeclampsia. Additionally, we found that induction of labor resulted in 795 fewer cases of intrauterine fetal demise and 49 fewer neonatal deaths, despite 50 more cases of brachial plexus injury and 54 cases of moderate cerebral palsy (Table 1). Induction of labor resulted in increased costs, but increased QALYs with an incremental cost-effectiveness ratio of $97,501 per QALY. Univariate sensitivity analysis demonstrated that induction of labor was cost-effective until the cost of induction exceeded $2000 (Figure 1). In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes, but increased costs. The cost-effectiveness ratio was marginally cost effective, but would lead to an additional $2.26 billion of health care costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity and patient preferences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Effects of induction of labor prior to post-term in low-risk pregnancies: a systematic review.

ABSTRACTObjective:The objective of this review was to identify, assess and synthesize the best available evidence on the effects of induction prior to post-term on the mother and fetus. Maternal and fetal outcomes after routine labor induction in low-risk pregnancies at 41+0 to 41+6 gestational weeks (prior to post-term) were compared to routine labor induction at 42+0 to 42+6 gestational weeks (post-term).Introduction:Induction of labor when a pregnancy exceeds 14 days past the estimated due date has long been used as an intervention to prevent adverse fetal and maternal outcomes. Over the last decade, clinical procedures have changed in many countries towards earlier induction. A shift towards earlier inductions may lead to 15–20% more inductions. Given the fact that induction as an intervention can cause harm to both mother and child, it is essential to ensure that the benefits of the change in clinical practice outweigh the harms.Inclusion criteria:This review included studies with participants with expected low-risk deliveries, where both fetus and mother were considered healthy at inclusion and with no known risks besides the potential risk of the ongoing pregnancy. Included studies evaluated induction at 41+1–6 gestational weeks compared to 42+1–6 gestational weeks. Randomized control trials (n = 2), quasi-experimental trials (n = 2), and cohort studies (n = 3) were included. The primary outcomes of interest were cesarean section, instrumental vaginal delivery, low Apgar score (≤ 7/5 min.), and low pH (< 7.10). Secondary outcomes included additional indicators of fetal or maternal wellbeing related to prolonged pregnancy or induction.Methods:The following information sources were searched for published and unpublished studies: PubMed, CINAHL, Embase, Scopus, Swemed+, POPLINE; Cochrane, TRIP; Current Controlled Trials; Web of Science, and, for gray literature: MedNar; Google Scholar, ProQuest Nursing & Allied Health Source, and guidelines from the Royal College of Obstetricians and Gynaecologists, and American College of Obstetricians and Gynecologists, according to the published protocol. In addition, OpenGrey and guidelines from the National Institute for Health and Care Excellence, World Health Organization, and Society of Obstetricians and Gynaecologists of Canada were sought. Included papers were assessed by all three reviewers independently using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The standardized data extraction tool from JBI SUMARI was used. Data were pooled in a statistical meta-analysis model using RevMan 5, when the criteria for meta-analysis were met. Non-pooled results were presented separately.Results:Induction at 41+0–6 gestational weeks compared to 42+0–6 gestational weeks was found to be associated with an increased risk of overall cesarean section (relative risk [RR] = 1.11, 95% confidence interval [CI] 1.09–1.14), cesarean section due to failure to progress (RR = 1.43, 95% CI 1.01–2.01), chorioamnionitis (RR = 1.13, 95% CI 1.05–1.21), labor dystocia (RR = 1.29, 95% CI 1.22–1.37), precipitate labor (RR = 2.75, 95% CI 1.45–5.2), uterine rupture (RR = 1.97, 95% CI 1.54–2.52), pH < 7.10 (RR = 1.9, 95% CI 1.48–2.43), and a decreased risk of oligohydramnios (RR = 0.4, 95% CI 0.24–0.67) and meconium stained amniotic fluid (RR = 0.82, 95% CI 0.75–0.91). Data lacked statistical power to draw conclusions on perinatal death. No differences were seen for postpartum hemorrhage, shoulder dystocia, meconium aspiration, 5-minute Apgar score < 7, or admission to neonatal intensive care unit. A policy of awaiting spontaneous onset of labor until 42+0–6 gestational weeks showed, that approximately 70% went into spontaneous labor.Conclusions:Induction prior to post-term was associated with few beneficial outcomes and several adverse outcomes. This draws attention to possible iatrogenic effects affecting large numbers of low-risk women in contemporary maternity care. According to the World Health Organization, expected benefits from a medical intervention must outweigh potential harms. Hence, our results do not support the widespread use of routine induction prior to post-term (41+0–6 gestational weeks).

Timing of Delivery in Women With Chronic Hypertension

To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery. We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801). Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57-0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69-1.17]). Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.

Development and Characterization of a Model for Inducing Fetal Hemoglobin Production in Cynomolgus Macaques (Macaca fasicularis).

Hydroxyurea induces production of fetal hemoglobin (HbF), a tetramer of α and γ globin proteins and corresponding heme molecules, normally found in less than 1% of adult RBC. Increases in circulating HbF are correlated with clinical improvement of patients with hemoglobinopathies, and hydroxyurea, as a daily medication, is the standard treatment for sickle cell anemia. Although olive baboons (Papio anubis) are considered a key model species for HbF induction, cynomolgus macaques (Macaca fasicularis) are another species that conserves the ability to produce HbF into maturity. In this study, moderate anemia was experimentally induced in cynomolgus macaques by phlebotomy, to stimulate accelerated erythropoiesis and HbF production. In contrast to previous studies, vascular access ports were implanted for phlebotomy of conscious monkeys, followed by fluid replacement. As total Hgb levels dropped, reticulocyte counts and the percentage of HbF-expressing cells increased. Once total Hgb levels declined to less than 8 g/dL, 2 courses of oral hydroxyurea (once daily for 5 d) were completed, with a 9-d interval between courses. After hydroxyurea dosing, the percentage of HbF-expressing cells and total HbF were increased significantly. In addition, a significant but transient decrease in reticulocyte count and a transient increase in MCV occurred, replicating the characteristic response of patients receiving hydroxyurea. Daily clinical observations revealed no serious health issues or decreases in food consumption or activity levels. Methods were established for assessing the patency of vascular access ports. This study details a new protocol for the safe and routine induction of moderate anemia in cynomolgus macaques and validates its use in the investigation of novel pharmacologic entities to induce the production of HbF.

Effect of Dexmedetomidine Hydrochloride on Early Cognitive Function in Postoperative Elderly Patients

Purpose: to explore the effect of dexmedetomidine hydrochloride on early cognitive function in postoperative elderly patients. Methods: during December 2015 to November 2016, 80 elderly patients who received surgical treatment in our hospital were selected as research object. Result: patients were randomly divided into two groups (control group and research group). On the basis of routine anesthetic induction, patients in research group took dexmedetomidine, in comparison, patients in control group took an equal dose of sodium chloride solution. The goal was to evaluate the anesthetic effect of those two methods. One hour before surgery, there was no significant difference in the MMSE score between the two groups (P＞0.05). In research group, the MMSE scores at postoperative 1d and 3d were (23.8 ± 2.4) and (27.1 ± 2.0) respectively. In control group, the MMSE scores at postoperative 1d and 3d were (20.5 ± 3.2) and (24.6 ± 3.4) respectively. The difference was statistically significant (P＜0.05). There was no significant difference in anesthesia time, awake time and extubation time between those two groups (P＞0.05). Conclusion: using dexmedetomidine in elderly patients after surgery can protect early cognitive function and improve the prognosis.

ABO-Incompatible Transplantation without Conventional Induction Immunosuppression (IL-2RB or Depleting agents)

Background Transplantation across ABO blood group ( ABOI-Tx) has facilitated to increase donor pool for living donor kidney transplantation. Increased risk of rejection despite augmented immunosuppression has been the concern for many transplant programs in initiating a ABOI-TX program. The benefits on long term graft surivial with induction immunosuppression in immunologically low risk individuals is still not clear. ABOI-Tx recipients are subjcted to increased immunosuppression prior to transplant which could provide and an opportunity to transplant without induction with IL2-R blockers or Lymphocyte depleting agents. Aim Aim of our study is to analyze the outcome of our series of 25 consecutive ABOI-Tx patients who underwent transplantation without routine Thymoglobulin or IL2R-blocker induction. Methods Our study is a prospective observational study for first 25 consecutive patients who had undergone ABOI-Tx from two tertiary care centers in Kerala, India having the same IS protocol. Anti-A and anti-B titers ≤ 1:512 by Gel-method(Biorad) were accepted for desensitization. All patients underwent CDC-crossmatch, Flow-crossmatch and Luminex-anti-HLA-antibody-screen. Desensitization regimen included- Rituximab 200mg on Day -21, Triple IS- Prednisolone 10mg, MMF 1000mg and Tacrolimus 0.05mg/bodywt from Day -14 and Plasma-exchange(PLEX) 3-4 sessions from day -7 to attain titer of 1:8 prior to transplantation. Transplantation was done without induction IS. Results Twenty five patients underwent ABOI-Tx from both centers. Twenty recipients were male. Average age was 34±8 yrs with follow-up of 431±298 days. Eight donors were spouse, 13 were parents and 3 siblings. Average age of donor was 46.3± 10.5years. Twenty-two patients have normal functioning transplant with creatinine 1.23± 0.2 mg/dL. Kaplan-Meier analysis showed patient survival of 91.2% and death censored graft survival of 95.6% at 32 months (Figure 1). Two patients were lost; one on post-op day(POD)3 due to ACS and second on POD-22 due to fungal sepsis. One graft loss occurred due to post-transplant HUS with no evidence of rejection. Of the functioning 22 allograft-recipients one had cellular rejection which resolved with pulse steroids; one developed HUS due to CNI which recovered with PLEX and switch to non-CNI based IS. One patient developed AMR on POD-4 which was completely reversed with PLEX and augmentation of IS. Three patients had CMV viremia and one 3 had BKV viremia ; all resolved with treatment and tailoring of IS. Conclusion Achieving acceptable anti A/B titers prior to transplantation is the most critical step in ABOI-Tx. Avoidance of induction IS can decrease the cost and infectious complications. Our data shows the there is no increased incidence of rejections in the first post transpalnt year for immunologically low risk individuals from histocompatibility standpoint undergoing ABOI-Tx without induction immunosuppression. Figure 1 Sreesan A Sreedharan. Ranjith Narayanan.

Repeat induction of labour for post-term pregnancy

Background: A previous post-term pregnancy is thought to influence the gestation of a subsequent pregnancy. Adverse maternal and perinatal outcomes are associated with post-term pregnancy and routine induction of labour by 42+0 weeks is advised to reduce these complications.Objective: To determine the recurrence rate of a post-term pregnancy and the need for repeat induction of labour.Methods: This observational cohort study featured women with a first and second singleton pregnancy, based on data recorded in the Aberdeen Maternity and Neonatal Databank (1986–2012). Term and post-term pregnancies were defined as ≥37+0 – 40+6 and ≥41+0 weeks, respectively. The exposure was a post-term pregnancy and the control a term pregnancy. Logistic regression was used to assess post-term recurrence and repeat induction of labour.Results: The study population consisted of 25,669 women with 33% of the women delivering post-term in their first pregnancy. In these women, the rate of a subsequent post-term pregnancy was 35.7% compared to 18.6% for women with an initial term pregnancy (adjusted odds ratio (aOR) 2.27, 95% confidence interval (CI) 2.11–2.44). Compared to women who had spontaneous term deliveries in both pregnancies, women who were induced post-term in the second pregnancy had increased odds of having been induced post-term in their first pregnancy. The adjusted odds ratio was found to be 6.08 (95% CI 5.30–6.98).Conclusions: Women with a first post-term pregnancy are less likely to labour spontaneously and more likely to have a second post-term pregnancy with a higher risk of repeat induction of labour, than women who have previously delivered at term. These findings could be useful in the counselling of women with a previous post-term pregnancy. Given that these women are less likely to labour spontaneously, the offer of an elective induction could also be considered to potentially improve maternal and perinatal outcomes.

Effects of different anesthetic methods on postoperative acute pain in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy

Objective To evaluate the effects of different anesthetic methods on postoperative acute pain in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Methods Fifty-four patients of both sexes, aged 18-64 yr, with body mass index of 20-28 kg/m2, of American Society of Anesthesiologists physical statusⅠor Ⅱ, scheduled for elective video-assisted thoracoscopic thymectomy, were allocated into 2 groups (n=27 each) using a random number table method: sevoflurane-based anesthesia group (group S) and propofol-based anesthesia group (group P). After routine anesthesia induction in two groups, anesthesia was maintained by inhaling sevoflurane and target-controlled infusion of remifentanil in group S and by target-controlled infusion of propofol and remifentanil in group P. Heart rate and mean arterial pressure were recorded before operation and at 5 and 10 min after extubation (T1, 2). The intensity of pain at T2 and visual analog scale (VAS) score and consumption of morphine at 1, 2, 4, 24 and 48 h after operation (T3-7) were recorded.The pressing times of analgesia pump, requirement for rescue analgesia and development of nausea and vomiting were recorded at T7. Results There were no significant differences in heart rate or mean arterial pressure at each time point between two groups (P>0.05). Compared with group S, the intensity of pain was significantly alleviated at T2, and VAS scores and morphine consumption were decreased at T3, 4 in group P (P 0.05). Conclusion Propofol-based anesthesia provides better efficacy in alleviating postoperative acute pain in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Key words: Propofol; Anesthetics, inhalation; Pain postoperative; Myasthenia gravis; Thoracoscopy; Thymectomy

Comparison of 25 Microgram of Sublingual Misoprostol with 25 Microgram Vaginal Misoprostol for Induction of Labour at Term

Comparison of 25 Microgram of Sublingual Misoprostol with 25 Microgram Vaginal Misoprostol for Induction of Labour at Term

345: Timing of delivery in women with preexisting hypertension

In women with preexisting hypertension (PHTN), it is not clear if routine induction of labor (IOL) before 40 weeks of gestation confers benefit to mother and newborn. Our objective was to compare pregnancy outcomes between women with PHTN who had IOL at either 38 or 39 weeks and those who were managed expectantly during the corresponding weeks using a large population-based cohort. The study group included all women with PHTN who had a singleton birth at ≥ 38 weeks gestation in Ontario, Canada from April 2012-March 2016. Data were obtained from the Better Outcomes Registry & Network (BORN) Ontario, BORN Information System (BIS) database. Women who underwent IOL at 38+0 to 38+6 weeks for PHTN (38-IOL group, N=225) were compared to those who remained undelivered at 39+0 weeks (38-Exp group, N=1,365). Separately, women who underwent IOL at 39+0 to 39+6 weeks for PHTN (39-IOL group, N=213) were compared to women who remained undelivered at 40+0 weeks (39-Exp group, N=669). Out of 462,334 women who delivered during the study period, 3,213 (0.7%) had PHTN, and of these, 2,075 (64.6%) met the study inclusion criteria. Women in the 39-IOL group were less likely to have Cesarean delivery (17.8% vs. 26.3%, p=0.01, aOR 0.59, 95%-CI 0.38-0.93) but had a higher rate of neonatal jaundice requiring phototherapy (5.6% vs. 2.1%, p=0.02, aOR 2.68, 95%-CI 1.13-6.37) compared with women in the 39-Exp group (Table). These differences were not observed in the case of IOL at 38 weeks. There were no other differences in neonatal outcomes between the IOL and expectant management groups at either 38 or 39 weeks (Table). The rate of superimposed preeclampsia in women who were managed expectantly at 38 and 39 weeks was 23.1% and 23.2%, respectively. In women with PHTN, routine IOL at 39 weeks is associated with a lower risk of CS and can prevent subsequent superimposed preeclampsia, but is associated with a small increase in the risk of neonatal jaundice requiring phototherapy.

Study of sevoflurane/remifentanil coadministration on improving emergence and recovery characteristics of patients following general anaesthesia with sevoflurane

Objective: To investigate the effects of remifentanil infusion on emergence and recovery characteristics of patients with thoracoscopic lobectomy following general anaesthesia with sevoflurane. Methods: One hundred patients, who were aged 37 to 65 years with American Society of Anesthesiologists (ASA) physical status 1-2, and scheduled for elective thoracoscopic lobectomy under general anaesthesia in National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from February 2016 to August 2016, were allocated to receive sevoflurane maintenance regimen(group S, n=50)or sevoflurane/remifentanil maintenance regimen(group SR, n=50)by random digital table. After routine induction and intubation, anaesthesia was maintained with 2% sevoflurane in group S and 1.5% sevoflurane/remifentanil(continuous intravenous injection at rate of 4 μg·kg(-1)·h(-1))coadministration in group SR respectively, with intermittent intravenous infusion of sulfentanil. Haemodynamic variables were collected at different time points and compared between two groups. Awaking time and extubation time, incidences of serious coughing and agitation were evaluated during emergence.Postoperative pain, nausea and cather-related bladder discomfort(CRBD)were evaluated in post anesthesia care unit. Results: Compared with group S, the arterial blood pressure and heart rate were significantly lower in group SR at extubation(all P<0.05). Time to awaking and to extubation in group SR were (4.2±2.1) min and (4.8±3.1)min respectively, in group S were (12.7±3.4) min and (15.4±4.1)min.The difference between two groups were statistically significant (t=-15.040, 14.582, all P<0.05). The incidences of serious coughing and agitation in group S were 48% and 58%, which were greater than those of group SR(6% and 10%). The difference were statistically significant(χ(2)=20.294, 23.574, all P<0.05). The NRS and incidence of complaining CRBD were similar in both groups(all P>0.05). Conclusion: Compared with sevoflurane maintenence, coadministration of remifentanil and sevoflurane maintenance regimen provides better emergence and recovery which are characterized by faster awakening and extubation with a lower incidence of emergence coughing and agitation.

Perinatal mortality associated with induction of labour versus expectant management in nulliparous women aged 35 years or over: An English national cohort study

BackgroundA recent randomised controlled trial (RCT) demonstrated that induction of labour at 39 weeks of gestational age has no short-term adverse effect on the mother or infant among nulliparous women aged ≥35 years. However, the trial was underpowered to address the effect of routine induction of labour on the risk of perinatal death. We aimed to determine the association between induction of labour at ≥39 weeks and the risk of perinatal mortality among nulliparous women aged ≥35 years.Methods and findingsWe used English Hospital Episode Statistics (HES) data collected between April 2009 and March 2014 to compare perinatal mortality between induction of labour at 39, 40, and 41 weeks of gestation and expectant management (continuation of pregnancy to either spontaneous labour, induction of labour, or caesarean section at a later gestation). Analysis was by multivariable Poisson regression with adjustment for maternal characteristics and pregnancy-related conditions. Among the cohort of 77,327 nulliparous women aged 35 to 50 years delivering a singleton infant, 33.1% had labour induced: these women tended to be older and more likely to have medical complications of pregnancy, and the infants were more likely to be small for gestational age.Induction of labour at 40 weeks (compared with expectant management) was associated with a lower risk of in-hospital perinatal death (0.08% versus 0.26%; adjusted risk ratio [adjRR] 0.33; 95% CI 0.13–0.80, P = 0.015) and meconium aspiration syndrome (0.44% versus 0.86%; adjRR 0.52; 95% CI 0.35–0.78, P = 0.002). Induction at 40 weeks was also associated with a slightly increased risk of instrumental vaginal delivery (adjRR 1.06; 95% CI 1.01–1.11, P = 0.020) and emergency caesarean section (adjRR 1.05; 95% CI 1.01–1.09, P = 0.019). The number needed to treat (NNT) analysis indicated that 562 (95% CI 366–1,210) inductions of labour at 40 weeks would be required to prevent 1 perinatal death. Limitations of the study include the reliance on observational data in which gestational age is recorded in weeks rather than days. There is also the potential for unmeasured confounders and under-recording of induction of labour or perinatal death in the dataset.ConclusionsBringing forward the routine offer of induction of labour from the current recommendation of 41–42 weeks to 40 weeks of gestation in nulliparous women aged ≥35 years may reduce overall rates of perinatal death.