Tuesday, May 17, 2016

Is outpatient preinduction cervical ripening an option at term? News from ACOG Annual Clinical and Scientific Meeting 2016.

Outpatient preinduction cervical ripening has always been debated. With nearly 1 in 4 pregnancies scheduled for induction of labor and  50% of these women having unfavorable cervix interest in this has grown. Those clinician and researchers in favor of it vouch that it offers many advantage like decreased hospitalization time, conserving resources due to decreased labor room staffing, and improving patient satisfaction.  

While clinicians against it advocate its use only in specific, well planned situation with valid indication. The reason behind it is lack of large scale data reporting experience behind it. There are also no large scale trials to back up the regime. Studies found in literature involve term pregnancies of living fetuses with some means of continuous monitoring of uterine activity and the fetal heart rate for the first few hours. Also there exist no studies comparing the mechanical vs various drug therapies for cervical ripening.

Samuel A. Cosgrove Memorial Lecture on May 17, 2016 took a detailed look at doing cervical ripening on an outpatient basis for low-risk patients.

Dr. Anthony C. Sciscione, DO, Christiana Care Health Services, Newark, DE was in favor of outpatient cervical ripening and he mostly shared his experiences with Foleys catheter.

He stressed that outpatient ripening has a very high rate of patient satisfaction and patients were willing to make extra trip to hospital. Studies also showed that in-patients have a very high level of anxiety and outpatients were more stress free.  

A small randomized trial at Christiana care was carried out to see if patients can manage Foleys catheter in outpatient setting.   Women who were low risks, with stable vital signs, adequate amniotic fluid had a catheter placed in and randomized to 2 groups inpatient (n=50) and outpatient (n=61) and observed for 2 hours. The outpatient group was discharged with proper instructions and advised to return next day 6 AM. Dr. Sciscione did not really observed any difference between the two groups. 

While Dr. William F. Rayburn, MD, MBA, University of New Mexico, Albuquerque, NM, scrutinized it because of lack of concrete and meticulous research behind it . He urged the audience that they should not postulate that all outpatient inductions are safe. He argued that Up to Date does not recommend it except in research settings and ACOG practice bulletin and leading textbook do not mention it. A review of literature found less than 10% of literature on this subject.

He quoted “What we all would agree with here, I assume, is that whatever we do with this procedure, we want to add as little, or ideally, no additional risk to the mother and the fetus, so we’ve got to have sufficient experience to really say that.”

In researching for the debate he only found two additional clinical trial to the one conducted by Dr. Sciscione. The total number of patients receiving outpatient balloon cervical ripening was only 141.

While adverse effects were rare, no consensus was reached on what constitutes unacceptable risk. 
The studies found that compared with placebo, PGE2 (vaginal or intracervical) and misoprostol (oral or vagina) are effective. But good benefits were documented with Foleys balloon catheter too.

He also commented on the difficulties faced by patients in transporting to and from hospitals and lack of monitoring at home.

In the end he stressed the need of having large randomized trial or meta-analysis to really exclude excess risk here and determine what works and what does not.

References:
http://www.acogdailynews.com/value-of-outpatient-cervical-ripening-debated/




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