Elective delivery of women with a previous unexplained intra-uterine fetal death at term (≥ 39 weeks) : a prospective cohort study at Tygerberg Hospital, South Africa

Oberholzer, Leana (2014-12)

Thesis (MMed)--Stellenbosch University, 2014.

Thesis

ENGLISH ABSTRACT: Introduction Pregnancies in women with a previous unexplained stillbirth may be jeopardized by increased antenatal surveillance and higher rates of induction of labour and caesarean delivery without clear evidence of benefit. Despite the fact that there have been no studies that adequately tested fetal benefit in routine induction of labour for a previous stillbirth, a policy of routine induction of labour at 38 weeks, with all the associated maternal, fetal and health-care associated costs, was in practice at Tygerberg Hospital for the past 30 years. This study aimed to investigate the safety of continuation of these pregnancies until term (≥39 weeks). Aims and Objectives To assess the clinical outcome and impact on the health service in a pregnancy with a previous unexplained intra-uterine demise (IUD) by routine induction of labour at term instead of at 38 weeks. Methodology This was a prospective observational study on the safety of a new hospital protocol which was introduced in 2012. The protocol extended the gestation for induction after a previous IUD from 38 weeks to term. The study population included all pregnant patients with a current singleton pregnancy, and a previous unexplained or unexplored (no data available) singleton fetal demise ≥24 weeks/500grams. All patients with a previous stillbirth in the metropolitan drainage area of Tygerberg Hospital are referred to Tygerberg for further care; and all referrals during 2012 were recruited for the study. Patients with known or recurrent risks for intra-uterine death were managed according to the relevant clinical condition and were excluded from the study. Results During the audit period, 306 patients with a previous intra-uterine fetal death were referred for further management. Of these, 161 had a clear indication for either earlier intervention or no intervention and were excluded from the protocol. Of the remaining 145 patients, 9 met exclusion criteria and there were 2 patients who defaulted. Forty-two of the study patients (with no known previous medical problems) developed complications during their antenatal course that necessitated a change in clinical management and earlier (<39 weeks) delivery. Of the remaining 92 patients in the audit, 47 (51%) went into spontaneous labour before their induction date. There were no intra-uterine deaths prior to delivery. Conclusions Careful follow up at a high risk clinic identifies new or concealed maternal or fetal complications in 29% of patients with a previous IUD and no obvious maternal or fetal disease in the index pregnancy. When all risks are excluded and the pregnancy allowed to progress to 39 weeks before an induction is offered, 51% will go into spontaneous labour.

AFRIKAANSE OPSOMMING: Inleiding Swangerskappe in vroue met vorige onverklaarbare stilgeboorte mag in gevaar gestel word deur meer intense voorgeboorte sorg en ‘n groter hoeveelheid induksies van kraam en keisersnitte sonder duidelike bewyse dat dit tot voordeel strek. Ten spyte van die feit dat daar geen studies is wat bewys het dat roetine induksie van kraam vir ‘n vorige stilgeboorte op 38 weke tot voordeel van die baba was nie, was ‘n beleid van roetine induksie van kraam op 38 weke, met al die geassosieërde moederlike en fetale risikos daaraan verbonde; asook die hoë gesondheidskostes, roetine praktyk in Tygerberg Hospitaal vir die afgelope 30 jaar. Hierdie studie het ten doel gehad om die veiligheid van voortsetting van hierdie swangerskappe tot voltyd (≥39 weke) te ondersoek. Doelwitte Om die kliniese uitkoms; asook die impak op gesondheidsdienste te evalueer in ‘n swanger vrou met n vorige onverklaarbare intra-uteriene sterfte; deur roetine induksie van kraam aan te bied op voltyd in plaas van 38 weke. Metodologie Hierdie was n prospektiewe kohort studie om die veiligheid van ‘n nuwe hospitaal protokol wat in 2012 geïmplimenteer is, te bepaal. Hierdie protokol het die gestasie tydperk van induksie van kraam van alle swanger pasiënte na ‘n vorige onverklaarbare stilgeboorte van 38 weke na voltyd verleng. Die studiepopulasie het alle swanger pasiënte met ‘n huidige enkelswangerskap en ‘n vorige onverklaarbare of onbekende (geen data beskikbaar) enkelvoudige fetale sterfte ≥24 weke/500gram, ingesluit. Alle pasiënte in die metropolitaanse dreineringsarea van Tygerberg Hospitaal met ‘n vorige stilgeboorte word na Tygerberg verwys vir verdere hantering, en alle verwysings gedurende 2012 was gewerf vir die studie. Pasiënte met bekende of herhalende risikofaktore vir ‘n intra-uteriene sterfte was hanteer volgens die relevante kliniese inligting en was uitgesluit by die studie. Resultate Drie-honderd-en-ses pasiënte met ‘n vorige intra-uteriene fetale sterfte was gedurende die oudit periode verwys vir verdere hantering. In 161 pasiënte was daar ‘n duidelike indikasie vir of vroeër intervensie of geen intervensie nie; en hulle was uitgesluit van die protokol. Van die oorblywende 145 pasiënte is 9 pasiënte uitgesluit as gevolg van die uitsluitingskriteria en daar was 2 pasiënte wat versuim het om op te volg. Twee-en-veertig pasiënte (met geen bekende vorige mediese probleme nie) het komplikasies gedurende hulle voorgeboorte verloop ontwikkel wat gelei het tot verandering in kliniese hantering en vroeëre verlossing (≤39 weke) genoodsaak het. Van die oorblywende 92 pasiënte in die oudit, het 47 (51%) in spontane kraam gegaan voor hulle induksiedatum. Daar was geen intra-uteriene sterftes voor verlossing nie. Gevolgtrekkings Noukeurige opvolg by ‘n hoërisiko kliniek identifiseer nuwe of versteekte moederlike en fetale komplikasies in 29% van pasiënte met ‘n vorige intra-uteriene sterfte sonder enige duidelike moederlike of fetale siekte in die indeks swangerskap. Wanneer alle risikos uitgesluit word en die swangerskap toegelaat word om voort te gaan tot 39 weke voor ‘n induksie aangebied word, sal 51% van pasiënte spontaan in kraam gaan.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/96107
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