Induction of labour vs expectant management for LGA fetuses

Danny Tucker
Mind Map by Danny Tucker, updated more than 1 year ago
Danny Tucker
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By Dr Danny Tucker, Director of Obtetrics & Gynaecology, Townsville Hospital, Queensland, Australia. Boulvain, Michel et al. Lancet 2015. Original paper & editorial: http://bit.ly/lgarct
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Induction of labour vs expectant management for LGA fetuses
1 Induction of labour vs expectant management for large-for-date fetuses: a RCT. Lancet Online 9 April 2015
1.1 Results
1.1.1 409 IOL vs 411 expectant
1.1.1.1 Baseline characteristics similar
1.1.1.2 10 days average difference in delivery date
1.1.2 Mean BW 3831g IOL vs 4118g expectant
1.1.2.1 50% reduction in >4000g infants & 75% reduction in >4500 infants
1.1.3 Primary outcome measure
1.1.3.1 8 (2%) of IOL and 25 (6%) of expectant management
1.1.3.1.1 NNT = 25
1.1.4 Caesarean section/operative vaginal delivery, PPH & 3rd degree tears: No significant difference
1.1.5 TTN, NICU admission no difference
1.1.5.1 Phototherapy 13% IOL vs 7% expectant, esp IOL<38/40
1.1.6 Individual outcomes
1.1.6.1 Significant SD: 16 vs 5 (4% vs 1%)
1.1.6.2 Delay of >60s: 10 vs 2 (2% vs 1%)
1.1.6.3 Fracture: 8 vs 2 (2% vs 1%)
2 Background
2.1 CS to prevent macrosomia-related complications only for >4500g GDM & >5000g non-GDM
2.2 Systematic review of IOL vs conservative Mx = no difference in CS, but no reduction in morbidity
2.2.1 Small sample size
2.2.2 EFW>4000g & >=40/40, so lower benefit as baby already big
3 Study design
3.1 19 tertiary care hospitals in France, Switzerland & Belgium
3.1.1 2002-2009
3.1.2 Single, macrosomic fetus, cephalic, no CI to vaginal delivery
3.1.3 Sample size 500/500 for 80% power, 5% type 1 error & RR 0.33-0.5. Note study ended at 407/411 due to financial constraints
3.2 1:1 randomisation
3.3 IOL 37-38+6 within 3d of randomisation
3.4 Primary composite outcome: shoulder dystocia, # clavicle or long bone, brachial plexus injury, ICH or death
3.4.1 SD = not resolved with McRoberts/suprapubic pressure
3.4.1.1 Note: also included >60s head-body interval
3.4.1.1.1 But no reduction in benefit with IOL when this outcome excluded from analysis
3.5 Intention to treat analysis
3.6 Screening via clinically LGA
3.6.1 Hadlock >95%ile
3.6.1.1 3500g at 36 weeks, 3700g at 37 weeks, 3900g at 38 weeks
4 Mind map by Danny Tucker
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