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Grand Rounds

Have Obstetrical Practices and Outcomes Changed in Response to the ARRIVE Trial?

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BACKGROUND AND PURPOSE:

  • The ARRIVE trial (published in 2018) found that elective induction at 39 weeks’ gestation led to fewer cesarean deliveries and lower incidence of adverse pregnancy outcomes
  • Gilroy et al. (AJOG, 2022) assessed whether there were changes in obstetric practices and perinatal outcomes in the US after the ARRIVE trial publication

METHODS:

  • Population based, retrospective cohort study
    • Data derived from National Vital Statistics System (NVSS) database
  • Population
    • Low-risk nulliparous women who initiated prenatal care by 12 weeks’ gestation with singleton, non-anomalous pregnancies that delivered at ≥ 39 weeks
  • Exposures
    • Pre-ARRIVE: Delivery between January 2015 and December 2017
    • Post-ARRIVE: Delivery between January 2019 and December 2019
  • Study design
    • Univariate and multivariate analyses were performed
    • Trends were tested across the time period represented by the pre-ARRIVE group
    • Adjustment was performed for differences (P<0.001 between exposure groups) for age, race, BMI, marital status, infertility treatment and smoking history
  • Primary outcomes
    • Practice outcomes
      • Rate of induction of labor
      • Timing of delivery
      • Cesarean rate
    • Maternal outcomes
      • Blood transfusion
      • ICU admission
    • Neonatal outcomes
      • Need for assisted-ventilation (immediate and >6 hours)
      • 5-minute APGAR score <3
      • NICU admission
      • Seizures
      • Surfactant use

RESULTS:

  • Pre-ARRIVE: 1,966,870 births | Post-ARRIVE: 609,322 births

Practice outcomes

  • The post-ARRIVE group was more likely to
    • Undergo induction
      • Pre: 30.2% | Post: 36.1%
      • aOR 1.39 (95% CI, 1.36 to 1.37)
    • Delivery by 39w6d weeks of pregnancy
      • Pre: 39.9% | Post: 42.8%
      • aOR 1.14 (95% CI, 1.14 to 1.15)
  • The post-ARRIVE group had a significantly lower rate of cesarean delivery
    • Pre: 27.9% | Post: 27.3%
    • aOR 0.94 (95% CI, 0.93 to 0.94)

Maternal outcomes

  • Patients in the post-ARRIVE group were more likely to
    • Receive a blood transfusion
      • Pre: 0.3% | Post: 0.4%
      • aOR 1.43 (95% CI 1.36 to 1.50)
    • Be admitted to the MICU
      • Pre: 0.08% | Post: 0.09%
      • aOR 1.20 (95% CI, 1.09 to 1.33)

Neonatal outcomes

  • Neonates in the post-ARRIVE group were more likely to
    • Need assisted ventilation at birth
      • Pre: 2.8% | Post: 3.5%
      • aOR 1.28 (95% CI, 1.26 to 1.30)
    • Need assisted ventilation at >6 hours
      • Pre: 0.5% | Post: 0.6%
      • aOR 1.36 (95% CI, 1.31 to 1.41)
    • Have low 5-min APGAR
      • Pre: 0.3% | Post: 0.4%
      • aOR 0.91 (95% CI, 0.86 to 0.95)
  • There was no difference in
    • NICU admission
      • Pre: 4.9% | Post: 4.9%
      • aOR 1.01 (95% CI, 0.99 to 1.03)
    • Neonatal seizures
      • Pre: 0.04% | Post: 0.04%
      • aOR 0.97 (95% CI, 0.84 to 1.13)

CONCLUSION:

  • Following the ARRIVE trial publication, there were more inductions, more deliveries at 39 weeks, and fewer cesarean deliveries 
  • Some adverse neonatal and maternal outcomes were increased following ARRIVE trial publication
  • Limitations include the extent of data that is available within the NVSS and birth certificates           
  • The authors state

There was a significant decrease in the rate of cesarean deliveries in 2019 after the publication of the ARRIVE trial…

There were also increased rates of MICU admissions and low 5-minute APGAR scores (albeit still within the range of the rates seen over the 3 years in the pre-ARRIVE group) in the post-ARRIVE group

Although the changes in adverse perinatal outcomes were small, their potential clinical implications warrant further inquiry

Learn More – Primary Sources:

Changes in obstetric practices and pregnancy outcomes following the ARRIVE trial

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Related ObG Topics:

Further Analysis of ARRIVE: What are the Perinatal Outcomes Associated with Expectant Management in Low-Risk, Nulliparous Individuals?
Low-Risk Multiparous Women: Induction of Labor at 39 Weeks or Expectant Management?
Expectant Management vs Induction at 39 Weeks: Is There a Difference in Cost?

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