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Obstetrics
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Cite this article as: Harper LM, Odibo AO, Stamilio DM, et al. Radiographic measures of the mid pelvis to predict cesarean delivery. Am J Obstet Gynecol
2013;208:460.e1-6.
460
R ESULTS
Of 652 women in the cohort, 426
women met inclusion criteria. The 2
groups are similar with respect to age,
gravidity, previous vaginal delivery, previous cesarean delivery, birthweight, and
labor type. Subjects with a mid pelvis circumference of 10th percentile were
more likely to be black or Asian.
A transverse diameter of the mid pelvis
10th percentile was not associated with
an increased risk of cesarean delivery
(positive predictive value, 45.5%; adjusted odds ratio, 2.0; 95% confidence
interval [CI], 1.0 3.8; Table). An APD
of 10th percentile was associated
Obstetrics
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strongly with cesarean delivery; 98% of
women with an APD of 9.5 cm required cesarean delivery (positive predictive value, 98%; adjusted odds ratio,
112.7; 95% CI, 14.9 854.1). Of the 28
subjects with an APD of 5th percentile,
all were delivered by cesarean delivery
(positive predictive value, 100%). The
sensitivity of an APD of 10th percentile
to detect subjects who require cesarean
delivery was low at 39%; however, the
specificity of the test was 99.7%.
An APD measurement of 90th percentile decreased the risk for cesarean
delivery (adjusted odds ratio, 0.1; 95%
CI, 0.03 0.4), as did a circumference of
90th percentile (adjusted odds ratio,
0.2; 95% CI, 0.04 0.82). No upper
threshold of radiographic measurements
existed above which every subject delivered vaginally.
Research
TABLE
Exposure group
Cesarean
delivery, Risk ratio
(95% CI)
n (%)a
Adjusted odds
ratio (95% CI)b
P value
Transverse diameter
.....................................................................................................................................................................................................................................
92 (26.3) Reference
2.0 (1.03.8)
.04
.....................................................................................................................................................................................................................................
Reference
.....................................................................................................................................................................................................................................
2.0 (0.75.5)
.19
.....................................................................................................................................................................................................................................
Reference
..............................................................................................................................................................................................................................................
Anteroposterior diameter
.....................................................................................................................................................................................................................................
77 (20.5) Reference
99 (24.9) Reference
.....................................................................................................................................................................................................................................
Reference
.....................................................................................................................................................................................................................................
c
.....................................................................................................................................................................................................................................
c
..............................................................................................................................................................................................................................................
Circumference
.....................................................................................................................................................................................................................................
86 (22.7) Reference
19.3 (6.953.6)
.01
.....................................................................................................................................................................................................................................
Reference
.....................................................................................................................................................................................................................................
c
C OMMENT
Our study demonstrated an almost
100% specificity of the APD of the mid
pelvis at 9.5 cm (10th percentile) for
the determination of the need for cesarean delivery. No subject delivered vaginally with an APD of 9 cm. Women
with APD of 90th percentile had a
much lower risk of cesarean delivery.
The inability to identify a threshold
above which every woman delivered vaginally was probably because a multitude
of factors, rather than the pelvic passage
alone, contribute to a vaginal delivery.
This information could be clinically
useful, particularly when counseling patients regarding TOLAC. A simple
method of predicting who will ultimately
have a failed trial of labor could decrease the morbidity of TOLAC. Radiographic pelvimetry with an APD of
10th percentile could be used to identify women who will require repeat cesarean delivery.
Our study has several strengths. The
large sample size allowed us to investigate a relatively infrequent exposure. Because radiography was performed after
delivery, physicians were unable to make
decisions regarding mode of delivery or
the use of vacuum or forceps based on
the measurements, thus limiting bias.
.....................................................................................................................................................................................................................................
c
..............................................................................................................................................................................................................................................
a
The percentage of cesarean deliveries represents the positive predictive value (10th, 5th) or the negative predictive value
(10th, 5th) of the pelvic measurement; b Adjusted for previous cesarean delivery, labor induction; c Adjusted analysis not
performed.
CLINICAL IMPLICATIONS
A minimum anteroposterior diameter of the mid pelvis of 9 cm was required for vaginal delivery.
Further prospective evaluations of radiographic pelvimetry to predict cesarean delivery are necessary.
f
461