Evaluation of postural therapy using lateral position according to fetal back orientation on breech presentation and breech recurrence (BRLT study): An open-label randomized controlled trial.

IF 15.8 1区 医学 Q1 Medicine
PLoS Medicine Pub Date : 2025-03-25 eCollection Date: 2025-03-01 DOI:10.1371/journal.pmed.1004555
Hiroki Shinmura, Youhei Tsunoda, Takashi Matsushima, Ryuhei Kurashina, Asako Watanabe, Eika Harigane, Nozomi Ouchi, Shunji Suzuki
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Abstract

Background: In Japan, the lateral position method is known as a postural therapy for breech presentation wherein the mother lies down in lateral position according to the orientation of the fetal back. Few studies have formally tested lateral position management for breech presentation, and no method exists to prevent breech recurrence after cephalic version. We hypothesized that postural management comprising a combination of opposite-side lateral position for breech presentation and same-side lateral position after cephalic version demonstrates a clinically relevant effect size on breech presentation.

Methods and findings: We conducted a stratified, open-label randomized controlled trial at an academic hospital in Kawasaki, Japan. A total of 200 women diagnosed with breech presentation between 28 +  0 and 30 +  0 gestational weeks were randomized to postural management (n =  100) or control (no intervention, n =  100) group. The intervention was instruction every 2 weeks on lying in the lateral position on the opposite-side of fetal back for breech presentation and on the same-side of fetal back for head-first presentation. The primary outcome was the rate of fetuses in breech presentation at 37 weeks of gestation, and the secondary outcomes were cesarean delivery, cesarean delivery for breech presentation, head presentation 2, 4, and 6 weeks later, breech presentation recurrence, and adverse events. Breech presentation rate at 37 gestational weeks was 11% in the intervention group, using the combination of the opposite-side and same-side lateral positions, compared with 19% in the control group. However, we found no statistical significance in the intention-to-treat analysis (11% [11/100] versus 19% [19/100]; relative risk, 0.58 [95% CI, 0.29 to 1.15]; p =  0.11). In the control group, 23 participants (23%) unknowingly took the same posture as the intervention group, and the prespecified per-protocol analysis excluding crossover found the same direction of effect but with statistical significance. In the intention-to-treat analysis, the intervention group had a higher cephalic version rate 2 weeks after the instruction (69% [69/100] versus 54% [54/100]; relative risk, 0.67 [95% CI, 0.47 to 0.96]; p =  0.029), and lower breech presentation recurrence rates (2% [2/91] versus 10% [9/88]; relative risk, 0.22 [95% CI, 0.048 to 0.97]; p =  0.031) than the control group. Regarding adverse events in the intervention group, three participants experienced discomfort and one participant complained of pain in the lateral abdomen; these symptoms resolved spontaneously.

Conclusions: For breech presentation at the beginning of the third trimester, providing postural therapy instruction on opposite-side lateral positioning and same-side lateral positioning was associated with 8% reduction of breech fetuses at 37 gestational weeks compared with the control group, but this primary endpoint did not reach statistical significance. Regarding the secondary endpoints, the intervention group showed a significantly higher rate of cephalic version after 2 weeks and lower rate of breech recurrence. The direction of the effect of postural therapy based on fetal back position on breech presentation was promising, and further research to validate this approach, with consideration for unplanned participant crossover, may be warranted.

Trial registration: UMIN Clinical Trials Registry (UMIN000043613, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800).

评估体位疗法使用侧位根据胎儿背部朝向对臀位表现和臀位复发(BRLT研究):一项开放标签随机对照试验。
背景:在日本,侧卧位法被称为一种针对臀位的体位疗法,其中母亲根据胎儿背部的方向侧卧。很少有研究正式测试侧位管理对臀位表现的影响,也没有任何方法可以预防头侧位后臀位复发。我们假设,体位管理包括髋部表现的对侧体位和头侧扭转后的同侧体位的组合,对髋部表现具有临床相关的效应大小。方法和发现:我们在日本川崎的一家学术医院进行了一项分层、开放标签的随机对照试验。共有200名28 + 0 ~ 30 + 0孕周诊断为臀位的妇女被随机分为体位管理组(n = 100)和对照组(无干预组,n = 100)。干预是每2周指导一次胎儿背部对面侧卧位为臀位,头朝前卧位为胎儿背部同侧卧位。主要结局是妊娠37周出现臀位的胎儿率,次要结局是剖宫产、剖宫产出现臀位、2周、4周和6周后出现头位、臀位复发和不良事件。干预组在37孕周时臀位发生率为11%,同时采用对侧和同侧侧卧位,而对照组为19%。然而,我们发现意向治疗分析没有统计学意义(11%[11/100]对19% [19/100];相对危险度为0.58 [95% CI, 0.29 ~ 1.15];P = 0.11)。在对照组中,23名(23%)受试者在不知情的情况下采取了与干预组相同的姿势,预先指定的排除交叉的per-protocol分析发现效果方向相同,但具有统计学意义。在意向治疗分析中,干预组在指导后2周的头侧版本率更高(69%[69/100]对54% [54/100];相对危险度为0.67 [95% CI, 0.47 ~ 0.96];P = 0.029),臀部症状复发率较低(2%[2/91]对10% [9/88];相对危险度为0.22 [95% CI, 0.048 ~ 0.97];P = 0.031)。关于干预组的不良事件,3名参与者感到不适,1名参与者抱怨外侧腹部疼痛;这些症状自然消失了。结论:对于孕晚期初出现臀位的患者,提供对侧侧位和同侧侧位的体位治疗指导,与对照组相比,37孕周时臀位胎数减少8%,但这一主要终点没有达到统计学意义。次要终点方面,干预组2周后头侧畸形发生率显著增高,臀侧复发率显著降低。基于胎儿背部位置的体位治疗对臀位表现的影响方向是有希望的,进一步的研究来验证这种方法,考虑到意外的参与者交叉,可能是有必要的。试验注册:UMIN临床试验注册中心(UMIN000043613, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800)。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
PLoS Medicine
PLoS Medicine MEDICINE, GENERAL & INTERNAL-
CiteScore
17.60
自引率
0.60%
发文量
227
审稿时长
4-8 weeks
期刊介绍: PLOS Medicine is a prominent platform for discussing and researching global health challenges. The journal covers a wide range of topics, including biomedical, environmental, social, and political factors affecting health. It prioritizes articles that contribute to clinical practice, health policy, or a better understanding of pathophysiology, ultimately aiming to improve health outcomes across different settings. The journal is unwavering in its commitment to uphold the highest ethical standards in medical publishing. This includes actively managing and disclosing any conflicts of interest related to reporting, reviewing, and publishing. PLOS Medicine promotes transparency in the entire review and publication process. The journal also encourages data sharing and encourages the reuse of published work. Additionally, authors retain copyright for their work, and the publication is made accessible through Open Access with no restrictions on availability and dissemination. PLOS Medicine takes measures to avoid conflicts of interest associated with advertising drugs and medical devices or engaging in the exclusive sale of reprints.
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