Aaron Deutsch

Maternal and neonatal outcomes based on the gestational age of midtrimester preterm premature rupture of membranes

Objectives. Determine neonatal and maternal outcomes based on the gestational age (GA) that midtrimester preterm premature rupture of membranes (mtPPROM) occurs. Study design. A retrospective chart review was conducted on pregnancies with mtPPROM between 180/7 and 236/7 weeks gestation from January 2000 to December 2007. Antenatal complications, maternal morbidity, and neonatal survival and morbidity were analysed by the specific GA of mtPPROM. Statistical analysis was performed using Chi-square, Fishers Exact, and Kruskal–Wallis tests. Results. A total of 105 patients met inclusion criteria. There was a trend for longer latency with earlier GA of mtPPROM (p = 0.05). Neonatal survival to discharge was 26.6%, with an overall morbidity of 86%. Survival was significantly higher with mtPPROM at 22 0/7–23 6/7 weeks compared to 18 0/7–19 6/7 (p = 0.01) and 20 0/7–21 6/7 weeks (p = 0.01). There was no difference in neonatal morbidity based on the GA of mtPPROM. Conclusions. While neonatal survival improves at later GAs of mtPPROM, morbidity continues to be high.

Increased risk of placental abruption in underweight women.

We sought to determine if there is a relationship between prepregnancy underweight status and placental abruption. We utilized the Missouri maternally linked cohort data files covering the period 1989 through 1997. We estimated the association between prepregnancy underweight subtypes and placental abruption using adjusted odds ratios. Subanalyses were performed to determine whether the amount of weight gained during pregnancy could modify the association. A total of 439,235 singleton pregnancies with 3696 abruptions were analyzed. Underweight mothers had a 40% greater likelihood for placental abruption (odds ratio 1.4; 95% confidence interval 1.3 to 1.5). The risk increased with ascending severity of underweight status ( P for trend <0.01). There was a trend toward decreased risk for placental abruption among underweight women with adequate weight gain in pregnancy. Prepregnancy maternal underweight status is associated with placental abruption. This risk may be reduced with adequate weight gain during pregnancy.

Assessment of the alveolar-arterial oxygen gradient as a screening test for pulmonary embolism in pregnancy.

OBJECTIVE The objective of the study was to determine whether the alveolar-arterial (A-a) oxygen gradient is an adequate screening test for pulmonary embolism (PE) in pregnancy and postpartum. STUDY DESIGN A chart review was performed at Tampa General Hospital. Patients who had a workup for a PE consisting of a computed tomography pulmonary angiogram and an arterial blood gas from 2002 to 2009 were included in the analysis. Sensitivity, specificity, and negative and positive predictive values were calculated. Additionally, common clinical signs and symptoms were assessed for their ability to accurately predict PE. RESULTS Of 102 patients, there were 13 PEs (2 antepartum and 11 postpartum). The best sensitivity, specificity, and negative and positive predictive values for A-a gradients were 76.9%, 20.2%, 80.0%, and 11.5%, respectively. CONCLUSION The A-a gradient is a poor screening test for PE in pregnancy and postpartum. Suspicion of PE should prompt early imaging studies to rapidly make the diagnosis and begin treatment.

Cesarean delivery versus vaginal delivery: impact on survival and morbidity for the breech fetus at the threshold of viability

Objective. To determine if cesarean delivery is associated with improved survival and morbidity in the breech fetus at the threshold of viability. Study design. The Missouri maternally linked cohort data files covering the period 1989 through 2005 were utilized for analysis. All pregnancies with singleton fetuses in the breech presentation delivered between 230 and 246 weeks gestation and birth weights between 400 and 750 g were included. Logistic regression was used to compare cesarean to vaginal delivery after controlling for maternal demographics and pregnancy complications. Results. A total of 325 breech singletons were analyzed; cesarean deliveries accounted for 46.1% (150) and vaginal deliveries accounted for 53.9% (175). Cesarean delivery was associated with a survival benefit across all birth weights. Morbidity was higher in cesarean compared to vaginal delivery. Conclusion. Although cesarean delivery appears to be associated with an increase in survival at the threshold of viability for the breech fetus, there is a concomitant increase in morbidity. Any benefit that cesarean delivery conveys on survival at the threshold of viability should be weighed against the increased maternal morbidity and high overall neonatal morbidity.

Cesarean or vaginal delivery for the breech fetus at the threshold of viability: results from a maternal–fetal medicine specialists survey

Objective. To determine how United States Maternal–Fetal medicine specialists recommend delivery of a breech fetus at the threshold of viability. Methods. U.S. Society for Maternal–Fetal Medicine (SMFM) members were surveyed about; geographic location, practice type, whether they performed deliveries, definition of threshold for viability, recommendations for delivery of a breech fetus at the threshold of viability, and if the current medical–legal climate had any bearing on their decisions. Chi-Square and Fishers Exact tests were used for analysis. Results. 510 SMFM members responded to the questionnaire. The highest percentage of respondents stated ‘23 weeks’ (31%) as the cutoff for viability, followed by ‘24 weeks’ (21%) and ‘23 weeks or 500 g’ (10%). Seventy percent recommended cesarean delivery for a breech fetus at the threshold of viability. The majority of respondents based their decision on ‘published data’ or ‘expert opinion’, however, 58.6% reported they felt current medical evidence was inadequate to support a recommendation. Fifty-three percent stated their recommendations are affected by medical–legal concerns. Conclusion. The majority of U.S. maternal fetal–medicine specialists who responded would recommend cesarean delivery for a breech fetus at the threshold of viability, despite the belief that there is inadequate evidence in the literature to support this recommendation.