Adi Hirshberg

Biomarkers and cervical length to predict spontaneous preterm birth in asymptomatic high-risk women.

OBJECTIVE: To investigate whether biomarkers from different pathways of spontaneous preterm birth (cervical membrane degradation [fetal fibronectin], cervical remodeling [soluble E-cadherin], and inflammation (elafin, surfactant protein-D, interleukin-6 [IL-6]) were superior to one biomarker alone in predicting preterm birth. Our secondary objective was to examine the association of these biomarkers with cervical length in predicting preterm birth. METHODS: We performed a single-center, prospective cohort study from August 2011 to November 2012 of asymptomatic women at risk for spontaneous preterm birth as a result of obstetric and gynecologic history. Cervicovaginal fluid and cervical length measurements were collected at two time points (20–23 6/7 weeks and 24–27 6/7 weeks of gestation). RESULTS: Among the 104 women with complete data, the preterm birth rate was 24.5%. Prior preterm birth (P=.006) and cervical length at visit 1 (P=.003) were significantly associated with preterm birth, whereas fetal fibronectin and median biomarker levels (elafin, soluble E-cadherin, IL-6) were not. Median surfactant protein-D levels at visit 1 by preterm birth status were statistically but not clinically different (0.44 ng/mL compared with 0.40 ng/mL, P<.001). Analyses of biomarkers from more than one pathway were not superior to single biomarker analyses in predicting prematurity. Neither inclusion of biomarkers nor fetal fibronectin improved the predictive ability of cervical length alone. CONCLUSION: Cervical length assessment and obstetric history but not fetal fibronectin or biomarkers were useful in the risk stratification of women identified to be at greatest risk for spontaneous preterm birth. LEVEL OF EVIDENCE: II

Term induction of labor and risk of cesarean delivery by parity

Abstract Objective: To evaluate the risk of cesarean delivery among both nulliparous and multiparous women undergoing a term induction of labor compared to women that present in spontaneous labor at term. Methods: We performed a retrospective cohort study of term (≥37 weeks) singleton pregnancies between 2005 and 2010 comparing women that had an induction to those that presented in spontaneous labor. Multiparity was defined as a prior delivery after 20 weeks’ gestation. Chi-square was used to compare categorical variables. Multivariable logistic regression was used to control for confounders. Analyses were stratified by parity. Results: 863 women were included in the analysis. There were 605 inductions (cesarean rate 23%) and 257 spontaneous labor (cesarean rate 7%), OR 3.4, 95% CI [2.1–5.4]. Stratified by parity, nulliparas undergoing induction had an increased cesarean rate compared to spontaneous labor (27% versus 11%, OR 3.13, 95% CI [1.76–5.57]) as did multiparas (13% versus 3%, OR 4.04, 95% CI [1.36–11.94]). This increased risk for cesarean after induction remained in both nulliparous and multiparous women even after controlling for confounders (aOR 2.90, 95% CI [1.60–5.25] and aOR 3.47, 95% CI [1.12–10.67], respectively). Neither starting cervical exam nor indication for induction altered this increased risk. Conclusions: The increased risk of cesarean in women undergoing an induction is present regardless of parity and indication for induction. This should be taken into account when counseling women regarding risks of induction, regardless of parity. Future studies should focus on other clinical characteristics of induction that may mitigate this risk.

Role of operative vaginal deliveries in prevention of cesarean deliveries.

Although the number of cesarean deliveries increased from 23% to 34.7% between 1996 and 2006, forceps and vacuum use declined, from 6.3% to 1.7% and 6.8% to 5.5%, respectively. When spontaneous vaginal delivery in the second stage of labor is not a possibility, operative vaginal delivery may be a safe, acceptable alternative to cesarean delivery. We explore indications for operative deliveries and the benefits and risks as compared with cesarean. In addition, we review the barriers to forceps and vacuum use and the importance of continued training to increase the number of providers who are able to safely perform these skills.

Clinical factors associated with readmission for postpartum hypertension in women with pregnancy-related hypertension: a nested case control study

Objective:To evaluate the association between mode of delivery and length of labor on readmission for postpartum hypertension in women with pregnancy-related hypertension.Study Design:Nested case control study within a cohort of 99 women with pregnancy-related hypertension who delivered at our institution between 2005 and 2009. Data were abstracted for clinical and labor information. Mode of delivery and length of labor were compared between women with previously diagnosed pregnancy-related hypertension readmitted within 4 weeks post partum (25 cases) and those not readmitted (74 controls). Categorical and continuous variables were compared using χ2 and T-tests, respectively. Multivariable logistic regression controlled for confounders.Result:Hypertension readmission was not associated with mode of delivery (cases: 10(40%) spontaneous vaginal delivery, 15(60%) cesarean delivery; controls: 38(51%) spontaneous vaginal delivery, 36(49%) cesarean delivery, P=0.33). Length of labor appeared longer in cases, with a trend toward significance (median: 15.5 [7,28] h vs 10.75 [5.8,15.9] h, P=0.12) and was significantly associated with readmission after controlling for delivery mode, induction and parity (adjusted odds ratio=1.06 [1 to 1.12], P=0.048). Readmitted patients were less likely to have initially been started on antihypertensive medications after controlling for age, race and chronic hypertension (adjusted odds ratio=0.23 [0.06 to 0.88], P=0.03).Conclusion:Postpartum readmission for hypertension in women with known pregnancy-related hypertension is not associated with mode of delivery, appears increased in those with longer length of labor and decreased in those initially started on antihypertensive medications. This provides targets for future research to continue to improve transitions of care and reduce preventable readmissions.

Labor length among overweight and obese women undergoing induction of labor.

Abstract Objective: Maternal weight is thought to impact labor. With rising rates of obesity and inductions, we sought to evaluate labor times among induced women by body mass index (BMI) category. Methods: Retrospective cohort study of term inductions from 2005 to 2010. BMI categories were: normal weight (NW), overweight (OW), and obese (Ob) (18.5–24.9, 25–29.9, ≥30 kg/m2). Kruskal–Wallis tests compared median latent labor (LL) length and active labor (AL) length. Chi-square determined associations. Multivariable logistic regression controlled for confounders. Analyses were stratified by parity. Results: A total of 448 inductions were analyzed. For nulliparas, there was no difference in LL by BMI category (p = 0.22). However, OW nulliparas had a longer AL compared to NW and Ob nulliparas (3.2, 1.7, 2.0 h, p = 0.005). For multiparas, NW had the shortest LL (5.5 h, p = 0.025) with no difference in AL among BMI categories (p = 0.42). The overall cesarean rate was 23% with no difference by BMI category (p = 0.95). However, Ob women had a greater percentage of first stage cesareans (41%) and NW had a greater percentage of second stage cesareans (55%), p = 0.06. Conclusion: The association between BMI and labor length among inductions differs by phase of labor and parity. BMI also influences the stage of labor in which a cesarean occurs.

Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial

Background Monitoring blood pressure at 72 hours and 7–10 days post partum in women with hypertensive disorders is recommended to decrease morbidity. However, there are no recommendations as to how to achieve this. Objective To compare the effectiveness of text-based blood pressure monitoring to in-person visits for women with hypertensive disorders of pregnancy in the immediate postpartum period. Methods Randomised clinical trial among 206 postpartum women with pregnancy-related hypertension diagnosed during the delivery admission between August 2016 and January 2017. Women were randomised to 2 weeks of text-based surveillance using a home blood pressure cuff and previously tested automated platform or usual care blood pressure check at their prenatal clinic 4–6 days following discharge. The primary study outcome was a single recorded blood pressure in the first 10 days post partum. The ability to meet American Congress of Obstetricians and Gynecologists (ACOG) guidelines, defined as having a blood pressure recorded on postpartum days 3–4 and 7–10 was evaluated in the text message group. The study was powered to detect a 1.4-fold increase in a single recorded blood pressure using text messaging. All outcomes were analysed as intention to treat. Results 206 women were randomised (103 in each arm). Baseline characteristics were similar. There was a statistically significant increase in a single blood pressure obtained in the texting group in the first 10 days post partum as compared with the office group (92.2% vs 43.7%; adjusted OR 58.2 (16.2–208.1), p<0.001). Eighty-four per cent of patients undergoing text-based surveillance met ACOG criteria for blood pressures at both recommended points. Conclusions Text-based monitoring is more effective in obtaining blood pressures and meeting current clinical guidelines in the immediate postdischarge period in women with pregnancy-related hypertension compared with traditional office-based follow-up. Trial registration number NCT03185455, Remote Surveillance of Postpartum Hypertension (TextBP), https://clinicaltrials.gov.

Reversed end-diastolic flow in the middle cerebral artery preceding death in a normally grown fetus.

BACKGROUND: Reversed diastolic flow in the middle cerebral artery has been described as a terminal sign in the growth-restricted fetus. The implication of this in a normally grown fetus is unknown. CASE: Middle cerebral artery Doppler velocimetry was performed at 28 weeks of gestation in the setting of decreased fetal movement and a category 2 fetal heart tracing. The middle cerebral artery pulsatility index was elevated, and follow-up studies revealed reversed flow. The fetus had appropriate growth, with mild polyhydramnios and no signs of cardiomegaly, effusion, or hydrops. Fetal death was diagnosed 4 days later in the setting of extensive intracranial hemorrhage. CONCLUSION: Regardless of fetal growth, persistent reversed middle cerebral artery Doppler with an elevated pulsatility index may be a feature of impending death.

Interpregnancy Body Mass Index Changes: Distribution and Impact on Adverse Pregnancy Outcomes in the Subsequent Pregnancy

Objective To examine the change in body mass index (BMI) categories between pregnancies and its effect on adverse pregnancy outcomes. Study Design We performed a retrospective cohort study of women with two consecutive deliveries from 2005 to 2010. Analysis was limited to women with BMI recorded at <24 weeks for both pregnancies. Standard BMI categories were used. Adverse pregnancy outcomes included preterm birth at <37 weeks, intrauterine growth restriction (IUGR), pregnancy‐related hypertension, and gestational diabetes mellitus (GDM). Women with increased BMI category between pregnancies were compared with those who remained in the same BMI category. Results In total, 537 women were included, of whom 125 (23%) increased BMI category. There was no association between increase in BMI category and risk of preterm birth, IUGR, or pregnancy‐related hypertension. Women who increased BMI category had an increased odds of GDM compared with women who remained in the same BMI category (6.4 vs. 2.2%; p = 0.018). The increased risk remained after controlling for age, history of GDM, and starting BMI (adjusted odds ratio: 8.2; 95% confidence interval: 2.1‐32.7; p = 0.003). Conclusion Almost one‐quarter of women increased BMI categories between pregnancies. This modifiable risk factor has a significant impact on the risk of GDM.

Determining the Rate and Causes of Severe Maternal Morbidity to Improve Obstetric Quality of Care [9R]

INTRODUCTION: Identifying cases of severe maternal morbidity (SMM) and reviewing the underlying cause is essential to improving quality of obstetrical care. We sought to determine the rate and causes of SMM using an expanded definition including ICU admission, unanticipated hysterectomies, 2 or more liters blood loss (EBL), transfusion of 4 or more units of any blood product, and select readmissions. METHODS: We prospectively identified women who met criteria for SMM at our institution from July 1, 2014 to June 30, 2015. All cases were reviewed and discussed by a multidisciplinary team. Analysis was limited to patients who delivered at our institution. RESULTS: 4198 deliveries occurred during the 12 month period. Fifty-two (1.2%) women experienced a SMM (62% cesarean deliveries, 89% postpartum). Of the 52 women, 29 (56%) met 1 criteria, 20 (38%) met 2 criteria, and 3 (6%) met 3 or more criteria (33% ICU, 46% blood products, 62% EBL, 6% hysterectomies, 12% readmissions). Women with cesarean delivery were more likely to experience more than 4 units pRBCs as reason for SMM (P=.05). ICU admissions were no different by mode of delivery. Restricting the definition of SMM to ICU admission and 4 or more units of pRBC identified only 69%. CONCLUSION: SMM occurs more postpartum and in women with cesarean deliveries. Restricting the SMM definition leads to missed opportunities in identifying additional cases of SMM, specifically those with large EBL and readmissions with delayed morbidity. Future tracking and evaluation of SMM should include large EBL and postpartum readmission to help identify and improve all aspects of SMM.

A random protein–creatinine ratio accurately predicts baseline proteinuria in early pregnancy

Abstract Objective: Data surrounding the use of a random urine protein:creatinine ratio (PCR) in the diagnosis of preeclampsia is conflicting. We sought to determine whether PCR in early pregnancy can replace the 24-hour urine collection as the primary screening test in patients at risk for baseline proteinuria. Methods: Women requiring a baseline evaluation for proteinuria supplied a urine sample the morning after their 24-hour collection. The PCR was analyzed as a predictor of significant proteinuria (≥150 mg). A regression equation to estimate the 24-hour protein value from the PCR was then developed. Results: Sixty of 135 subjects enrolled completed the study. The median 24-hour urine protein and PCR were 90 mg (IQR: 50–145) and 0.063 (IQR: 0.039–0.083), respectively. Fifteen patients (25%) had significant proteinuria. PCR was strongly correlated with the 24-hour protein value (r = 0.99, p < 0.001) and highly predictive of significant proteinuria (AUC = 0.86). A PCR cut-point of 0.079 yielded a sensitivity of 93.3% and a specificity of 57.8%. The resulting regression equation [total protein = 46.5 + 904.2*PCR] accurately estimates the actual 24-hour protein (95% CI: ±88 mg). Conclusion: A random urine PCR accurately estimates the 24-hour protein excretion in the first half of pregnancy and can be used as the primary screening test for baseline proteinuria in at-risk patients.