Amanda Yeaton-Massey

Uterine rupture after uterine artery embolization for symptomatic leiomyomas.

BACKGROUND: There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. CASE: We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. CONCLUSION: Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies.

Racial/ethnic variations in perineal length and association with perineal lacerations: a prospective cohort study.

Abstract Objective: To examine the association between race/ethnicity, perineal length and the risk of perineal laceration. Methods: This is a prospective cohort study of a diverse group of women with singleton gestations in the third trimester of pregnancy. Perineal length was measured and mean values calculated for several racial/ethnic groups. Chi-squared analyses were used to examine rates of severe perineal laceration (third or fourth degree laceration) by race/ethnicity among women considered to have a short perineal length. Further, subgroup analyses were performed comparing nulliparas to multiparas. Results: Among 344 study participants, there was no statistically significant difference in mean perineal length by race/ethnicity (White 4.0 ± 1.1 cm, African-American 3.7 ± 1.0 cm, Latina 4.1 ± 1.1 cm, Asian 3.8 ± 1.0 cm, and other/unknown 4.0 ± 0.9 cm). Considering parity, more multiparous Asian and African-American women had a short perineal length (20.7 and 23.5%, respectively, p = 0.05). Finally, the rate of severe perineal lacerations in our cohort was 2.6% overall, but was 8.2% among Asian women (p = 0.04). Conclusions: We did not find a relationship between short perineal length and risk of severe perineal laceration with vaginal delivery, or a difference in mean perineal length by maternal race/ethnicity. However, we did find that women of different racial/ethnic groups have varying rates of severe perineal laceration, with Asian women comprising the highest proportion.

Maternal bladder cancer diagnosed at routine first-trimester obstetric ultrasound examination.

BACKGROUND: Bladder cancer is exceedingly rare in pregnancy and most commonly presents with gross hematuria. CASES: We describe two patients with the incidental finding of maternal bladder masses identified during routine first-trimester obstetric ultrasonographic evaluation and an ultimate diagnosis of carcinoma. After referral for urology evaluation and biopsy confirmation of bladder cancer, patients underwent surgical resection during their pregnancies without the need for further treatment and had uncomplicated pregnancy courses. CONCLUSION: The distended maternal urinary bladder at the time of first-trimester ultrasonographic evaluation offers a unique opportunity for examination and early diagnosis of incidental maternal bladder carcinoma.

Preference toward future mode of delivery: how do antepartum preferences and prior delivery experience contribute?

Abstract Objective: Examine postpartum preferences toward future mode of delivery (MOD), considering recent MOD, antepartum preferences, and demographics. Study design: Prospective cohort study where a survey was distributed in outpatient obstetrics clinics to pregnant women over 18 years at 28 weeks gestation or later. Surveys gathered demographics, obstetric history, and preference toward vaginal delivery (VD) versus cesarean delivery (CD). Women were again surveyed at 6–8 weeks postpartum. Chi-square test compared proportions, and logistic regression controlled for potential confounders. Results: A total of 299 women returned postpartum surveys and expressed preferences. Comparing women who experienced VD versus CD, the majority who had a VD (92.1%) would choose this again, while only 1.9% preferred CD. Among the CD group, preferences were mixed: 29.4% desired repeat CD, 34.1% preferred VD, and 36.5% were undecided (p < 0.001). Adjusted odds were 34.4 (95% CI 9.4–126.1) for preferring VD over CD among women who experienced a recent VD, adjusting for parity, age, ethnicity, education, possible depression, and type of provider. Conclusions: The majority of women preferred VD postpartum. Of the minority who desired CD, antenatal preference for cesarean and prior experience with CD were important factors. This highlights the impact of individual desires and experience, and underscores importance of antenatal counseling.

Effect of Glycemic Control on Maternal Serum Pregnancy-Associated Plasma Protein A

INTRODUCTION: The objective of this study was to determine if pregnancy-associated plasma protein A (PAPP-A) is correlated with glycosylated hemoglobin A1C in women with and without pregestational diabetes. METHODS: Retrospective cohort study of women with singleton pregnancies and an A1C collected within 4 weeks of first-trimester analyte screening. Pregnancies with aneuploidy or not continued beyond 20 weeks were excluded. We used American Diabetes Association guidelines to define glycemic control categories (prediabetes: A1C 5.7–6.4%; diabetes: greater than 6.5%). Analysis of variance was used to compare mean difference in logarithmic PAPP-A by glycemic control. Bivariate correlation between PAPP-A and A1C was examined using Pearsons correlation coefficient. Multiple logistic regressions were used to further understand the relationship between PAPP-A and A1C after controlling for age and the time interval between the two tests. RESULTS: There were 372 eligible women; 8.3% had diabetes and 10.0% had prediabetes by A1C. There were no significant differences in mean PAPP-A by glycemic control (no diabetes 0.0238, prediabetes 0.0680, diabetes 0.0010; P=.548). There was no significant correlation between A1C and PAPP-A across A1C values (r=−0.05, P=.35) or between A1C and PAPP-A in the subset of women with A1C values greater than 6.5% (n=31, r=−0.11, P=.56) and women who required medication to treat diabetes in the first-trimester (n=38, r=−0.24, P=.13). After adjusting for age, body mass index, and time between the two tests, a significant correlation was found between logarithmic A1C and PAPP-A among women who required medication to treat diabetes (P=.048). CONCLUSIONS: There is a negative correlation between A1C and PAPP-A, particularly in women who used medication to treat diabetes.

How do maternal views of delivery outcomes vary by demographics and preferred mode of delivery

OBJECTIVE To investigate how maternal views of delivery outcomes vary by demographic characteristics and preference toward mode of delivery (MOD). STUDY DESIGN Survey of 719 pregnant women in outpatient clinics at an academic institution during their third trimester. Women ranked outcomes such as vaginal delivery (VD), cesarean delivery (CD), urinary incontinence, perineal lacerations, and induction of labor (IOL) on a visual analog scale (VAS) in order of worst imaginable (0) to best possible (100) outcomes. RESULTS Women of all ages ranked VD as more desirable than CD. However, women ≥ 35 years of age had greater valuations of both MOD compared with women <35 years, with mean VAS scores of 88.4 versus 86.4 for VD (p < 0.001) and 61.5 versus 51.9 for CD (p < 0.001). Women with a college education or higher also rated both MOD as more desirable than women with less than a college education. Additionally, women who preferred VD rather than CD had greater valuations of perineal laceration (43.3 vs. 31.5, p = 0.001) and urinary incontinence (40.7 vs. 30.1, p = 0.002). CONCLUSION Significant differences exist in womens views toward MOD and peripartum outcomes, by demographics and preferred MOD. Understanding delivery preferences better enables clinicians to counsel women about labor and management options.

Risk factors for classical hysterotomy in twin pregnancies.

OBJECTIVE: To describe the rate of classical hysterotomy in twin pregnancies across gestational age and examine risk factors that increase its occurrence. METHODS: This is a secondary analysis of the Cesarean Registry, a cohort study of women who underwent a cesarean delivery or a trial of labor after cesarean delivery at 19 academic centers between 1999 and 2002. Our study included all women with twin pregnancies and a recorded hysterotomy type who underwent cesarean delivery between 23 0/7 and 41 6/7 weeks of gestation. Primary exposures were gestational age at delivery and combined birth weight of twin A and twin B. Multivariate logistic regression was used to study factors thought to influence hysterotomy type including maternal age, body mass index (BMI) at delivery, obesity (BMI 30 or higher), nulliparity, labor, prior cesarean delivery, emergent delivery, and fetal presentation at delivery. RESULTS: Of 1,820 women meeting inclusion criteria, 125 (7%) underwent a classical hysterotomy. The risk of classical hysterotomy was greatest at 25 weeks of gestation (41%) and declined thereafter. The adjusted odds ratio (OR) for cesarean delivery declined as gestation age advanced (OR 0.87, 95% confidence interval 0.78–0.98). African American race and emergent delivery were associated risk factors for classical hysterotomy at 32 weeks of gestation or greater. CONCLUSION: Among women with twin pregnancies who deliver by cesarean, the incidence of classical hysterotomy is inversely related to gestational age but does not exceed 50% at any week; African American race and emergent delivery are associated risk factors at 32 weeks of gestation or greater. LEVEL OF EVIDENCE: II

Urine Culture Results and Adverse Outcomes in Women With Pyelonephritis

INTRODUCTION: A retrospective cohort study of patients with pyelonephritis in pregnancy and immediately postpartum was conducted. Participants delivered between 2005 and 2009 at a single university center (Lucile Packard Childrens Hospital at Stanford) were reviewed. Pyelonephritis was defined by a temperature greater than 38.0°C, flank pain or costovertebral angle tenderness, and bacteruria or pyuria on urinalysis. All patients with pyelonephritis and urine culture results were included. Univariate analyses were performed with the &khgr;2 test. Means were compared with the Students t test. RESULTS: One hundred thirteen patients were admitted with pyelonephritis and had a urine culture performed. Of the entire cohort, 70% of patients were Hispanic, 53% were nulliparous, and most were diagnosed in the third trimester. A total of 94 patients (83%) had positive urine cultures. There were no differences in adverse outcomes (preterm birth, anemia, bacteremia, acute respiratory distress syndrome, and hospital stay) between those with positive and negative urine cultures. Among those with positive cultures, there was a statistically significant increase in preterm birth (less than 37 weeks of gestation) between those with resistant uropathogens and those with pan-sensitive pathogens (26.5% compared with 7.6%, P=.01) (Table 1). Table 1 Complications Rates by Culture Status CONCLUSION: Among women with pyelonephritis, complications did not differ between those with positive and negative urine culture results. Women with resistant bacterial uropathogens are at increased risk for preterm birth compared with those with sensitive pathogens.