Amber M. Wood

Optimal Admission Cervical Dilation in Spontaneously Laboring Women.

OBJECTIVE To estimate the impact of admission cervical dilation on the risk of cesarean in spontaneously laboring women at term. STUDY DESIGN Secondary analysis of a prospective cohort study of women admitted in term labor with a singleton gestation. Women with rupture of membranes before admission, induction of labor, or prelabor cesarean were excluded. The association between cesarean and cervical dilation at admission was estimated, and results were stratified by parity. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated, using cervical dilation ≥ 6 cm as the reference group. Cesarean for arrest was secondarily explored. RESULTS A total of 2,033 spontaneously laboring women met inclusion criteria. Women admitted at <6 cm dilation had an increased risk of cesarean compared with those admitted at ≥6 cm (13.2 vs. 3.5%; RR 3.73; 95% CI 1.94-7.17). The increased risk was noted in nulliparous (16.8 vs. 7.1%; RR 2.35; 95% CI 0.90-6.13) and multiparous (11.0 vs. 2.5%; RR 4.36; 95% CI 1.80-10.52) women, but was statistically significant only in multiparous women. CONCLUSIONS Decreasing cervical dilation at admission, particularly <6 cm, is a modifiable risk factor for cesarean, especially in multiparous women. This should be considered in the decision-making process about timing of admission in term labor.

Prenatal genetic diagnosis of Neu-Laxova syndrome

A 21-year-old woman, gravida 3 para 0, presented for first trimester screening. Pregnancy was notable for consanguinity (Figure 1) and a history of a prior foetus with Neu-Laxova syndrome (NLS). Her first pregnancy was terminated at 7months in India due to abnormal ultrasound findings, including foetal growth restriction, foetal akinesia, microcephaly, micrognathia and scoliosis. The autopsy revealed microcephaly, lissencephaly, agenesis of the corpus callosum, cerebellar hypoplasia, small long bones, lumbar kyphosis, congenital cataracts and dysmorphic features, and a clinical diagnosis of NLS was made. Genetic testing was not performed. Her subsequent pregnancy was terminated at 6weeks. Ultrasound at 12weeks of gestation demonstrated a thickened nuchal translucency (NT) and abnormal CNS with a small cranium and abnormal posterior fossa. Chorionic villus sampling (CVS) was performed and the patient and her husband underwent carrier testing for NLS. CVS karyotype results were normal (46, XY). Parental NLS results revealed that both the parents were heterozygous for the point mutation c.399G>A in the phosphoglycerate dehydrogenase (PHGDH) gene. Following identification of the mutation, directed prenatal molecular testing for NLS on the CVS tissue was performed. The 18-week ultrasound revealed a thickened nuchal fold and facial oedema. There was no apparent cavum septum pellucidum. Minimal foetal movement was noted, concerning for foetal akinesia. The upper extremities appeared short and fixed, with contracted hands and the lower legs were also fixed in a crossed position. A significant growth lag and microcephaly was noted, with foetal measurements 3weeks behind expected. Genetic analysis from the CVS returned at this time and the foetus was found to be homozygous for the familial variant c.399G>A in the PHGDH gene, consistent with a diagnosis of NLS1. The pregnancy was terminated by dilation and evacuation. Autopsy was not performed.

Detection and Prevention of Perinatal Infection

Congenital cytomegalovirus is the most common viral congenital infection, and affects up to 2% of neonates. Significant sequelae may develop after congenital cytomegalovirus, including hearing loss, cognitive defects, seizures, and death. Zika virus is an emerging virus with perinatal implications; a congenital Zika virus syndrome has been identified, and includes findings such as microcephaly, fetal nervous system abnormalities, and neurologic sequelae after birth. Screening, diagnosis, prevention, and treatment of these perinatal infections are reviewed in this article.

Cervical Cerclage versus Vaginal Progesterone for Management of Short Cervix in Low-Risk Women

Objective To evaluate the risk of preterm birth in low‐risk women with cervical length (CL) ≤25 mm on transvaginal ultrasound (TVUS) managed with vaginal progesterone (VagP) therapy versus cerclage. Study Design This is a retrospective cohort of women with no prior history of preterm birth or cervical insufficiency and CL ≤ 25 mm on TVUS, managed with either VagP therapy alone or cerclage (with or without VagP). The primary outcome was rate of preterm delivery < 37 weeks gestational age (GA). Secondary outcomes included delivery at ≤ 32 or ≤ 28 weeks GA, premature preterm rupture of membranes, pregnancy latency, GA at delivery, and composite neonatal outcome. Results Women undergoing cerclage placement (n = 31) were older and had an earlier GA at the time of diagnosis of short cervix compared with women receiving VagP (n = 62). Delivery at < 37 weeks occurred in 21/62 (33.9%) in the VagP group and 14/31 (45.2%) in the cerclage group (adjusted odds ratio: 1.72, 95% confidence interval: 0.52, 5.66). There were no differences in secondary outcomes. Conclusion Cerclage compared with VagP therapy did not decrease risk of preterm birth in women with CL ≤ 25 mm. Further research is needed to determine optimal management in such women given a residual 40% risk of preterm birth despite optimal therapy.

Neonatal Outcomes Associated with Noncephalic Presentation at Delivery in Preterm Birth

Objective The objective of this study is to evaluate the effect of noncephalic presentation on neonatal outcomes in preterm delivery. Study Design In this study a secondary analysis of the BEAM trial was performed. It included women with singleton, liveborn, and nonanomalous fetuses. Neonatal outcomes were compared in noncephalic versus cephalic presentation. Adjusted odds ratios and 95% confidence intervals were calculated for each outcome with logistic regression while controlling for possible confounders. A stratified analysis by mode of delivery was also performed in this study. Results A total of 458 noncephalic deliveries were compared with 1,485 cephalic deliveries. In multivariate analysis, noncephalic presentation was associated with increased risk of death in the neonatal intensive care unit (NICU) or death at <15 months corrected gestational age (cGA), and a decreased risk of IVH. The risk of death persisted in stratified analysis, with increased risk of death at <15 months cGA in noncephalic neonates born via cesarean delivery. In the vaginal delivery group, there was an increased risk of death at <15 months cGA and NICU death. Conclusion After controlling for possible confounders, neonates who are noncephalic at delivery have higher risk for death <15 months cGA and death in the NICU while their risk of IVH is reduced. The risk of death persisted in stratified analyses by mode of delivery.

Group B strep and associated complications in cesarean delivery

1 Group B strep and associated complications in cesarean delivery A. M. Wood, B. L. Hughes, R. P. Heine, M. S. Villers Duke University Medical Center, Durham, NC OBJECTIVES: The objective of this study is to determine the effect of Group B streptococcus (GBS) on maternal infectious complications in women undergoing cesarean delivery (CD) in an era of routine GBS antibiotic prophylaxis during labor. METHODS: Retrospective cohort of women undergoing CD during labor at 37 weeks gestation or greater from January to December 2014. Intrapartum and postpartum complications were compared between women without GBS and those with a positive culture or unknown GBS status. Routine pre-operative antibiotics were used for all women. Labor at time of cesarean was documented by physician notes. Univariate analysis was performed using chi-square and Mann-Whitney U tests. A logistic regression analysis was then performed to control for potential confounders. RESULTS: 398 women had complete data and were included. 255 women (64%) were GBS negative, and 143 were GBS positive or unknown (36%). Compared to GBS negative women, GBS positive women were had a higher BMI and parity, and lower gestational age at delivery. They were less likely to have private insurance or be of white race. They had an increased incidence of gestational diabetes or hypertensive disorders of pregnancy. There were no significant differences in length of rupture of membranes, reported penicillin allergies, or surgical technique. In univariate analysis, women with GBS were noted to have a significantly lower incidence of clinical chorioamnionitis (5% vs 18%, p1⁄40.001). There were no differences in rates of endometritis or wound infection. In adjusted analysis for the outcome chorioamnionitis, women with GBS had a decreased risk of chorioamnionitis (aOR 0.17, 95% CI 0.07, 0.44). CONCLUSIONS: Within our cohort, women who were GBS positive and underwent CD in labor had a significantly lower risk of chorioamnionitis than women who were GBS negative. There were no significant differences in other postpartum infectious complications.