Anat Kalter

Maternal and neonatal outcomes of large for gestational age pregnancies.

Objective. To compare maternal and neonatal outcomes of term large for gestational age (LGA) pregnancies and adequate for gestational age (AGA) pregnancies. Design. Retrospective analysis. Setting. Large university research medical center. Population. All term singleton LGA (birthweight ≥90th percentile) and AGA pregnancies (birthweight 10.1–89.9th percentile) delivering between 2004 and 2008. Methods. Data collected included maternal age, gestational age at delivery, mode of delivery, birthweight, fetal sex, and maternal and neonatal complications. Birthweight percentiles were determined according to locally derived gender‐specific birthweight tables. Main outcome measures. Comparisons between LGA and AGA pregnancies and between LGA 90–94.9th, 95–98.9th and ≥99th percentile. Results. The study population comprised 34 685 pregnancies; 3900 neonates matched the definition of term LGA. Maternal age and gestational age at delivery were significantly higher for LGA neonates. Significantly more LGA neonates were born by cesarean section, and significantly more LGA pregnancies were complicated by postpartum hemorrhage (PPH), shoulder dystocia or neonatal hypoglycemia, and had a longer hospitalization period. Maternal and neonatal risks increased as birthweight increased from the 90–94.9th to 95–98.9th to ≥99th percentile. Specifically, the risks of shoulder dystocia (odds ratio 2.61, 3.35 and 5.11, respectively), PPH (odds ratio 1.81, 2.12 and 3.92, respectively) and neonatal hypoglycemia (odds ratio 2.53, 3.8 and 5.19, respectively) all increased linearly with birthweight percentile. Conclusions. Large for gestational age pregnancies are associated with an increased rate of cesarean section, PPH, shoulder dystocia and neonatal hypoglycemia, as well as longer hospitalization. These risks increase as the birth percentile rises. These risks need to be emphasized in pre‐delivery counseling.

Maternal and neonatal outcomes of macrosomic pregnancies

Summary Background To compare maternal and neonatal outcomes of term macrosomic and adequate for gestational age (AGA) pregnancies. Material/Methods A retrospective analysis was performed on all term singleton macrosomic (birth weight ≥4000 g) and AGA (birth weight >10th percentile and <4000 g) pregnancies delivered at our hospital between 2004 and 2008. Data collected included maternal age, gestational age at delivery, mode of delivery, birth weight, fetal gender, maternal and neonatal complications. Comparisons were made between macrosomic and AGA pregnancies and between different severities of macrosomia (4000–4250 g, 4250–4500 g and ≥4500 g). Results The study population comprised of 34,685 pregnancies. 2077 neonates had birth weight ≥4000 g. Maternal age and gestational age at delivery were significantly higher for macrosomic neonates. Significantly more macrosomic neonates were born by cesarean section, and were complicated with shoulder dystocia, neonatal hypoglycemia, and had longer hospitalization period (both in vaginal and cesarean deliveries). Specifically, the odds ratio (OR) relative to AGA pregnancies for each macrosomic category (4000–4250 g, 4250–4500 g and ≥4500 g) of shoulder dystocia was 2.37, 2.24, 7.61, respectively, and for neonatal hypoglycemia 4.24, 4.41, 4.15, respectively. The risk of post partum hemorrhage was statistically increased when birth weight was >4500 g (OR=5.23) but not for birth weight between 4000–4500 g. No differences were found in the rates of extensive perineal lacerations between AGA and the different macrosomic groups. Conclusions Macrosomia is associated with increased rate of cesarean section, shoulder dystocia, neonatal hypoglycemia, and longer hospitalization, but not associated with excessive perineal tears. Increased risk of PPH was found in the >4500g group.

Subsequent pregnancy after stillbirth: obstetrical and medical risks

Abstract Objective: To evaluate obstetric outcome after stillbirth according to placental and prothrombotic risk factors. Methods: Obstetric outcomes of women with prior stillbirth and subsequent pregnancies were reviewed. Data on the immediate subsequent pregnancy included fetal loss, stillbirth, obstetric/medical complications, gestational age and birth weight at delivery, mode of delivery, thrombophilia, and prescribed medication. Placental stillbirth was defined as stillbirth associated with placental abruption, intrauterine growth restriction (IUGR), or histological evidence of placental infarcts. Controls were unselected women who gave birth at our center during a single calendar year. Factors influencing recurrence risks were estimated. Results: Seventy-three subsequent pregnancies were identified. Five out of 73 (6.8%) women had a repeat stillbirth, significantly higher than controls (relative risk 22.2, 95% confidence interval 8.9–55.4). Four out of five repeat stillbirth cases occurred <37 weeks gestation. Hypertensive complications, diabetes and abruption were higher, while gestational age and birth weight at delivery were significantly lower than controls. Prior placental stillbirth was associated with a 10.5 times higher risk of IUGR in the subsequent pregnancy compared with non-placental stillbirth. All five repeat stillbirth cases occurred in thrombophilic women. Conclusion: Women with prior stillbirth face an increased risk of pregnancy complications and stillbirth recurrence, especially with concurrent thrombophilia. Most repeat stillbirth cases occur preterm.

Reduced fetal movement: factors affecting maternal perception

Abstract Objective: Evaluate physiologic factors associated with reduced maternal perception of fetal movements (RFM). Methods: A historical cohort study of all women (years 2011–2013, n = 399) that visited the maternal emergency room (ER) (gestational age 24 + 0–42 + 0) due to RFM (group A), that was compared to a control group consisted from women with normal perception of fetal movements (group B). Groups were compared for maternal characteristics (age, gravity, parity, BMI), gestational age, placental location, gestational age at birth and fetal outcomes (birth-weight and Apgar scores). Results: In a multivariate regression analysis, including maternal age, height, weight, BMI, gestational age on admission to ER, gravity, parity and placental location, only two variables remained significantly associated with RFM – nulliparity (OR = 2.28, p = 0.001) and anterior placenta (OR = 1.44, p = 0.034). Group A was not associated with lower Apgar scores (1 and 5-min, p = 0.40 and 0.57, respectively) or low birth-weight (p = 0.76), nor was it associated with prematurity (p = 0.41), low (<7) 5-min Apgar score, fetal death or neonatal death. Conclusions: Reduced fetal movements are associated with anterior placenta and nulliparity.

Combined Effect of Fetal Sex and Advanced Maternal Age on Pregnancy Outcomes

Background Fetal sex and maternal age are each known to affect outcomes of pregnancies. The objective of the present study was to investigate the influence of the combination of maternal age and fetal sex on pregnancy outcomes in term and post-term singleton pregnancies. Material/Methods This was a retrospective study on term singleton pregnancies delivered between 2004 and 2008 at the Chaim Sheba Medical Center. Data collected included maternal age, fetal sex, and maternal and neonatal complications. The combined effect of fetal sex and maternal age on complications of pregnancy was assessed by multivariable logistic regression models. Results The study population comprised 37,327 pregnancies. The risk of operative deliveries increased with maternal age ≥40 and in pregnancies with male fetuses. The risk of maternal diabetes and of longer hospitalization increased as maternal age increased, and in women <40 carrying male fetuses. The risk of hypertensive disorders increased in pregnancies with males as maternal age advanced. The risk of shoulder dystocia and neonatal respiratory complications increased in male neonates born to women<40. The risk of neonatal hypoglycemia increased in males for all maternal ages. Conclusions Risk assessment for fetal sex and advanced maternal age were given for different pregnancy complications. Knowledge of fetal sex adds value to the risk assessment of pregnancies as maternal age increases.

Choosing between bad, worse and worst: what is the preferred mode of delivery for failure of the second stage of labor?*

Abstract Objective: To determine the preferred mode of delivery (vacuum, forceps or cesarean delivery) for second-stage dystocia. Methods: Retrospective cohort study of women delivered by forceps, vacuum or cesarean delivery due to abnormalities of the second stage of labor. Primary outcome included neonatal and maternal composite adverse effects. Results: A total of 547 women were included: 150 (27.4%) had forceps delivery, 200 (36.5%) had vacuum extraction, and 197 (36.1%) had cesarean section. The rate of neonatal composite outcome was significantly increased in vacuum extraction (27%) compared to forceps delivery (14.7%) or cesarean section (9.7%) (p < 0.001). There was no difference in the rate of maternal composite outcome among the groups. Both operative vaginal delivery modes were associated with significantly lower rate of postpartum infection compared to cesarean delivery (0% versus 3%, p = 0.004). Conclusion: Operative vaginal delivery was associated with reduced postpartum infection compared to cesarean section. Forceps delivery was associated with reduced risk for adverse neonatal outcome compared to vacuum extraction, with no increase in the risk of composite maternal complications.

Advanced cervical dilatation and spontaneous preterm labor: a comparison between twin and singleton gestations

Abstract Objective: To determine the admission to delivery interval and the rate of immediate delivery in twin versus singleton gestation complicated by spontaneous preterm labor (SPTL). Methods: A retrospective cohort study of pregnant women presenting with advanced cervical dilatation of 3–5 cm and frequent uterine contractions at 24–34 weeks of gestation was performed. The rate of progression to delivery within 12 h and 24 h, as well as rates of prolonged latency, were compared between twins and singletons gestations. Results: Sixty-nine women were included, of which 25 carried twins and 44 singletons. The overall rate of spontaneous delivery within 12 h and 24 h was 47.8% and 59.4%, respectively, and similar between twins and singletons. Nevertheless, prolonged latency of 10 days or more after presentation was more frequent among twins compared with singletons [10/25 (40%) vs. 7/44 (15.9%), respectively; P=0.026]. Moreover, women carrying twins presenting with advanced cervical dilatation had a better chance of completing a full 2-dose antenatal betamethasone course compared with singletons [19/25 (76%) of twins compared with 21/44 (47.7%) of singletons, odds ratio 3.5, 95% confidence interval 1.16–10.34; P=0.022]. Conclusion: Up to 60% of women presenting with advanced cervical dilatation prior to 34 weeks’ gestation give birth within 24 h. Nevertheless, women carrying twins have a better chance of completing a betamethasone course and having prolonged latency compared with singletons.

Disparity in post-treatment maternal circulating magnesium sulfate levels between twin and singleton gestation: Is this the missing link between plurality and adverse outcome?

Abstract Objective: Magnesium sulfate (MgSO4) administered to women at risk for preterm delivery decreases the risk of cerebral palsy in their children. However, the neuroprotective effect of MgSO4 has not been shown in twin gestations. Thus, the aim of this study was to determine the maternal serum levels of magnesium in twin vs. singleton pregnancies following intravenous treatment of MgSO4. Methods: Case control study including two groups of pregnant women who received intravenous MgSO4: (1) twin gestations (n=83) and (2) singleton pregnancies (n=83). Maternal serum magnesium levels 6 and 24 h after initiation of treatment were determined in both groups. Results: Maternal serum levels of magnesium were significantly lower among patients with twin gestations compared to those with singleton ones 6 h after initiation of treatment (4.6 vs. 4.8 mg/dL, P=0.003). In addition, the rate of pregnant women who obtained therapeutic levels 6 h after initiation of treatment was significantly lower in twin gestations than in singleton ones (36% vs. 58%, P=0.008). Multiple regression analysis revealed that twin gestations were independently and significantly associated with low maternal serum magnesium levels. Conclusions: Maternal serum concentrations of magnesium are lower in twin pregnancies than in singleton ones following MgSO4 treatment, which might explain the decreased neuroprotective effect of MgSO4 reported in twin pregnancies.

Trial of labour after caesarean (TOLAC) is associated with increased risk for instrumental delivery

Abstract We compared the rates of instrumental delivery in a cohort of nulliparous women at term (n = 19,416), to primiparous women who attempted labour after prior caesarean (TOLAC) (n = 1747). The rate of instrumental deliveries was higher in the TOLAC group compared to nulliparous gravidas (17.3 vs. 15% respectively, p = 0.001). The difference was more prominent for women who eventually had successful vaginal delivery (TOLAC: 23.9% vs. controls: 17.1%, p < 0.0001 respectively). Based on our results, previous caesarean whether urgent or elective was associated with an increased risk of instrumental delivery in the subsequent pregnancy.