Anat Shmueli

Obstetric antiphospholipid syndrome and long term arterial thrombosis risk

Antiphospholipid syndrome (APS) is classified as the association of a thrombotic event and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies and/or lupus anticoagulant. To evaluate the incidence of subsequent thrombosis among women diagnosed with purely obstetric APS. We retrospectively reviewed and collected demographic and clinical data from the computerized charts of all patients with obstetric APS, from 1992 to 2017. Eligibility criteria included all women diagnosed with APS, according to the 2006 revised criteria, for whom the clinical manifestations were purely obstetric. The primary endpoint was the occurrence of subsequent thromboembolic events, following diagnosis of obstetric APS. The study included 115 women diagnosed with obstetric APS. During the study’s follow up period, 12 (10.4%) women developed thrombosis. Of the 12 women who developed thrombosis, 9 (75%) of the thrombotic events were arterial. The site of arterial thrombosis was cerebral in all cases. Venous thrombosis occurred in 3 (25%) women, including one in each of the following sites—pulmonary embolism, ovarian vein thrombosis and proximal leg deep vein thrombosis. Our data suggests that women with obstetric APS are at risk for subsequent long-term thrombosis, especially arterial cerebral events. We did not identify any clinical or laboratory unique features among women with obstetric APS who will eventually develop thrombosis.

Pregnancy Outcome in Women with Decreased Sensation of Fetal Movements at Term According to Parity

BACKGROUNDnDecreased sensation of fetal movements (DFM) is a common maternal complaint. Thus, we aimed to evaluate the association between DFM and pregnancy outcome in singleton gestation at term according to parity.nnnMETHODSnA retrospective cohort study of singleton pregnancies at term between 2008 and 2013. Eligibility was limited to women carrying a fetus with no known structural or chromosomal anomalies, at 37+0/7 to 42+0/7xa0weeks of gestation. Women presenting to the delivery ward with DFM were compared with women without similar complaints.nnnRESULTSnOverall, 12,564 nulliparous women and 25,292 multiparous women gave birth during the study period; of them, 300 nulliparous women (2.4%) and 525 multiparous women (2.1%) complained of DFM. For nulliparous women, after adjusting for potential confounders, DFM was associated with antepartum fetal death (aOR 4.6 [95% CI 1.1-19.8]), cesarean delivery (CD) (aOR 1.3 [95% CI 1.01-1.8]), 1-minute Apgar score less thanxa07 (aOR 2.3 [95% CI 1.5-3.5]) and neonatal seizures (aOR 3.2 [95% CI 1.3-8.2]). For multiparous women, DFM was associated with unscheduled CD (aOR 2.7 [95% CI 1.6-4.6]) and CD indicated by intermediate/abnormal fetal heart rate tracing (aOR 4.8 [95% CI 2.8-8.4]).nnnCONCLUSIONSnDFM carries different outcomes according to parity. Although for nulliparous women, DFM is associated with increased risk of CD and immediate adverse perinatal outcome, for multiparous women it is associated with increased risk for CD, with no immediate increased risk for adverse perinatal outcome.

Delivery outcomes of large‐for‐gestational‐age newborns stratified by the presence or absence of gestational diabetes mellitus

To evaluate separate and combined contributions of gestational diabetes mellitus (GDM) and large‐for‐gestational age (LGA) on delivery outcomes.

Sonographic prediction of small and large for gestational age in breech-presenting fetuses

Abstract Introduction: To evaluate various sonographic estimated fetal weight (sEFW) formulas’ accuracy for small- and large-for-gestational age (SGA/LGA) prediction in breech-presenting fetuses. Materials and methods: A retrospective analysis of all ultrasound-based fetal biometrical measurements performed within 3 days of delivery in term pregnancies, in one medical center (2007–2014). Overall, 274 breech-presenting fetuses (study group) were compared to 274 vertex-presenting fetuses (control group) matched by gender, gestational age and birth weight. sEFW was calculated by six previously published formulas. Accuracy was compared utilizing systematic error and random error for every formula. Prediction precision of SGA and LGA was evaluated by calculating each formula’s sensitivity, specificity, +/− predictive value, and the area under the receiver-operating characteristic (ROC) curve (AUC). Results: Systematic error and random error varied greatly between formulas, ranging from −7.4% to 3.1%, 7.3% to 8.3% for the vertex-presenting fetuses and −8.9% to 1.9%, 7.9% to 8.6% for the breech-presenting fetuses, respectively. There was no statistical difference in small- or large-for-gestational age prediction parameters between the groups. The highest sensitivity and specificity for prediction was achieved by same formula regardless of presentation. Conclusion: In our cohort, overall accuracy was slightly superior among vertex-presenting fetuses without difference in prediction accuracy for small- and large-for-gestational age neonates.

Antiphospholipid syndrome characteristics and adverse pregnancy outcomes after 20 weeks of pregnancy

To assess outcomes after 20 weeks of pregnancy according to autoantibody profile and clinical presentation of maternal antiphospholipid syndrome (APS).

The association between neonatal head circumference and second stage duration

Abstract Purpose: To determine if head circumference (HC) is an independent factor influencing second stage duration stratified by parity and epidural use. Materials and methods: A retrospective cohort analysis of all live, singleton, term (37–42 weeks) vaginal deliveries in one university affiliated medical center (2012–2014). Exclusion criteria included operative deliveries due to fetal distress, major fetal anomalies/chromosomal abnormalities or cases with missing anthropometric data. Maternal demographics, labor characteristics and neonatal anthropometrics including birth weight and HC were retrieved. Multivariate linear regression was utilized to evaluate the association between HC and second stage duration. Analysis was stratified into four groups by parity and epidural use. Results: Of the 16 240 singleton vaginal deliveries during study period, 12 428 deliveries met inclusion criteria. Stratification by parity and epidural analgesia yielded four groups: 3337 (26.9%), 735 (5.9%), 5099 (41.0%) and 3257 (26.2%) deliveries – nullipara with/without epidural and multipara with/without epidural, respectively. In all groups, a large neonatal HC was significantly and independently associated with longer second stage duration: nullipara with epidural (beta 10.06, 95% CI 7.75–12.37), nullipara without epidural (beta 7.58, 95% CI 4.73–10.43), multipara with epidural (beta 4.64, 95%CI 3.47–5.8) and multipara without epidural (beta 1.35, 95% CI 0.76–1.94), pu2009<u2009.001 for all. Birth weight was not associated with second stage duration in any of the groups (pu2009>u2009.05). Conclusion: Large neonatal HC is significantly associated with longer second stage duration.

Perioperative noninvasive cardiac output monitoring in parturients with singleton and twin pregnancies undergoing cesarean section under spinal anesthesia with prophylactic phenylephrine drip: a prospective observational cohort study

Abstract Purpose: Spinal anesthesia is considered the gold standard anesthetic technique for cesarean deliveries (CDs) but is associated with a high rate of hypotension. The recent international consensus recommends continuous prophylactic phenylephrine infusion (PPI) administered throughout CD to prevent hypotension. However, little information is available on the hemodynamic profiles of women with twin pregnancies as compared to singleton pregnancies perioperatively. Therefore, in this study, we aim to compare maternal hemodynamic changes both intraoperatively and postoperatively with the use of the NICAS bioimpendence monitor in healthy singleton versus twin parturients undergoing CD deliveries with spinal anesthesia with PPI. Materials and methods: After IRB approval and signed informed consent, healthy term women with either twin or singleton pregnancies undergoing spinal anesthesia for uncomplicated CD were enrolled. The following data were collected – cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), and total peripheral resistance (TPR). Measurements were measured at five time points: (1) before arrival in OR, (2) after spinal anesthesia with PPI, (3) after beginning of oxytocin infusion, (4) in post anesthesia care room, (5) 24u2009hours postoperatively, and (6) 48u2009hours postoperatively. All parturients received standardized spinal solution consisting of 12u2009mg hyperbaric bupivacaine, 20u2009µg fentanyl and 100-µg preservative-free morphine. PPI administered was titrated to preserve blood pressure to 20% of baseline blood pressure and stopped at the end of surgery. Oxytocin was administered as a continuous infusion (20-units/1000u2009cm3 Ringer’s lactate) at a rate of 100u2009cm3/h. Results: One hundred and thirty seven parturients with singleton pregnancies and 27 parturients with twin pregnancies completed the study. There were no significant differences between groups in age or BMI. Intraoperatively, there was no difference in any hemodynamic parameter. However, postoperatively at all three times women with twin pregnancies had higher MAP, lower CO and higher TPR compared with parturients with singleton pregnancies. Conclusions: There were significant hemodynamic changes postoperatively but not intraoperatively in parturients with twin pregnancies compared to women with singleton pregnancies. These changes need to be further investigated.

Pharmacotherapy for hyperglycemia in pregnancy – Do oral agents have a place?

Diabetes is a frequent condition in pregnancy and achieving adequate glycemic control is of paramount importance. Insulin treatment is the gold standard, oral agents are more attractive, but their safety and efficiency should be a prerequisite for their use. We have more information regarding treatment of women with gestational diabetes mellitus where glyburide can induce a picture of fetal hyperinsulinism (higher birthweight and more neonatal hypoglycemia) whereas metformin requires supplemental insulin in a larger proportion of women but achieves satisfactory perinatal outcomes with the exception of preterm birth. Information in patients with Type 2 Diabetes Mellitus is much more limited but also favors metformin. Combinations provide additional possibilities. However, as to long-term outcomes, we have no information on the impact of exposure to glyburide and it is still unclear if in utero exposure to metformin will have any effect on the offspring and the direction of this effect. Women prefer oral agents, indicating the need of additional studies.

The impact of epidural analgesia on the duration of the second stage of labor

BACKGROUNDnWe aimed to describe the length of second stage of labor in a contemporary cohort. We calculated the 5th, 50th, and 95th percentiles for second-stage length stratified by parity and epidural analgesia use and evaluated the effect of labor induction and oxytocin augmentation in our cohort.nnnMETHODSnWe did a retrospective analysis of all live, singleton, term vaginal deliveries in one tertiary hospital. Multivariate linear regression was used to evaluate second-stage duration confounders. First, we calculated the second-stage length and presented it as 5th, 50th, and 95th percentiles stratified by epidural analgesia and parity. Second, we evaluated the effect of labor induction and oxytocin augmentation on second-stage length, and third, we determined the demographic and obstetrical confounders that affected second-stage length.nnnRESULTSnOverall, 15xa0500 deliveries were included. Nulliparity, oxytocin augmentation, epidural use, birthweight, labor induction, lower body mass index, and higher maternal age were found to be significantly associated with prolongation of the second stage. Epidural use was associated with an additional 82xa0minutes for the 95th percentile for both nulliparas and multiparas and tripled the rate of prolonged second stage for the entire cohort. Labor induction was associated with clinically significant prolongation of the second stage in nulliparas with epidural analgesia only. Oxytocin was associated with longer duration of the second stage for nulliparas, regardless of epidural use.nnnDISCUSSIONnOur findings suggest a significant prolongation of the second stage in women receiving epidural analgesia. Recommendations for management of second stage should be reconsidered by contemporary data.

Complicated primary cesarean delivery increases the risk for uterine rupture at subsequent trial of labor after cesarean

PurposeTo evaluate whether cesarean delivery (CD) indication, labor status, and other primary CD characteristics affect the risk for uterine rupture in subsequent deliveries.MethodsA case–control study of women attempting trial of labor after cesarean (TOLAC) in a single, tertiary, university-affiliated medical center (2007–2016). Deliveries complicated by uterine rupture were matched to successful vaginal birth after cesarean (VBAC) deliveries in a 1:3 ratio. Indication, labor status and post-partum complications (postpartum hemorrhage and postpartum infection) at primary CD were compared between study and control group.ResultsDuring study period, there were 75,682 deliveries, of them, 3937 (5.2%) were TOLAC. Study group included 53 cases of uterine rupture at TOLAC and 159 women with successful VBAC. Women in study group had significantly lower rates of previous VBAC (15.1 vs. 28.9%, pu2009=u20090.047). Rate of postpartum complications at primary CD was significantly higher in women with TOLAC complicated by uterine rupture (7.5 vs. 1.9%, respectively, pu2009=u20090.042). Utilizing the multivariate logistic regression analysis, postpartum complications remained an independent risk factor for uterine rupture in the following TOLAC (aOR 4.07, 95% CI 1.14–14.58, pu2009=u20090.031).ConclusionPostpartum hemorrhage and infection, in primary CD, seem to be associated with increased risk for uterine rupture during subsequent TOLAC.