Andrei Rebarber

Lifestyle modification program decreases pregnancy weight gain in obese women.

We assessed the impact of a lifestyle modification program (LMP) on weight gain in pregnancy and evaluated its effect on adverse pregnancy outcomes. A prospective matched controlled study design was employed. Inclusion criteria consisted of pregnant women with singleton gestations and body mass index (BMI) > or = 30 without underlying medical conditions. In the study group, patients were prospectively enrolled in the first trimester. Through the LMP, women participated in a comprehensive program on nutrition, exercise, and weight control in pregnancy. The control group consisted of matched patients by starting BMI, parity, and socioeconomic status during the same study period cared for at the same institution. The primary outcome evaluated was weight gain in pregnancy. Adverse pregnancy outcomes including preeclampsia, gestational diabetes, gestational hypertension, and various postpartum complications were evaluated between the two groups. Statistical analysis was performed using nonparametric methods, with p < 0.5 considered significant. Twenty-eight patients were recruited for this study and underwent the intervention. Patient compliance with the LMP was 75%, two patients were lost to follow-up, one had a preterm delivery, and four had incomplete data due to various reasons. Twenty-one patients completed their pregnancy and were available for analysis. Twenty matched control patients were identified for analysis. Study participants gained significantly less weight in their pregnancies when compared with controls (mean weight gain 17 versus 34 pounds, respectively; p = 0.008). Secondary outcomes of preeclampsia, gestational diabetes, cesarean section, as well as infant birth weight did not significantly differ between the groups. This study suggests an effective method of reducing prenatal weight gain in the obese population. This type of comprehensive intervention could be an important, cost-effective risk-reduction strategy.

The Efficacy of Sonographically Indicated Cerclage in Multiple Gestations

The purpose of this study was to determine the efficacy of sonographically indicated cerclage in multiple gestations with sonographic evidence of short cervical length (CL).

Active Second-Stage Management in Twin Pregnancies Undergoing Planned Vaginal Delivery in a U.S. Population

OBJECTIVE: To estimate neonatal morbidity and delivery outcomes according to planned mode of delivery in twin pregnancies with active second-stage management. METHODS: This was an historic cohort of twin pregnancies delivered in one practice between June 2005 and September 2009 using a strict protocol of second-stage management, including breech extraction of a second noncephalic twin and internal version of a nonengaged cephalic second twin followed by breech extraction. Primary outcome was a 5-minute Apgar score less than 7 for twin B. Secondary outcomes were 5-minute Apgar score less than 7 for twin A and 1-minute Apgar score less than 7 and arterial cord pH below 7.20 for each twin. RESULTS: A total of 287 twin pregnancies were included. There were 157 patients (54.7%) in the planned cesarean group and 130 patients (45.3%) in the planned vaginal delivery group. There was no significant difference in the rates of twin B having a 5-minute Apgar score lower than 7 or an arterial cord pH below 7.20. Among the patients in the planned vaginal delivery group, the cesarean delivery rate was 15.4%. No patients had a vaginal delivery of twin A followed by cesarean delivery of twin B. Among the patients in the planned vaginal delivery group, patients who had a successful vaginal delivery were more likely to be younger (31.56±6.6 compared with 36.88±6.1 years, P=.001) and were more likely to have a prior vaginal delivery (47.3% compared with 15.0%, P=.007). CONCLUSION: Planned vaginal delivery of twin pregnancies seems to be associated with neonatal outcomes similar to those with planned cesarean delivery. Active second-stage management is associated with good neonatal outcomes and a low risk of combined vaginal-cesarean delivery. LEVEL OF EVIDENCE: II

The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes.

Objective. To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM). Methods. Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI ≥ 30 kg/m2) and non-obese (pre-pregnancy BMI < 30 kg/m2) women and for women across five increasing pre-pregnancy BMI categories. Results. A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes. Conclusion. In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

Intravaginal misoprostol versus Foley catheter for labour induction: a meta‐analysis

Please cite this paper as: Fox N, Saltzman D, Roman A, Klauser C, Moshier E, Rebarber A. Intravaginal misoprostol versus Foley catheter for labour induction: a meta‐analysis. BJOG 2011;118:647–654.

Obstetric management of Klippel-Trenaunay syndrome.

BACKGROUND: Klippel-Trenaunay syndrome is a rare congenital disease characterized by extensive cutaneous vascular malformations, venous varicosities, focal abnormalities of the deep venous system, and underlying soft tissue or bony hypertrophy. Given the rarity of the disease, there is little information available to counsel patients with Klippel-Trenaunay syndrome regarding obstetric outcome. CASES: We report our experience with 3 patients in whom Klippel-Trenaunay syndrome complicated 4 pregnancies. Successful delivery of a healthy infant at or beyond 36 weeks of gestation was achieved in all pregnancies. One of the 4 pregnancies was complicated by pulmonary embolism. CONCLUSION: Klippel-Trenaunay syndrome was once thought to be a contraindication to pregnancy. With careful management, successful pregnancies can be achieved.

Weight gain in twin pregnancies and adverse outcomes: examining the 2009 Institute of Medicine guidelines.

OBJECTIVE: To estimate whether the weight gain recommendations for twin pregnancies in the 2009 Institute of Medicine (IOM) guidelines are associated with improved perinatal outcomes. METHODS: A cohort of 297 twin pregnancies was identified from a single practice with measured prepregnancy body mass index (BMI) and weight gain during pregnancy. Recommended IOM guidelines were applied to our cohort based on prepregnancy BMI categories (normal weight, overweight, obese). Pregnancy outcomes were compared between patients whose weight gain met or exceeded the IOM recommendations and patients who did not meet these recommendations. RESULTS: Patients with normal prepregnancy BMIs whose weight gain met the IOM recommendations had significantly improved outcomes compared with patients who did not meet the IOM recommendations. They were less likely to have preterm birth before 32 weeks (5.0% compared with 13.8%) and spontaneous preterm birth before 32 weeks (3.4% compared with 11.5%). They also delivered significantly larger neontates (larger twin birth weight 2,582.1±493.4 g compared with 2,370.3±586.0 g; smaller twin birth weight 2,277.0±512.1 g compared with 2,109.3±560.9 g) and were significantly more likely to have both neonates weigh more than 2,500 g (38.8% compared with 22.5%) and more than 1,000 g (97.5% compared with 91.2%) and were less likely to deliver any twin with a birth weight lower than the fifth percentile for gestational age (21.5% compared with 35.0%). CONCLUSION: In women with twin pregnancies and normal starting BMIs, weight gain during pregnancy is significantly associated with improved outcomes, including a decreased risk of prematurity and larger birth weights. LEVEL OF EVIDENCE: II

Influence of maternal body mass index on the clinical estimation of fetal weight in term pregnancies.

OBJECTIVE: To estimate the effect of maternal body mass index (BMI) on clinical estimated fetal weight in term pregnancies. METHODS: We compared the clinical estimated fetal weight to the actual birth weight on 400 consecutive term pregnant patients admitted for delivery. We then evaluated whether the maternal BMI was significantly associated with the clinical estimated fetal weight accuracy in estimating birth weight. Patients with singleton pregnancies at 37–42 weeks of gestation were included. Patients with an ultrasound-estimated fetal weight within 3 weeks of admission were excluded. Estimated fetal weight accuracy was defined as the absolute error (absolute value of estimated fetal weight minus birth weight) and absolute percent error (absolute error divided by birth weight multiplied by 100). The primary outcome was an absolute percent error of less than 10% (ie, an estimated fetal weight within ±10% of the birth weight). RESULTS: The proportion of clinical estimated fetal weights within ±10% and within ±20% of the birth weight significantly decreased with increasing BMI categories (&khgr;2 for trend P=.040 and 0.020, respectively). Clinical estimated fetal weights obtained in women with BMI at or greater than 30 were significantly less likely to be within ±10% of the birth weight when compared with women with a BMI less than 25 (66.4% compared with 82.5%, P=.011). Body mass index was significantly positively associated with the absolute error (P=.046) and the absolute percent error (P=.011), even after controlling for birth weight. CONCLUSION: Increased maternal BMI is significantly associated with decreased clinical estimated fetal weight accuracy. LEVEL OF EVIDENCE: II

Blind vaginal fetal fibronectin as a predictor of spontaneous preterm delivery.

OBJECTIVE: To assess the accuracy of vaginal fetal fibronectin sampling without use of a sterile speculum examination as a screening test for predicting spontaneous preterm birth. METHODS: A historical cohort of patients who were followed up with serial fetal fibronectin testing between 1998 and 2001 was identified. All patients were considered to be at high risk for preterm delivery and were screened with fetal fibronectin testing without using a speculum at 2- to 3-week intervals from 22 weeks to 32 weeks of gestation. Charts were reviewed for fetal fibronectin results and pregnancy outcome data. Groups were compared using χ2 analysis or Fisher exact test with significance defined as P < .05. RESULTS: A total of 1,396 fetal fibronectin tests from 416 pregnancies were performed via the “blind” sampling technique. Overall, 24.9% of pregnancies delivered spontaneously before 37 weeks; 9.1% delivered spontaneously before 34 weeks. For delivery before 34 weeks of gestation, the test had a sensitivity of 44.7%, a specificity of 88.4%, a positive predictive value of 27.9%, and a negative predictive value of 94.1%. For delivery within 14 and 21 days of a single fetal fibronectin assessment, the test had a sensitivity of 52% and 45.5%, a specificity of 94.5% and 94.9%, a positive predictive value of 14.6% and 22.5%, and a negative predictive value of 99.1% and 98.2%, respectively. CONCLUSION: “Blind” vaginal fetal fibronectin sampling has high negative predictive values and specificities in predicting spontaneous preterm birth. LEVEL OF EVIDENCE: II-2

Intrauterine Growth Restriction in Twin Pregnancies: Incidence and Associated Risk Factors

We sought to estimate the association of several maternal risk factors with intrauterine growth restriction (IUGR) in twin pregnancies. This is a case-control study of 313 patients with twin pregnancies delivered greater than 24 weeks between June 2005 and January 2010. We used three definitions of IUGR: (1) either twin with a birth weight < 10th percentile for gestational age; (2) either twin with a birth weight < 5th percentile for gestational age; and (3) birth-weight discordance ≥ 20%. Using each definition of IUGR, we estimated the association between IUGR and maternal age, weight, monochorionicity, in vitro fertilization, pregnancy reduction, thrombophilia, hypertension, and diabetes. Overall, 47% of patients delivered at least one twin with a birth weight <10th percentile, 27% of patients delivered at least one twin with a birth weight <5th percentile, and 16% of patients had birth-weight discordance of ≥20%. Using any of these three definitions for IUGR in twin pregnancies, there was no significant association between IUGR and any of the risk factors examined. This remained true when we excluded all patients who delivered <34 weeks. IUGR is very common in twin pregnancies. However, in twin pregnancies, IUGR cannot be predicted by maternal risk factors.