Anjali J Kaimal

Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation

There has been a substantial increase in the use of computed tomography (CT) and magnetic resonance imaging (MRI) in pregnancy and lactation. Among some physicians and patients, however, there are misperceptions regarding risks, safety, and appropriate use of these modalities in pregnancy. We have developed a set of evidence-based guidelines for the use of CT, MRI, and contrast media during pregnancy for selected indications including suspected acute appendicitis, pulmonary embolism, renal colic, trauma, and cephalopelvic disproportion. Ultrasonography is the initial modality of choice for suspected appendicitis, but if the ultrasound examination is negative, MRI or CT can be obtained. Computed tomography should be the initial diagnostic imaging modality for suspected pulmonary embolism. Ultrasonography should be the initial study of choice for suspected renal colic. Ultrasonography can be the initial imaging evaluation for trauma, but CT should be performed if serious injury is suspected. Pelvimetry now is used rarely for suspected cephalopelvic disproportion, but when required, low-dose CT pelvimetry can be performed with minimal risk. Although iodinated contrast seems safe to use in pregnancy, intravenous gadolinium is contraindicated and should be used only when absolutely essential. It seems to be safe to continue breast-feeding immediately after receiving iodinated contrast or gadolinium. Although teratogenesis is not a major concern after exposure to prenatal diagnostic radiation, carcinogenesis is a potential risk. When used appropriately, CT and MRI can be valuable tools in imaging pregnant and lactating women; risks and benefits always should be considered and discussed with patients.

Prenatal antidepressant exposure is associated with risk for attention-deficit hyperactivity disorder but not autism spectrum disorder in a large health system

Previous studies suggested that risk for Autism Spectrum Disorder (ASD) may be increased in children exposed to antidepressants during the prenatal period. The disease specificity of this risk has not been addressed and the possibility of confounding has not been excluded. Children with ASD or attention-deficit hyperactivity disorder (ADHD) delivered in a large New England health-care system were identified from electronic health records (EHR), and each diagnostic group was matched 1:3 with children without ASD or ADHD. All children were linked with maternal health data using birth certificates and EHRs to determine prenatal medication exposures. Multiple logistic regression was used to examine association between prenatal antidepressant exposures and ASD or ADHD risk. A total of 1377 children diagnosed with ASD and 2243 with ADHD were matched with healthy controls. In models adjusted for sociodemographic features, antidepressant exposure prior to and during pregnancy was associated with ASD risk, but risk associated with exposure during pregnancy was no longer significant after controlling for maternal major depression (odds ratio (OR) 1.10 (0.70–1.70)). Conversely, antidepressant exposure during but not prior to pregnancy was associated with ADHD risk, even after adjustment for maternal depression (OR 1.81 (1.22–2.70)). These results suggest that the risk of autism observed with prenatal antidepressant exposure is likely confounded by severity of maternal illness, but further indicate that such exposure may still be associated with ADHD risk. This risk, modest in absolute terms, may still be a result of residual confounding and must be balanced against the substantial consequences of untreated maternal depression.

Peak serum estradiol level during controlled ovarian hyperstimulation is associated with increased risk of small for gestational age and preeclampsia in singleton pregnancies after in vitro fertilization.

OBJECTIVE To assess the impact of elevated peak serum E(2) levels (EPE(2); defined as levels >90th percentile) on the day of hCG administration during controlled ovarian hyperstimulation (COH) for IVF on the likelihood for small for gestational age (SGA), preeclampsia (PreE), and preterm delivery (PTD) in singleton pregnancies. DESIGN Retrospective cohort study. SETTING Tertiary-care academic medical center. PATIENT(S) Singleton live-birth pregnancies conceived after fresh IVF-ET. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The delivery rate of SGA infants and the development of PreE and PTD in patients with and without EPE(2). RESULT(S) Patients with EPE(2) during COH were more likely to deliver SGA infants (7 [26.9%] vs. 10 [3.8%]; odds ratio [OR], 95% confidence interval [CI] {9.40, 3.22-27.46}) and develop PreE (5 [18.5%] vs. 12 [4.5%]; adjusted OR, 95% CI {4.79, 1.55-14.84}). No association was found between EPE(2) and the likelihood for delivery before 37 weeks, 35 weeks, or 32 weeks of gestation. Receiver operating characteristic analysis revealed that EPE(2) level predicted adverse obstetrical outcome (SGA + PreE) with 38.5% and 91.7% sensitivity and specificity, respectively. Using a serum peak E(2) cutoff value of 3,450 pg/mL (>90th percentile level), the positive predictive value was 37%, while the negative predictive value was 92%. CONCLUSION(S) EPE(2) level (>3,450 pg/mL) on the day of hCG administration during COH is associated with greater odds of developing PreE and delivery of an SGA infant in singleton pregnancies resulting from IVF cycles.

Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes.

OBJECTIVE: To test the association of elective induction of labor at term compared with expectant management and maternal and neonatal outcomes. METHODS: This was a retrospective cohort study of all deliveries without prior cesarean delivery in California in 2006 using linked hospital discharge and vital statistics data. We compared elective induction at each term gestational age (37–40 weeks) as defined by The Joint Commission with expectant management in vertex, nonanomalous, singleton deliveries. We used multivariable logistic regression to test the association of elective induction and cesarean delivery, operative vaginal delivery, maternal third- or fourth-degree lacerations, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, hyperbilirubinemia, and macrosomia (birth weight greater than 4,000 g) at each gestational week, stratified by parity. RESULTS: The cesarean delivery rate was 16%, perinatal mortality was 0.2%, and neonatal intensive care unit admission was 6.2% (N=362,154). The odds of cesarean delivery were lower among women with elective induction compared with expectant management across all gestational ages and parity (37 weeks [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.34–0.57], 38 weeks [OR 0.43, 95% CI 0.38–0.50], 39 weeks [OR 0.46, 95% CI 0.41–0.52], 40 weeks [OR 0.57, CI 0.50–0.65]). Elective induction was not associated with increased odds of severe lacerations, operative vaginal delivery, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, or macrosomia at any term gestational age. Elective induction was associated with increased odds of hyperbilirubinemia at 37 and 38 weeks of gestation and shoulder dystocia at 39 weeks of gestation. CONCLUSION: Elective induction of labor is associated with decreased odds of cesarean delivery when compared with expectant management. LEVEL OF EVIDENCE: II

Diagnosis and morbidity of placenta accreta

To examine the diagnostic precision of ultrasound examination for placenta accreta in women with placenta previa and to compare the morbidity associated with accreta to that of previa alone.

Perinatal outcomes among different Asian-American subgroups

OBJECTIVE The objective of the study was to investigate the differences in perinatal outcomes between various Asian ethnic subgroups at a national level. STUDY DESIGN This is a retrospective cohort study of all non-Hispanic Chinese, Japanese, Filipino, Asian Indian, Korean, Vietnamese, Samoan, Guamanian, and Hawaiian women whose deliveries were recorded by US birth certificates within the year 2003. Perinatal outcomes were compared between groups and potential confounders controlled for with multivariable logistic regression. RESULTS We found significant differences (P < .001) in the incidence of all perinatal outcomes of interest among the different Asian subgroups. These differences persisted after adjusting for potential confounders. The incidence of diabetes in pregnancy varied from 2.9% (Korean) to 5.7% (Filipina). CONCLUSION Our study demonstrates significant differences in preterm labor, primary cesarean delivery, pregnancy-associated hypertension, eclampsia, diabetes in pregnancy, low birthweight, macrosomia, and cephalopelvic disproportion among Asian subgroups at a national level, affirming the importance of examining these subgroups separately.

Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes

OBJECTIVE We sought to examine the association of labor induction and perinatal outcomes. STUDY DESIGN This was a retrospective cohort study of low-risk nulliparous women with term, live births. Women who had induction at a given gestational age (eg, 39 weeks) were compared to delivery at a later gestation (eg, 40, 41, or 42 weeks). RESULTS Compared to delivery at a later gestational age, those induced at 39 weeks had a lower risk of cesarean (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.88-0.91) and labor dystocia (aOR, 0.88; 95% CI, 0.84-0.94). Their neonates had lowered risk of having 5-minute Apgar <7 (aOR, 0.81; 95% CI, 0.72-0.92), meconium aspiration syndrome (aOR, 0.30; 95% CI, 0.19-0.48), and admission to neonatal intensive care unit (aOR, 0.87; 95% CI, 0.78-0.97). Similar findings were seen for women who were induced at 40 weeks compared to delivery later. CONCLUSION Induction of labor in low-risk women at term is not associated with increased risk of cesarean delivery compared to delivery later.

Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections.

OBJECTIVE The purpose of this study was to examine the effect of a change in policy regarding the timing of antibiotic administration on the rates of postcesarean delivery surgical-site infections (SSI). STUDY DESIGN This was a retrospective cohort study of 1316 term, singleton cesarean deliveries at 1 institution. A policy change was instituted wherein prophylactic antibiotics were given before skin incision rather than after cord clamp. The primary outcome that was examined was SSI; secondary outcomes were the rates of endometritis and cellulitis. Multivariable regression was performed to control for potential confounders. RESULTS The overall rate of SSI fell from 6.4-2.5% (P = .002). When we controlled for potential confounders, there was a decline in overall SSI with an adjusted odds ratio (aOR) of 0.33 (95% CI, 0.14,0.76), a decrease in endometritis (aOR, 0.34; 95% CI, 0.13,0.92), and a trend towards a decrease in cellulitis (aOR, 0.22; 95% CI, 0.05,1.22). CONCLUSION At our institution, a change in policy to administer prophylactic antibiotics before skin incision led to a significant decline in postcesarean delivery SSIs.

Perinatal morbidity associated with late preterm deliveries compared with deliveries between 37 and 40 weeks of gestation

Please cite this paper as: Cheng Y, Kaimal A, Bruckner T, Hallaron D, Caughey A. Perinatal morbidity associated with late preterm deliveries compared with deliveries between 37 and 40 weeks of gestation. BJOG 2011;118:1446–1454.

Elective cryopreservation of all embryos with subsequent cryothaw embryo transfer in patients at risk for ovarian hyperstimulation syndrome reduces the risk of adverse obstetric outcomes: a preliminary study.

OBJECTIVE To test the hypothesis that patients who undergo elective cryopreservation of all embryos, due to risk of ovarian hyperstimulation syndrome and elevated peak serum estradiol (E(2)), previously defined as level >3,450 pg/mL (90th percentile) during in vitro fertilization (IVF), will be less likely to have small for gestational age (SGA) infants and preeclampsia as compared with patients with elevated peak serum E(2) who undergo fresh embryo transfer (ET). DESIGN Cohort study. SETTING Tertiary care academic medical center. PATIENT(S) Twenty women who underwent elective cryopreservation of all embryos with subsequent cryothaw ET and 32 similar women with elevated peak E(2) during controlled ovarian hyperstimulation for IVF who underwent a fresh ET. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Prevalence of SGA infants and development of preeclampsia in patients with cryothaw ET or fresh ET in the setting of elevated peak E(2). RESULT(S) After adjusting for confounders (body mass index, antral follicle count, peak serum E(2) level) using forward stepwise logistic regression, the patients who elected cryopreservation of all embryos and subsequent cryothaw ET were statistically significantly less likely to deliver SGA infants as compared with the patients who had fresh ET in the setting of elevated peak E(2). In the entire cohort, a total of seven women had preeclampsia, all of whom had had fresh ET in the setting of elevated peak serum E(2): 7 (21.9%) in the fresh ET group versus 0 women in the elective cryopreservation group. CONCLUSION(S) This preliminary study suggests that elective cryopreservation of all embryos in patients with elevated peak serum E(2) for subsequent cryothaw ET in cycles with a better physiologic hormonal milieu may reduce the odds of SGA and preeclampsia in IVF singleton deliveries.