Anjel Vahratian

Labor progression and risk of cesarean delivery in electively induced nulliparas

OBJECTIVE: To describe the pattern of labor progression and risk of cesarean delivery in women whose labor was electively induced. METHODS: We analyzed data on all low-risk, nulliparous women with an elective induction or spontaneous onset of labor between 37 + 0 and 40 + 6 weeks from January 2002 to March 2004 at a single institution. The median duration of labor by each centimeter of cervical dilation and the risk of cesarean delivery were computed for 143 women with preinduction cervical ripening and oxytocin induction, 286 women with oxytocin induction, and 1,771 women with a spontaneous onset of labor. An intracervical Foley catheter was used to ripen the cervix. RESULTS: Electively induced labor with cervical ripening had substantially slower latent and early active phases. After controlling for potential confounders, women who had an elective induction with cervical ripening had 3.5 times the risk of cesarean delivery during the first stage of labor (95% confidence interval 2.7–4.5), compared with those admitted in spontaneous labor. Elective induction without cervical ripening, on the other hand, was associated with a faster labor progression from 4 to 10 cm (266 compared with 358 minutes, P < .01) and did not increase the risk of cesarean delivery, compared with those in spontaneous labor. CONCLUSION: The pattern of labor progression differs substantially for women with an electively induced labor compared with those with spontaneous onset of labor. Furthermore, elective induction in nulliparous women with an unfavorable cervix has a high rate of labor arrest and a substantially increased risk of cesarean delivery. LEVEL OF EVIDENCE: II-2

Maternal Prepregnancy Overweight and Obesity and the Pattern of Labor Progression in Term Nulliparous Women

OBJECTIVE: To examine the effect of maternal overweight and obesity on labor progression. METHODS: We analyzed data from 612 nulliparous women with a term pregnancy that participated in the Pregnancy, Infection, and Nutrition Study from 1995 to 2002. The median duration of labor by each centimeter of cervical dilation was computed for normal-weight (body mass index [BMI] 19.8–26.0 kg/m2), overweight (BMI 26.1–29.0 kg/m2), and obese (BMI > 29.0 kg/m2) women and used as a measurement of labor progression. RESULTS: After adjusting for maternal height, labor induction, membrane rupture, oxytocin use, epidural analgesia, net maternal weight gain, and fetal size, the median duration of labor from 4 to 10 cm was significantly longer for both overweight and obese women, compared with normal-weight women (7.5, 7.9, and 6.2 hours, respectively). For overweight women, the prolongation was concentrated around 4–6 cm, whereas for obese women, their labor was significantly slower before 7 cm. CONCLUSION: Labor progression in overweight and obese women was significantly slower than that of normal-weight women before 6 cm of cervical dilation. Given that nearly one half of women of childbearing age are either overweight or obese, it is critical to consider differences in labor progression by maternal prepregnancy BMI before additional interventions are performed.

Comparison of labor progression between induced and noninduced multiparous women.

OBJECTIVE: The incidence of labor induction is rising rapidly in the United States. Among multiparas, labor is often followed with traditional labor curves derived from noninduced pregnancies. We sought to determine how labor progression of multiparous women who presented in spontaneous labor differed from those who were electively induced with and from those induced without preinduction cervical ripening. METHODS: We analyzed data on all low-risk multiparous women with an elective induction or spontaneous onset of labor between 37+0 and 40+6 weeks of gestation from January 2002 to March 2004 at a single institution. The median duration of labor by each centimeter of cervical dilatation and the risk of cesarean delivery were computed for 61 women with preinduction cervical ripening and oxytocin induction, 735 women with oxytocin induction, and 1,885 women with a spontaneous onset of labor. An intracervical Foley catheter was used to ripen the cervix. RESULTS: Those women who experienced electively induced labor without cervical ripening had a shorter active phase of labor than did those admitted in spontaneous labor (99 minutes in induced labor versus 161 minutes in spontaneous labor, P < .001). However, the cesarean delivery rate was elevated in the induction group (3.9% versus 2.3%, P < .05). Women who underwent preinduction cervical ripening also had a shorter active phase than those admitted in spontaneous labor (109 minutes versus 161 minutes, P = .01). CONCLUSION: The pattern of labor progression differs for women with an electively induced labor without cervical ripening compared with those who present with spontaneous onset of labor. LEVEL OF EVIDENCE: II-2

Family-planning practices among women with diabetes and overweight and obese women in the 2002 National Survey For Family Growth.

OBJECTIVE To examine contraceptive practices among diabetic women and obese women. RESEARCH DESIGN AND METHODS We analyzed the responses of 5,955 participants aged 20–44 years in the 2002 National Survey for Family Growth. Diabetes, BMI, desire for pregnancy, history of infertility treatment, sexual activity, parity, and demographic variables (age, race/ethnicity, education, marital status, income, insurance, and smoking history) were obtained by self-report. Lack of contraception was defined as absence of hormonal-, barrier-, or sterilization-based methods. Associations among contraception, diabetes, and BMI category were assessed in multivariable logistic regression models in nonsterile, sexually active women. RESULTS In unadjusted comparisons among sexually active women who were not sterilized, women with diabetes were more likely to lack contraception than women without diabetes (odds ratio [OR] 2.61 [95% CI 1.22–5.58]). Women with BMI ≥35 kg/m2 were more likely to lack contraception than women with BMI <25 kg/m2(1.63 [1.16–2.28]), but associations between contraception use and lesser degrees of overweight and obesity were not significant. In multivariable models, women who were older (aged ≥30 vs. 20–29 years), were of non-Hispanic black race, were cohabitating, had a history of infertility treatment, and desired or were ambivalent about pregnancy were significantly more likely to lack contraception. The associations among diabetes, BMI, and contraception were no longer significant after these adjustments. CONCLUSIONS Older women with diabetes and obesity who desire pregnancy, regardless of pregnancy intention, should be targeted for preconceptive management.

Prepregnancy body mass index and gestational age-dependent changes in lipid levels during pregnancy.

OBJECTIVE: To examine the effect of maternal prepregnancy overweight and obesity on gestational age-dependent variation in lipid levels during pregnancy. METHODS: Women between 6 and 10 weeks of gestation who carry a single, live intrauterine pregnancy were eligible to participate in a prospective pregnancy study (N=142). The exposure, maternal prepregnancy body mass index (BMI), was classified as: normal weight (BMI 18.5–26.0 kg/m2) and overweight or obese (BMI over 26.0 kg/m2). Our outcomes of interest, total cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol were measured at 6–10, 10–14, 16–20, 22–26, and 32–36 weeks of gestation. Mixed linear models were used to examine how the trajectory of lipid levels during pregnancy differs between overweight or obese and normal-weight women. RESULTS: Levels of total cholesterol, triglycerides, LDL cholesterol, and HDL choloesterol increased over the prenatal period. The rate of change in LDL cholesterol (P<.001) and total cholesterol (P=.01) levels was lower for overweight or obese women than for normal-weight women in late-second and early-third trimester. As a result, overweight or obese women had significantly lower total cholesterol and LDL cholesterol levels than their normal-weight counterparts between 32–36 weeks of gestation. CONCLUSION: Overweight and obese women have different lipid profiles during pregnancy than their normal-weight peers. This difference may be the result of metabolic dysregulation associated with maternal overweight and obesity that mediates the increased risk of adverse outcomes found in these women. LEVEL OF EVIDENCE: II

Secondhand tobacco smoke exposure is associated with increased risk of failed implantation and reduced IVF success

BACKGROUND Infertility and early pregnancy loss are prevalent as is exposure to secondhand tobacco smoke (STS). Previous research has suggested a relationship between STS exposure and early pregnancy loss, but studies have been limited by small study sizes and/or imprecise methods for exposure estimation. IVF allows for the collection of follicular fluid (FF), the fluid surrounding the pre-ovulatory oocyte, which may be a more biologically relevant sample media than urine or serum in studies of early reproduction. METHODS In a retrospective analysis of a prospective cohort study, we measured cotinine in FF collected during 3270 IVF treatment cycles from 1909 non-smoking women between 1994 and 2003 to examine the relationship between STS exposure and implantation failure. RESULTS In adjusted models, we found a significant increase in the risk of implantation failure among women exposed to STS compared with those unexposed [odds ratio (OR) = 1.52; 95% confidence interval (CI) = 1.20-1.92; risk ratio (RR) = 1.17; 95% CI = 1.10-1.25]. We also found a significant decrease in the odds for a live birth among STS-exposed women (OR = 0.75; 95% CI = 0.57-0.99; RR = 0.81; 95% CI = 0.66-0.99). CONCLUSIONS Female STS exposure, estimated through the measurement of cotinine in FF, is associated with an increased risk of implantation failure and reduced odds of a live birth.

Should access to fertility-related services be conditional on body mass index?

Guidelines for the clinical management of obese, reproductive age women with reduced fertility in the USA are limited. Clinical professional organizations have yet to publish practice guidelines on this topic. Thus, treatment decisions are made at the provider and/or clinic level and the variation in clinic policy regarding fertility treatment for obese women is not readily available. Globally, there is an ongoing discussion among reproductive endocrinologists that practice in countries with government-funded health care about whether treatment should be restricted to women under a certain body mass index. Our analysis of a representative US population identified that differences exist in the utilization of fertility-related services according to female body mass. Women with class II/III obesity were the group reporting the highest percentage seeking medical attention to become pregnant, but the lowest percentage receiving medical or surgical fertility-related services, although these differences were not statistically significant. As the prevalence of obesity among women of reproductive age increases both in the USA and abroad, it is critical to consider the medical, social and ethical issues involved in allocating resources for fertility treatment. Ongoing monitoring of trends in service utilization in light of the obesity epidemic and delayed childbearing will provide further insight into this clinical health policy issue.

Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery

OBJECTIVE To test the hypothesis that there is no difference in perioperative morbidity and the type of uterine incisions between vertical skin incisions (VSI) and low transverse skin incisions (LTSI) at the time of cesarean delivery in morbidly obese women. STUDY DESIGN Retrospective cohort study of morbidly obese women (BMI > 35 kg/m(2)) who underwent cesarean delivery between June 2004 and December 2006. RESULTS During the study, 424 morbidly obese women underwent cesarean section. Patients with VSI were older (31.0 ± 6.2 years vs. 26.7 ± 5.8 years), heavier (48.2 ± 9.1 kg/m(2) vs. 41.7 ± 6.7 kg/m(2)), and more likely to have a classical than a low transverse uterine incision (65.9% vs. 7.3%), p < 0.001. After controlling for confounders, women with VSI did not have an increase in perioperative morbidity, but underwent more vertical uterine incisions (adjusted odds ratio = 18.49, 95% CI: 6.44, 53.07). CONCLUSION VSI and LTSI are safe in morbidly obese patients undergoing cesarean section, but there is a tendency for increased vertical uterine incisions in those who underwent VSI.

Self-Rated Health and Health Care Use Among Women With Histories of Gestational Diabetes Mellitus

OBJECTIVE To examine self-rated health and health care utilization among women with a history of gestational diabetes mellitus (hGDM). RESEARCH DESIGN AND METHODS This study was a cross-sectional analysis of the 2006 National Health Interview Survey of parous women with (n = 370) and without (n = 6,695) hGDM. RESULTS Women with hGDM reported fair or poor health status and ≥10 office visits in the past year more frequently than women without hGDM. The higher prevalence of obesity in hGDM women accounted for their poorer self-rated health after adjustment for other demographic factors. Whereas the association between hGDM and more frequent office visits was reduced after adjustment for demographic factors including health insurance, hGDM was still associated with a lower odds of contact with a mental health professional. CONCLUSIONS Because of obesity, women with hGDM have poorer self-rated health than women without hGDM. Contact with mental health providers was reduced compared with women without hGDM.

Longitudinal depressive symptoms and state anxiety among women using assisted reproductive technology

We examined the relationship between infertility treatment and psychosocial health through a longitudinal analysis. Women who underwent FSH-IUI or IVF had higher levels of depressive symptoms and state anxiety at baseline compared with those who attempted conception naturally, and this difference persisted over time.