Annelee Boyle

Is 40 the New 30?: Pregnancy Outcomes by Degree of Weight Gain Among Obesity Subclasses

INTRODUCTION: The objective of this study was to evaluate pregnancy outcomes by obesity classification using the 2009 Institute of Medicine weight gain guidelines. METHODS: We conducted a retrospective cohort analysis of 1,886 obese women who delivered a singleton pregnancy at our institution from 2009 to 2012. Women were stratified based on prepregnancy body mass index (BMI) into subclasses of obesity: class I (BMI 30.0–34.9 kg/m2), class II (BMI 35.0–39.9 kg/m2), and class III (BMI 40.0 kg/m2 or greater). The primary outcome was cesarean delivery. Secondary outcomes included hypertensive disorders of, gestational diabetes, preterm delivery, small for gestational age, and large for gestational age. Odds ratios and 95% confidence intervals were calculated based on weight gain less than or greater than the recommended 11–20 pounds. Weight gain within guidelines was the referent for each class. RESULTS: Before pregnancy, 957 women were obese class I, 508 women were obese class II, and 421 women were obese class III. During pregnancy, 60.1% of women gained more than the recommended amount of weight; only 18.7% of women gained the recommended 11–20 pounds. Women with class I obesity increased their risk of hypertensive disorders and large for gestational age with excessive weight gain. Women with class II obesity increased their risk of cesarean delivery with excessive weight gain. Women with class III obesity increased their risk of cesarean delivery and hypertensive disorders with excessive weight gain. Less than recommended weight gain had no clear associations. CONCLUSION: Weight gain above the guideline was common and associated with adverse pregnancy outcomes among all subclasses of obesity.

Route of delivery in women with stillbirth: Results from the stillbirth collaborative research network

OBJECTIVE To describe delivery management of singleton stillbirths in a population-based, multicenter case series. METHODS We conducted a retrospective chart review of 611 women with singleton stillbirths at 20 weeks of gestation or greater from March 2006 to September 2008. Medical and delivery information was abstracted from medical records. Both antepartum and intrapartum stillbirths were included; these were analyzed both together and separately. The primary outcome was mode of delivery. Secondary outcomes included induction of labor and indications for cesarean delivery. Indications for cesarean delivery were classified as obstetric (abnormal fetal heart tracing before intrapartum demise, abruption, coagulopathy, uterine rupture, placenta previa, or labor dystocia) or nonobstetric (patient request, repeat cesarean delivery, or not documented). RESULTS Of the 611 total cases of stillbirth, 93 (15.2%) underwent cesarean delivery, including 43.0% (46/107) of women with prior cesarean delivery and 9.3% (47/504) of women without prior cesarean delivery. No documented obstetric indication was evident for 38.3% (18/47) of primary and 78.3% (36/46) of repeat cesarean deliveries. Labor induction resulted in vaginal delivery for 98.5% (321/326) of women without prior cesarean delivery and 91.1% (41/45) of women with a history of prior cesarean delivery, including two women who had uterine rupture. Among women with a history of prior cesarean delivery who had spontaneous labor, 74.1% (20/27) delivered vaginally, with no cases of uterine rupture. CONCLUSION Women with stillbirth usually delivered vaginally regardless of whether labor was spontaneous or induced or whether they had a prior cesarean delivery. However, 15% underwent cesarean delivery, often without a documented obstetric indication.OBJECTIVE To describe delivery management of singleton stillbirths in a population-based, multicenter case series. METHODS We conducted a retrospective chart review of 611 women with singleton stillbirths at 20 weeks of gestation or greater from March 2006 to September 2008. Medical and delivery information was abstracted from medical records. Both antepartum and intrapartum stillbirths were included; these were analyzed both together and separately. The primary outcome was mode of delivery. Secondary outcomes included induction of labor and indications for cesarean delivery. Indications for cesarean delivery were classified as obstetric (abnormal fetal heart tracing before intrapartum demise, abruption, coagulopathy, uterine rupture, placenta previa, or labor dystocia) or nonobstetric (patient request, repeat cesarean delivery, or not documented). RESULTS Of the 611 total cases of stillbirth, 93 (15.2%) underwent cesarean delivery, including 43.0% (46/107) of women with prior cesarean delivery and 9.3% (47/504) of women without prior cesarean delivery. No documented obstetric indication was evident for 38.3% (18/47) of primary and 78.3% (36/46) of repeat cesarean deliveries. Labor induction resulted in vaginal delivery for 98.5% (321/326) of women without prior cesarean delivery and 91.1% (41/45) of women with a history of prior cesarean delivery, including two women who had uterine rupture. Among women with a history of prior cesarean delivery who had spontaneous labor, 74.1% (20/27) delivered vaginally, with no cases of uterine rupture. CONCLUSION Women with stillbirth usually delivered vaginally regardless of whether labor was spontaneous or induced or whether they had a prior cesarean delivery. However, 15% underwent cesarean delivery, often without a documented obstetric indication.

The Utilization of Antenatal Late Preterm Steroids at a Tertiary Care Academic Medical Center [24I]

INTRODUCTION:The purpose of this study was to examine the utilization of antenatal late preterm steroids (ALPS) at a single institution following publication of recent evidence suggesting neonatal benefits in the late preterm period.METHODS:A retrospective cohort study was performed including all pa

Targeted delivery at 34 versus 35 weeks in women with preterm prelabor rupture of membranes.

Abstract Objective: To compare planned delivery at 34 versus 35 weeks for women with preterm prelabor rupture of membranes (PPROM). Materials and methods: We performed a retrospective cohort study of singleton pregnancies with PPROM after 24 weeks delivered from 2006 to 2014. In 2009, an institutional practice change established 35 weeks as the target gestational age before induction of labor was initiated after PPROM. Demographic and outcome measures were compared for two cohorts: women delivered 2006–2008 – target 34 weeks (T34) and women delivered 2009–2014 – target 35 weeks (T35). The primary outcome was neonatal intensive care unit (NICU) admission. Results: Of the 382 women with PPROM, 153 (40%) comprized the T34 cohort and 229 (60%) comprized the T35 cohort. Demographic characteristics were similar between groups. There were no differences between groups in gestational age at PPROM (31.0 ± 3.3 weeks versus 31.2 ± 3.1 weeks; p = .50) or maternal complications. The mean gestational age at delivery was earlier in the T34 group (31.8 ± 3.2 weeks versus 32.4 ± 2.7 weeks; p = .04). The median predelivery maternal length of stay (LOS) was 1 day longer in the T35 group (p = .03); the total and postpartum LOS were similar between groups (p > .05). There were no differences in the rate of NICU admission (T34 89.5% versus T35 92.1%; p = .38) or median neonatal LOS (T34 14 days versus T35 17 days; p = .15). In those patients who reached their target gestational age, both maternal predelivery LOS and total LOS were longer in the T35 group (p > .05). The frequency of NICU admission in those reaching their target gestational age was similar between groups (T34 83.37% versus T35 76.19%; p = .46). Conclusions: A 35-week target for delivery timing for women with PPROM does not decrease NICU admissions or neonatal LOS. This institutional change increased maternal predelivery LOS, but did not increase maternal or neonatal complications.

Vigorous Neonates With Acidemia at Term

INTRODUCTION: The objective of this study was to compare outcomes among vigorous neonates (5-minute Apgar score 7 or greater) with acidemia (arterial cord pH less than 7) at birth with vigorous neonates without acidemia (arterial cord pH 7.1 or greater). METHODS: A retrospective case–control study was performed using the Medstar PeriBirth labor database. Universal cord gas analysis was adopted at Medstar Washington Hospital Center in 2009. All singleton term deliveries between 37.0 and 42.0 weeks of gestation with arterial cord pH 7.0 or less and 5-minute Apgar score 7 or greater from 2010 to 2012 (cases, n=170) were matched one-to-one by gestational age and mode of delivery with those in a control group with arterial cord pH 7.1 or greater and 5-minute Apgar score 7 or greater (controls, n=170). Outcomes included mode of delivery, neonatal intensive care unit (NICU) admission, and type of acidosis. Statistical significance was defined as P⩽.05. RESULTS: Of 4,107 term, singleton deliveries in which cord blood gas analysis was available, 170 vigorous, acidemic neonates were delivered (incidence of 4.1%). There were no significant differences in identified obstetric or medical risk factors between the two groups. Those in the case group and those in the control group did not differ in the National Institute of Child Health and Human Development category of fetal heart tracing with the majority of tracings classified as category II. Neonates in the case group were more likely to be delivered by emergent cesarean delivery compared with those in the control group (25.5% compared with 14.7%, P=.004). Case neonates had an increased odds for NICU admission (odds ratio 2.68 95% confidence interval 1.6–4.5). CONCLUSION: Vigorous neonates with acidemia are at increased risk for NICU admission compared with nonacidemic neonates. Close observation may be warranted in neonates with acidemia irrespective of 5-minute Apgar scores.