Annie M. Dude

Maternal and neonatal outcomes in triplet gestations by trial of labor versus planned cesarean delivery

Abstract Objective: To determine the rate of vaginal delivery after vaginal trial of labor (TOL) among women with triplet gestations. Study design: This is a retrospective cohort study of all women delivering a viable triplet gestation between 2005 and 2016. The primary outcome was rate of vaginal delivery among all women attempting vaginal delivery. Secondary outcomes included factors associated with undergoing triplet TOL, and maternal and neonatal complications by planned delivery approach. Results: Of the 83 eligible women, 21 (25.3%) underwent TOL. A majority of these (57.1, 95% confidence interval 36.5–75.5%) achieved a vaginal delivery of all three triplets. Women who underwent TOL were more likely to be multiparous or to have spontaneous preterm labor. There were no differences in adverse maternal or neonatal outcomes by planned delivery approach. Conclusions: The rate of vaginal delivery among women with triplet gestations is higher in this institution than in reported literature, without increased morbidity.

Management of Diabetes in the Intrapartum and Postpartum Patient

Abstract Achieving maternal euglycemia in women with pregestational and gestational diabetes mellitus is critical to decreasing the risk of neonatal hypoglycemia, as maternal blood glucose levels around the time of delivery are directly related to the risk of hypoglycemia in the neonate. Many institutions use continuous insulin and glucose infusions during the intrapartum period, although practices are widely variable. At Northwestern Memorial Hospital, the “Management of the Perinatal Patient with Diabetes” policy and protocol was developed to improve consistency of management while also allowing individualization appropriate for the patients specific diabetic needs. This protocol introduced standardized algorithms based on maternal insulin requirements to drive real‐time maternal glucose control during labor as well as provided guidelines for postpartum glycemic control. This manuscript describes the development and implementation of this protocol to encourage other institutions to adopt a standardized protocol that allows highly individualized intrapartum care to women with diabetes.

Pre-pregnancy blood pressure and body mass index trajectories and incident hypertensive disorders of pregnancy

There are few studies examining patterns in body mass index (BMI) and blood pressure (BP) and subsequent hypertensive disorders of pregnancy (HDPs). We examined the association of BMI (n = 1342) or BP (n = 2266) trajectories in the 5 years preceding birth with HDPs using adjusted logistic regression. Compared to normal-weight BMI and low-normal BP groups, membership to the overweight BMI group (OR: 2.95, 95%CI: 1.57-5.53, p = 0.001) and higher-normal (OR: 2.74, 95%CI:1.49-5.04, p = 0.001) and prehypertensive (OR:7.27, 95%CI: 3.29-16.06, p < 0.001) BP groups were associated with higher odds of HDPs. Our data suggest maintaining normal-weight and low-normal BP in the years preceding pregnancy may help avoid HDPs.

Identifying Fetal Growth Disorders Using Ultrasonography in Women With Diabetes

We evaluated the ability of third‐trimester ultrasonography (US) to diagnose disorders of fetal growth among women with diabetes mellitus.

Interdelivery Interval and Medically Indicated Preterm Delivery

Objective The objective of this study was to examine whether a medically indicated preterm delivery is relatively more likely following longer interdelivery intervals. Study Design This is a case‐control study of women with two consecutive deliveries of a live singleton at the same institution between 2005 and 2015, with the subsequent delivery occurring preterm. Preterm deliveries were classified as spontaneous if women delivered following preterm labor, preterm premature rupture of membranes, or placental abruption. Preterm deliveries were classified as medically indicated if women underwent delivery for fetal or maternal medical indications. Interdelivery interval was categorized as < 18, 18 to 59, and 60 months or more. Characteristics of women who had a medically indicated versus spontaneous preterm delivery were compared. Results Of the 1,276 women, 25.6% had a medically indicated preterm delivery and 74.4% had a spontaneous preterm delivery. Compared with women with an interdelivery interval of 18 to 59 months (of whom 25.7% had a preterm delivery for medical indications), women with a shorter interdelivery interval were less likely (19.3%), while women with a longer interdelivery interval were more likely (37.4%; p = 0.003) to have a medically indicated preterm delivery. This relationship persisted even when accounting for other factors. Conclusion Preterm deliveries are more likely to be medically indicated as the interdelivery interval lengthens.

Association between Sonographic Estimated Fetal Weight and the Risk of Cesarean Delivery among Nulliparous Women with Diabetes in Pregnancy.

Objective The objective of this study was to examine the association between an ultrasound‐estimated fetal weight (US‐EFW) and mode of delivery among nulliparous diabetic women. Study Design This is a retrospective cohort study of nulliparous women with medication‐requiring gestational or pregestational diabetes who delivered term, singleton gestations following a trial of labor. We determined whether having had an US‐EFW within 35 days of delivery was associated with cesarean delivery. Results Of 304 women who met the eligibility criteria, 231 (76.0%) had an US‐EFW within 35 days of delivery. An US‐EFW was associated with increased likelihood of intrapartum cesarean (51.5% for those with an ultrasound vs. 27.4% for those without, p < 0.001); this finding persisted even when controlling for birth weight and other confounding factors (adjusted odds ratio: 2.23, 95% confidence interval: 1.16‐4.28). Among women with a recent US‐EFW, a diagnosis of a large‐for‐gestational‐age (LGA) fetus was associated with overall intrapartum cesarean frequency (65.2% for women with an LGA fetus vs. 46.1% for those without, p = 0.009), but this association did not remain significant in multivariable models. Conclusion An US‐EFW within 35 days of delivery among nulliparous women with medication‐requiring diabetes was positively associated with intrapartum cesarean delivery.

Interdelivery weight gain and risk of cesarean delivery following a prior vaginal delivery

Background Approximately one third of all deliveries in the United States are via cesarean. Previous research indicates weight gain during pregnancy is associated with an increased risk of cesarean delivery. It remains unclear, however, whether and to what degree weight gain between deliveries (ie, interdelivery weight gain) is associated with cesarean delivery in a subsequent pregnancy following a vaginal delivery. Objectives The objective of the study was to determine whether interdelivery weight gain is associated with an increased risk of intrapartum cesarean delivery following a vaginal delivery. Study Design This was a case‐control study of women who had 2 consecutive singleton births of at least 36 weeks’ gestation between 2005 and 2016, with a vaginal delivery in the index pregnancy. Women were excluded if they had a contraindication to a trial of labor (eg, fetal malpresentation or placenta previa) in the subsequent pregnancy. Maternal characteristics and delivery outcomes for both pregnancies were abstracted from the medical record. Maternal weight gain between deliveries was measured as the change in body mass index at delivery. Women who underwent a subsequent cesarean delivery were compared with those who had a repeat vaginal delivery using χ2 statistics for categorical variables and Student t tests or analysis of variance for continuous variables. Multivariable logistic regression was used to determine whether interdelivery weight gain remained independently associated with intrapartum cesarean delivery after adjusting for potential confounders. Results Of 10,396 women who met eligibility criteria and had complete data, 218 (2.1%) had a cesarean delivery in the subsequent pregnancy. Interdelivery weight gain was significantly associated with cesarean delivery and remained significant in multivariable analysis for women with a body mass index increase of at least 2 kg/m2 (adjusted odds ratio, 1.53, 95% confidence interval, 1.03–2.27 for a body mass index increase of 2 kg/m2 to <4 kg/m2; adjusted odds ratio, 1.99, 95% confidence interval, 1.19–3.34 for body mass index increase of 4 kg/m2 or more). Furthermore, women who gained 2 kg/m2 or more were significantly more likely to undergo cesarean delivery specifically for the indications of arrest of dilation or arrest of descent (adjusted odds ratio, 2.01, 95% confidence interval, 1.21–3.33 for body mass index increase of 2 to <4 kg/m2; adjusted odds ratio, 2.34, 95% confidence interval, 1.15–4.76 for body mass index increase of ≥4 kg/m2). Contrarily, women who lost ≥2 kg/m2 were less likely to undergo any cesarean delivery (adjusted odds ratio, 0.41, 95% confidence interval, 0.21–0.78) as well as less likely to undergo cesarean delivery for an arrest disorder (adjusted odds ratio, 0.29, 95% confidence interval, 0.10–0.82). Weight gain or loss was not significantly associated with a cesarean delivery for fetal indications. Conclusion Among women with a prior vaginal delivery, interdelivery weight gain was independently associated with an increased risk of intrapartum cesarean delivery in a subsequent pregnancy.