Arnon Wiznitzer

Inflammatory bowel disease: risk factors for adverse pregnancy outcome and the impact of maternal weight gain.

Objective: To identify risk factors for adverse pregnancy outcome in women with inflammatory bowel disease (IBD) and to assess the effect of maternal pre-pregnancy weight and weight gain during pregnancy on pregnancy outcome. Methods: A retrospective, matched control study of all gravid women with IBD treated in a single tertiary center. Data were compared with healthy controls matched to by age, parity and pre-pregnancy BMI in a 3:1 ratio. Results: Overall, 300 women were enrolled, 75 women in the study group (28 with ulcerative colitis and 47 with Crohn’s disease) and 225 in the control group. The rates of preterm delivery and small for gestational age were higher in the study group (13.3 vs. 5.3% p = 0.02 and 6.7 vs. 0.9%, p = 0.004). The rate of cesarean section (36 vs. 19.1%; p = 0.002), NICU admission (10.7 vs. 4.0%, p = 0.03) and low 5-Min Apgar (4.0 vs. 0.4%, p = 0.02) were increased in the study group. Disease activity within 3 months of conception [OR 8.4 (1.3–16.3)] and maternal weight gain of less than 12 kg. [OR 3.6 (1.1–12.2)] were associated with adverse pregnancy outcome. Conclusion: Active disease at conception and inappropriate weight gain during pregnancy are associated with increased adverse pregnancy outcome in patients with IBD.

Third- and fourth-degree perineal tears--incidence and risk factors.

Abstract Objective: To assess the incidence and risk factors for third- and fourth-degree perineal tears (34DPT), and to identify subgroups of women who are at especially high risk for 34DPT. Methods: A cohort study of women who underwent vaginal delivery in a single tertiary medical center between 1999 and 2011, (58u2009937 deliveries). Women diagnosed with 34DPT following delivery were compared to control group. Multivariate logistic regression analysis and tree classification analysis were used to identify combinations of risk factors which were associated with considerable risk for 34DPT. Results: Overall, 356 (0.6%) deliveries were complicated by 34DPT (340 (95.5%) third-degree tears and 16 (4.5%) fourth-degree tears). Independent predictors of 34DPT were: forceps delivery (odds ratio (OR)u2009=u20095.5, confidence interval (CI) 3.9–7.8), precipitate labor (ORu2009=u20095.2, CI 2.9–9.2), persistent occiput posterior position (ORu2009=u20092.6, CI 1.6–4.3), vacuum extraction (ORu2009=u20091.9, CI 1.4–2.6) as well as large for gestational age (LGA) infant and gestational ageu2009>u200940 weeks. Fourth-degree tears were associated with forceps delivery (ORu2009=u200912.5, CI 2.3–66.2), precipitate labor (ORu2009=u20099.7, 95%-CI 1.2–75.4) and LGA infant (ORu2009=u20097.4, 95%-CI 1.7u2009–1.5). Overall, the predictability of 34DPT was limited (R2u2009=u20090.4). In subgroups of women with certain combinations of risk factors the risk of 34DPT ranged from 10% to 25%. Conclusion: Despite the limited predictability of 34DPT by individual risk factors, the use of combinations of risk factors may assist obstetricians in identifying women who are at especially high risk for 34DPT.

Risk for recurrence of preeclampsia and outcome of subsequent pregnancy in women with preeclampsia in their first pregnancy

Objective: To assess subsequent pregnancy outcome and to identify risk factors for recurrence of preeclampsia (PET) in women with PET in their first pregnancy. Methods: A retrospective cohort study of all nulliparous women diagnosed with PET during the years 1996–2008 (PET group, N = 600). Outcome of subsequent pregnancy was compared with a control group of nulliparous women without PET matched by maternal age in a 3:1 ratio (N = 1800). Results: Subsequent pregnancies in the PET group were characterized by a higher rate of preterm delivery at less than 37 and 34 weeks (15.2% vs. 5.7%, p < 0.001 and 3.8% vs. 0.8%, p < 0.001, respectively), placental abruption (1.7% vs. 0.2%, p = 0.004), IUGR (2.8% vs. 0.9%, p = 0.016), and PET (5.9% vs. 0.8%, p < 0.001). Risk factors for PET and adverse outcome in the subsequent pregnancy included: PET complicated by placental abruption in the index pregnancy (OR = 10.8, 95%-CI = 1.8–34.6), PET requiring delivery prior to 34 weeks in the index pregnancy (OR = 6.5, 95%-CI = 1.6–22.5), chronic hypertension (OR = 5.3, 95%-CI = 1.9–12.7), and maternal age > 35 (OR = 4.3, 95%-CI = 1.2–20.5). Conclusion: PET in the first pregnancy is independently associated with an increased risk for adverse pregnancy outcome and recurrence of PET in the subsequent pregnancy in a manner that is related to the severity of PET in the first pregnancy.

Is abnormal 50-g glucose-challenge testing an independent predictor of adverse pregnancy outcome?

Objective: To determine whether an abnormal 50-g glucose-challenge test (GCT) is independently associated with adverse pregnancy outcome. Methods: A retrospective study of women with abnormal GCT (>140u2009mg/dL) but normal subsequent 100-g oral glucose-tolerance test (OGTT). Pregnancy outcome was compared with that of women with normal GCT (<140u2009mg/dL). Results: Of the 79,153 women delivered during the study period, the results of the GCT were available for 14,268. Of these, 809 (5.7%) had an abnormal GCT and normal OGTT and were eligible for the study group. An abnormal GCT was independently associated with an increased risk for macrosomia (odds ratio [OR] = 2.0, 95% CI: 1.5–2.7), large for gestational age (OR = 1.6, 95% CI: 1.3–2.0), cesarean section (OR = 1.3, 95% CI: 1.1–1.6), respiratory morbidity (OR = 1.6, 95% CI: 1.1–2.7) and neonatal hypoglycemia (OR = 1.8, 95% CI: 1.1–3.2). In contrast, an abnormal GCT was associated with decreased risk for preterm delivery at less than 37 weeks (OR = 0.7, 95% CI: 0.5–0.9) and 34 weeks (OR = 0.3, 95% CI: 0.1–0.6). The association between abnormal GCT and adverse pregnancy outcome was unrelated to the degree of GCT abnormality except for cases in which the GCT was extremely high (≥180u2009mg/dL). Conclusion: Women with abnormal-GCT result are at increased risk for adverse pregnancy outcome even in the presence of a normal subsequent OGTT.

Pregnancy course and outcome following blunt trauma

Objective: To investigate short- and long-term outcome following blunt trauma in pregnancy, and to identify risk factors for adverse pregnancy outcome in these cases. Methods: A retrospective cohort study of all pregnant women who were admitted following blunt trauma (Nu2009=u2009411). Women who experienced immediate complications (Nu2009=u200913) were compared with those who did not (Nu2009=u2009398). Pregnancy outcome of women who experienced trauma during pregnancy and did not deliver during the trauma admission (Nu2009=u2009303) were compared with a control group of women matched to by maternal age and parity in a 3:1 ratio (Nu2009=u2009909). Results: The overall rate of immediate complications was 3.2%, with the most common complications being preterm labor (2.0%) and placental abruption (1.7%). Independent risk factors for immediate complications were higher severity of trauma, multiple gestation, vaginal bleeding and uterine contractions at admission. Patients who experienced trauma were at increased risk for long-term adverse outcome including preterm labor, placental abruption, and perinatal morbidity. Increased trauma severity (ISS ≥ 5) and the need for laparotomy during the trauma hospitalization were independently associated with long-term adverse pregnancy outcome. Conclusion: Trauma during pregnancy is associated with both immediate and long-term adverse pregnancy outcome. Women who experience trauma should be followed more closely throughout pregnancy.

Association and risk factors between induction of labor and cesarean section

Abstract Objective: To determine risk factors and to quantify the risk of cesarean section (CS) associated with labor induction. Method: A prospective controlled study of women admitted for labor induction with PGE2 in a single tertiary medical center. Outcome was compared with women who presented with spontaneous onset of delivery. Results: The induction group were characterized by a higher body mass index (BMI), lower Bishop score and a higher cervical length at presentation compared with controls. Labor induction with PGE2 was associated with increased risk of CS (14.8% versus 4.5%, pu2009=u20090.02). This association persists after adjustment for potential confounders including Bishop score at presentation (ORu2009=u20092.9, 95% CI 1.03–11.8). The risk of CS was especially high for nulliparous (24.4% versus 5.1%, pu2009=u20090.02), overweight (21.2% versus 3.7%, pu2009=u20090.047), induction at <40 weeks of gestation (22.2% versus 2.2%, pu2009=u20090.004), in Bishop score <4 (18.2% versus 4.5%, pu2009=u20090.03), cervical length >25u2009mm (19.2% versus 4.5%, pu2009=u20090.005), or intact membranes (25.0% versus 4.5%, pu2009=u20090.02) at presentation. Conclusions: Labor induction with PGE2 is associated with increased risk of CS. These data should be taken into consideration when deciding on labor induction, especially in the absence of clear medical indication.

Outcome of trial of labor after cesarean section in women with past failed operative vaginal delivery.

OBJECTIVEnThe objective of the study was to assess the outcome ofxa0trial of labor after cesarean (TOLAC) in women with past failed operative vaginal delivery (OVD).nnnSTUDY DESIGNnA retrospective study of all women who underwent cesarean section (CS) because of a failed OVD in a tertiary medical center between 1996 and 2011. Women who had a subsequent delivery were identified, and the outcome of subsequent delivery was analyzed.nnnRESULTSnOverall, 533 women underwent CS because of failed OVDxa0during the study period. A total of 204 women (38.3%) had a subsequent delivery, of whom 93 (45.6%) had a TOLAC and 111 (54.4%) had a repeat elective CS. The success rate in the TOLAC group was 61.3% (nxa0= 57). The most common indication for repeat CSxa0was lack of progress (72.3%) among the 36 women in whom TOLAC failed (38.7%). The rate of postpartum hemorrhage and prolonged maternal hospitalization was lower in the TOLAC group than inxa0the repeat CS group (2.2% vs 10.8%, Pxa0= .02, and 0% vs 8.1%, Pxa0= .005). There were no cases of rupture or dehiscence of the uterinexa0scar. Factors associated with failed TOLAC were the occiput-posterior position and prolonged the second stage as the indication for OVD in the index pregnancy, maternal age older than 30 years atxa0the time of subsequent delivery, and a birthweight in the subsequentxa0pregnancy that is higher than the birthweight in the index pregnancy.nnnCONCLUSIONnTOLAC in women who underwent a previous CS because of a failed OVD is associated with a relatively high success rate compared with the reported success rates among women with past CS during the second stage of labor. This information and the risk factors for TOLAC failure can be used when counseling these women regarding mode of delivery in subsequent pregnancy.

The performance of the screening test for gestational diabetes in twin versus singleton pregnancies

Abstract Objective: To compare the performance of the 50u2009g glucose challenge test (GCT) and the 100u2009g oral glucose tolerance test (OGTT) in twin versus singleton pregnancies. Methods: A retrospective study of all women who underwent a GCT (24–28 weeks) and delivered in a single tertiary medical center (2001–2012). The performance of the GCT and the OGTT tests were compared between twin and singleton pregnancies. Results: The results of the GCT were available for 14u2009797 women, of whom 14u2009268 were singleton and 529 were twin pregnancies. Women in the twins group were characterized by a higher mean GCT result (104.7u2009±u200928 versus 98.5u2009±u200925, pu2009<u20090.001), a higher rate of GCTu2009>u2009130u2009mg/dl (20.2% versus 11.8%, pu2009<u20090.001) or GCT >140u2009mg/dl (13.8% versus 9.6%, pu2009=u20090.001). The positive prediction value (PPV) for a GCT >140u2009mg/dl was significantly lower in the twins group for the prediction of either ≥1 abnormal values (21.1% versus 33.8%, pu2009=u20090.03) or ≥2 abnormal values (12.7% versus 23.0%, pu2009=u20090.04) in the OGTT. Twin pregnancy was independently associated with an increased risk for a GCT result >130u2009mg/dl [odds ratio (OR)u2009=u20092.2, 95% confidence interval (CI) 1.7–2.7] or >140u2009mg/dl (ORu2009=u20091.9, 95% CI 1.5–2.5) even after adjustment for maternal age, parity and fetal sex. Conclusion: The 50u2009g GCT appears to be associated with a higher false positive rate and a lower positive predictive value in twin compared with singleton pregnancies.

New onset of meconium during labor versus primary meconium-stained amniotic fluid – is there a difference in pregnancy outcome?

Abstract Objective: To compare pregnancy outcome between deliveries complicated by new onset of meconium during labor following prior evidence of clear amniotic fluid and labors in which meconium was present to begin with. Methods: A retrospective cohort study of all singleton term (≥37u2009+u20090 weeks) deliveries complicated by intrapartum meconium-stained amniotic fluid in a tertiary referral medical center during the year 2012. Outcome was compared between deliveries with new onset of meconium during labor following prior evidence of clear amniotic fluid (secondary meconium group) and those in which meconium was already evident at the time of membranes rupture (primary meconium group). Results: Of the 9167 deliveries during the study period, 694 were eligible for the study group. Of these, 537 were complicated by primary meconium and 157 by secondary meconium. Only secondary meconium, but not primary meconium, was independently associated with an increased risk of operative vaginal delivery (OVD) and adverse neonatal outcome. Pregnancies complicated by secondary meconium were independently associated with a higher rate of OVD (28.0% versus 11.4%, pu2009<u20090.001), POP position of the fetal head (6.4% versus 2.6%, pu2009=u20090.02), and adverse neonatal outcome (17.2% versus 8.9%, pu2009=u20090.003). Conclusion: Secondary meconium is associated with a higher rate of adverse obstetrical and neonatal outcome compared with primary meconium.

Timing of planned repeat cesarean delivery after two or more previous cesarean sections – Risk for unplanned cesarean delivery and pregnancy outcome

Abstract Objective: To assess the effect of the scheduled gestational age for a repeat planned cesarean section (CS) on the risk for adverse pregnancy outcome in women with two or more previous CS. Methods: A retrospective cohort study of all women after ≥2 previous CS who were scheduled for a repeat planned CS. Women were divided into two groups at which the planned CS was scheduled: 38-week group or 39-week group. Results: Overall, 377 were enrolled, 264 (70.0%) and 113 (30.0%) in the 38-week and the 39-week groups, respectively. The rate of an unplanned CS was significantly higher in the 39-week versus the 38-week group (23.0% versus 13.3%, pu2009=u20090.02). A repeat planned CS scheduled to week 39 was associated with an increased risk of maternal adverse outcome (31.9% versus 21.6%, pu2009=u20090.03). There was no significant difference in the rate of adverse neonatal outcome between the two groups (20.8% versus 23.0%, pu2009=u20090.5). The lowest rate of any adverse outcome (maternal and/or neonatal) was observed when CS was scheduled to 38u2009+u20091 weeks of gestation. Conclusions: In women after two cesarean sections, scheduling a planned CS at around 39 weeks compared with at around 38 weeks is associated with an increased risk for maternal adverse outcome with no apparent advantage in terms of neonatal outcome.