Ashley N. Battarbee

Association of Isolated Single Umbilical Artery With Small for Gestational Age and Preterm Birth.

OBJECTIVE: To assess the association of an isolated single umbilical artery with small for gestational age (SGA) and preterm birth. METHODS: In this retrospective cohort study, 219 consecutive women carrying a fetus with an isolated single umbilical artery diagnosed during routine second-trimester anatomic survey were compared with 219 women carrying a fetus with a three-vessel cord. Pregnancies with fetal anomalies or aneuploidy were excluded from the analysis. Outcomes included pregnancy-induced hypertension, gestational age at birth, birth weight, SGA, defined as birth weight less than the 10th percentile, and indicated or spontaneous preterm birth, defined as delivery before 37 weeks of gestation. RESULTS: In univariable analysis, the presence of an isolated single umbilical artery was significantly associated with lower birth weight (3,146 compared with 3,430 g) and with SGA (11.9% compared with 2.7%; P<.001 for each outcome). The rates of pregnancy-induced hypertension (7.3% compared with 1.8%, P=.01) and indicated but not spontaneous preterm delivery (5.5% compared with 0.9%, P=.01 for indicated and 8.2% compared with 4.6%, P=.12 for spontaneous) were also more common in pregnancies with an isolated single umbilical artery. In multivariable analysis controlling for potential confounders, an isolated single umbilical artery remained associated with SGA, pregnancy-induced hypertension, and medically indicated preterm birth (adjusted odds ratio [OR] 3.97, confidence interval [CI] 1.55–10.12; adjusted OR 3.50, CI 1.10–11.18; adjusted OR 7.35, CI 1.60–33.77, respectively). CONCLUSION: Pregnancies complicated by isolated single umbilical artery are at increased risk for SGA and pregnancy-induced hypertension but not for spontaneous preterm birth. LEVEL OF EVIDENCE: II

Association of Early Amniotomy After Foley Balloon Catheter Ripening and Duration of Nulliparous Labor Induction.

OBJECTIVE: To evaluate the association between early amniotomy after ripening with a Foley balloon catheter and duration of labor induction. METHODS: In this retrospective matched cohort study, 546 nulliparous women with a singleton viable gestation undergoing cervical ripening with a Foley balloon catheter were compared based on timing of amniotomy after catheter removal: early (defined as artificial rupture of membranes less than 1 hour after Foley removal) compared with no artificial rupture of membranes in the first hour. Women in the early amniotomy group were matched to women in the control group according to health care provider type, cervical examination after Foley removal, and indication for induction in a one-to-one ratio. Bivariable and multivariable analyses were performed to determine whether early amniotomy was associated with vaginal delivery within 24 hours and other adverse maternal and neonatal outcomes. Cox proportional hazard regression was used to compare time intervals from catheter removal to complete dilation and from catheter removal to delivery. RESULTS: In univariable analysis, the frequency of vaginal delivery within 24 hours of Foley placement was higher in women with early amniotomy (42.9% compared with 33.0%, P=.02). The median time intervals from Foley catheter removal to complete dilation (9.0 hours compared with 12.1 hours) and to delivery (10.6 hours compared with 13.8 hours) were also significantly shorter for women who underwent early amniotomy (P<.001 for both). There were no significant differences in any other adverse maternal or neonatal outcomes. In multivariable analysis, early amniotomy remained associated with higher odds of vaginal delivery within 24 hours and shorter times from catheter removal to complete dilation and to delivery. CONCLUSION: Early amniotomy after Foley balloon catheter removal is associated with shorter duration of labor induction among nulliparous women.

The Association between Cervical Exam after Ripening with Foley Balloon Catheter and Outcomes of Nulliparous Labor Induction

Objective Evaluate the association between cervical examination after ripening with Foley catheter and labor induction outcomes. Materials and Methods In this retrospective cohort, nulliparous women with singleton, viable gestation undergoing cervical ripening with Foley catheter were compared based on cervical status after catheter removal or expulsion: favorable (modified Bishop score ≥ 5) or unfavorable (score < 5). Bivariable and multivariable analyses were performed to determine whether cervical examination postripening was associated with time to delivery and chance of vaginal delivery. Results A total of 774 women were eligible. Women with favorable examination postripening had lower body mass index (BMI) and more favorable admission cervical examination. The frequency of vaginal delivery was higher in women with favorable cervical examination postripening (57.9% versus 46.8%, p < 0.01). Median durations from Foley removal or expulsion to complete dilation (8.6 h versus 11.5 h) and vaginal delivery (10.4 h versus 13.2 h) were shorter for women with favorable cervical examination postripening (p < 0.001). In multivariable analysis, favorable examination postripening remained associated with vaginal delivery (adjusted odds ratio 1.39, 95% confidence interval 1.04‐1.87), and time to vaginal delivery (adjusted hazard ratio 1.39, 95% confidence interval 1.13‐1.70). Conclusion A favorable modified Bishop score after cervical ripening with Foley balloon catheter is associated with higher chance of vaginal delivery and shorter labor duration.

Occult Placenta Accreta: Risk Factors, Adverse Obstetrical Outcomes, and Recurrence in Subsequent Pregnancies

Objective To assess the risk factors, adverse obstetrical outcomes, and recurrence risk associated with pathologically diagnosed occult placenta accreta. Study Design This was a retrospective observational study of clinically adherent placentas requiring manual extraction that underwent pathological examination. Cases were defined as those with histological evidence of placenta accreta, and controls were defined as those without accreta. All subsequent pregnancies were evaluated to determine the recurrence risk of occult accreta in future pregnancies. Results Of 491 women with clinically adherent placentas, 100 (20.1%) with a pathological diagnosis of occult accreta were compared with 391 (79.9%) without occult accreta. In bivariable analysis, risk factors associated with occult accreta included a history of previous cesarean (19 vs. 10.7%; p = 0.03) and prior uterine surgery (35 vs. 19.7%; p = 0.001). Adverse obstetrical outcomes were more common in women with occult accreta including postpartum hemorrhage (59 vs. 31.7%; p < 0.001) and peripartum hysterectomy (21 vs. 0.3%; p < 0.001). In 130 subsequent pregnancies, there was an increased risk of retained placenta (42.9 vs. 19%; p = 0.04) and recurrence of occult accreta (29.6 vs. 6.8%; p = 0.05). Conclusion Occult accreta is associated with an increased risk of hemorrhagic morbidity and recurrence of morbidly adherent placenta in subsequent pregnancies.

Practice Variation in Antenatal Steroid Administration for Anticipated Late Preterm Birth: A Physician Survey

Objective The objective of this study was to measure knowledge and practice variation in late preterm steroid use. Study Design Electronic survey of American College of Obstetricians and Gynecologists (ACOG) members about data supporting the ACOG/Society for Maternal‐Fetal Medicine (SMFM) recommendations and practice when caring for women with anticipated late preterm birth (PTB), 340/7 to 366/7 weeks. Results Of 352 administered surveys, we obtained 193 completed responses (55%); 82.5% were generalist obstetrician‐gynecologists (OB/GYNs), and 42% cared for women with anticipated late PTB at least weekly. Most believed that late preterm steroids provided benefit by reducing respiratory distress syndrome (93%), transient tachypnea of the newborn (83%), and neonatal intensive care unit admission (82%). More than half administered late preterm steroids to women with multiple gestations (73%), and pregestational diabetes (55‐80%) depending on glycemic control. OB/GYNs administered steroids to insulin‐dependent and poorly controlled diabetics more often than MFMs (75 vs. 46% and 59 vs. 37% respectively, p < 0.05 for both). While providers believed there was increased maternal hyperglycemia (88%) and neonatal hypoglycemia (59%), 88% believed neonatal respiratory benefits outweighed these risks. Respondents agreed research is needed to determine who are appropriate candidates (77%) and how to minimize adverse outcomes (82%). Conclusion Most providers are administering late preterm steroids to all women, even those populations who have been excluded from previous trials. Despite widespread use, providers believe more research is needed to optimize management.

Placental abnormalities associated with isolated single umbilical artery in small-for-gestational-age births

BACKGROUND Previous studies have shown that pregnancies complicated by placentas with an isolated single umbilical artery (iSUA) are at increased risk for small-for-gestational-age (SGA) births. The etiology of SGA in this population, however, remains unknown. OBJECTIVE The primary objective of this study was to evaluate whether placental abnormalities in pregnancies with SGA births differ according to the presence of iSUA. STUDY DESIGN This was an observational study of all women with pathologic examination of the placenta after delivering a non-anomalous, singleton SGA neonate between January 2009 and August 2015. SGA was defined as birthweight less than 10th percentile for gestational age. Women were categorized according to whether they had an iSUA or a three-vessel cord. The following placental pathologies were compared between the groups using bivariable and multivariable analyses: SGA placenta, maternal vascular malperfusion, high grade fetal vascular malperfusion, and chronic villitis. RESULTS 1833 women were included in the analysis: 34 with iSUA and 1799 with three-vessel cord. More than 85% of women in both groups had at least one placental abnormality. After adjusting for nulliparity and neonatal gender, the presence of iSUA was associated with increased odds of high grade fetal vascular malperfusion (adjusted odds ratio 2.8, 95% confidence interval 1.1-7.5) and decreased odds of maternal vascular malperfusion (adjusted odds ratio 0.2, 95% confidence interval 0.1-0.9). There was no significant association with other pathologic findings. CONCLUSION Pathologic placental findings associated with SGA birth differed based on umbilical cord composition. The presence of iSUA in an SGA birth was associated with a higher odds of high grade fetal vascular malperfusion abnormalities and lower odds of maternal vascular malperfusion abnormalities, compared to SGA birth with a 3VC.

Applicability of the modified ACOG/SGO referral criteria for adnexal mass within a limited‐resource setting

To evaluate the performance of the modified American Congress of Obstetricians and Gynecologists (ACOG)/Society of Gynecologic Oncology (SGO) referral guidelines in a high‐risk limited‐resource setting.

Barriers to Postpartum Follow-Up and Glucose Tolerance Testing in Women with Gestational Diabetes Mellitus

Objective This study aims to examine factors associated with postpartum follow‐up and glucose tolerance testing (GTT) in women with gestational diabetes mellitus (GDM). Materials and Methods Case‐control study of women with GDM at a single institution with available outpatient records (January 2008‐February 2016). Women with pregestational diabetes mellitus were excluded. The postpartum follow‐up, GTT completion, and the reason for GTT completion failure (provider vs. patient noncompliance) were assessed. Bivariable and multivariable analyses were performed to identify factors associated with postpartum follow‐up and GTT completion. Results Of 683 women, 82.0% (n = 560) returned postpartum, and 49.8% (n = 279) of those completed GTT. Women with Medicaid and late presentation to care were less likely to return (adjusted odds ratio [aOR]: 0.3, 95% confidence interval [CI]: 0.2‐0.6 and aOR: 0.4, 95% CI: 0.2‐0.7), but if they did, both factors were associated with increased odds of GTT completion (aOR: 2.0, 95% CI: 1.3‐2.9 and aOR: 3.5, 95% CI: 1.8‐6.6). Patient and provider noncompliance contributed equally to GTT completion failure. Trainee involvement was associated with improved test completion (aOR: 4.6, 95% CI: 2.4‐8.8). Conclusion The majority of women with GDM returned postpartum, but many did not receive recommended GTT. Public insurance and late presentation were associated with failure to return postpartum, but better GTT completion when a postpartum visit occurred. Trainee involvement was associated with improved adherence to screening guidelines.