Audrey Merriam

Trends in operative vaginal delivery, 2005–2013: a population‐based study

The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery.

Bed Rest and Gestational Diabetes: More Reasons to Get Out of Bed in the Morning

INTRODUCTION: Activity restriction or “bed rest” is a commonly prescribed obstetric intervention, which lacks data demonstrating efficacy. Complications including bone demineralization, pulmonary atelectasis, venous thromboembolism, and muscle deconditioning have been attributed to bed rest. Exercise has a known beneficial effect toward achieving good glycemic control in women with gestational diabetes mellitus (GDM). We sought to quantitate the effect that bed rest has on GDM. METHODS: We performed a retrospective cohort study from 2007 to 2012 at a large tertiary hospital. Charts for women with singleton pregnancies who were admitted for 7 days or longer with diagnosis codes for preterm labor, cervical shortening, preterm premature rupture of membranes, advanced cervical dilation, and preeclampsia were identified. Those who had their 1-hour screening Glucola test during admission were included. Logistic regression analysis was done to determine the effect of bed rest on GDM. RESULTS: Five hundred nine women were available for inclusion. Fifty-four were diagnosed with gestational diabetes during a prolonged hospital stay (10.6%). Patient characteristics between the two groups were similar. Maternal age (relative risk 2.66, P=.008) and maternal length of stay (relative risk 6.13, P=0.00) were associated with the development of GDM. For every day a patient was admitted to the hospital on bed rest, their risk of GDM increased 1.04 times. CONCLUSION: Antenatal bed rest increases the risk of acquiring GDM. The association between bed rest and GDM is biologically plausible because skeletal muscle is the primary site of maternal insulin resistance. Activation of these muscles has been shown to increase insulin sensitivity and decrease blood glucose levels. This finding supports the mounting evidence that bed rest does more harm than good.

Do Doppler studies enhance surveillance of uncomplicated monochorionic diamniotic twins

To determine whether isolated abnormal Doppler indices before 28 weeks predict adverse pregnancy outcomes in uncomplicated monochorionic diamniotic (MCDA) twins.

Harness shared data in international Zika registry

We welcome the paper by Morris and colleagues on the prevalence of microcephaly in Europe.1 The authors state that increases in prevalence such as expected with Zika virus in a non-endemic region would be unlikely to be detected in Europe through routine surveillance. As a newly identified teratogen, Zika requires global and dedicated tools to allow comprehensive characterisation of the …

Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals

Abstract Objective: The objective of this study was to characterize risk for and temporal trends in postpartum hemorrhage across hospitals with different delivery volumes. Study design: This study used the Nationwide Inpatient Sample (NIS) to characterize risk for postpartum hemorrhage from 1998 to 2011. Hospitals were classified as having either low, moderate or high delivery volume (≤1000, 1001 to 2000, >2000 deliveries per year, respectively). The primary outcomes included postpartum hemorrhage, transfusion, and related severe maternal morbidity. Adjusted models were created to assess factors associated with hemorrhage and transfusion. Results: Of 55,140,088 deliveries included for analysis 1,512,212 (2.7%) had a diagnosis of postpartum hemorrhage and 361,081 (0.7%) received transfusion. Risk for morbidity and transfusion increased over the study period, while the rate of hemorrhage was stable ranging from 2.5 to 2.9%. After adjustment, hospital volume was not a major risk factor for transfusion or hemorrhage. Discussion: While obstetric volume does not appear to be a major risk factor for either transfusion or hemorrhage, given that transfusion and hemorrhage-related maternal morbidity are increasing across hospital volume categories, there is an urgent need to improve obstetrical care for postpartum hemorrhage. Those risk factors are able to discriminate women at increased risk supports routine use of hemorrhage risk assessment.

Femur-sparing pattern of abnormal fetal growth in pregnant women from New York City after maternal Zika virus infection

BACKGROUND: Zika virus is a mosquito‐transmitted flavivirus, which can induce fetal brain injury and growth restriction following maternal infection during pregnancy. Prenatal diagnosis of Zika virus–associated fetal injury in the absence of microcephaly is challenging due to an incomplete understanding of how maternal Zika virus infection affects fetal growth and the use of different sonographic reference standards around the world. We hypothesized that skeletal growth is unaffected by Zika virus infection and that the femur length can represent an internal standard to detect growth deceleration of the fetal head and/or abdomen by ultrasound. OBJECTIVE: We sought to determine if maternal Zika virus infection is associated with a femur‐sparing pattern of intrauterine growth restriction through analysis of fetal biometric measures and/or body ratios using the 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project and World Health Organization Fetal Growth Chart sonographic references. STUDY DESIGN: Pregnant women diagnosed with a possible recent Zika virus infection at Columbia University Medical Center after traveling to an endemic area were retrospectively identified and included if a fetal ultrasound was performed. Data were collected regarding Zika virus testing, fetal biometry, pregnancy, and neonatal outcomes. The 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project and World Health Organization Fetal Growth Chart sonographic standards were applied to obtain Z‐scores and/or percentiles for fetal head circumference, abdominal circumference, and femur length specific for each gestational week. A novel 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project standard was also developed to generate Z‐scores for fetal body ratios with respect to femur length (head circumference:femur length, abdominal circumference:femur length). Data were then grouped within clinically relevant gestational age strata (<24, 24–27 6/7, 28–33 6/7, >34 weeks) to analyze time‐dependent effects of Zika virus infection on fetal size. Statistical analysis was performed using Wilcoxon signed‐rank test on paired data, comparing either abdominal circumference or head circumference to femur length. RESULTS: A total of 56 pregnant women were included in the study with laboratory evidence of a confirmed or possible recent Zika virus infection. Based on the Centers for Disease Control and Prevention definition for microcephaly after congenital Zika virus exposure, microcephaly was diagnosed in 5% (3/56) by both the 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project and World Health Organization Fetal Growth Chart standards (head circumference Z‐score ≤–2 or ≤2.3%). Using 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project, intrauterine fetal growth restriction was diagnosed in 18% of pregnancies (10/56; abdominal circumference Z‐score ≤–1.3, <10%). Analysis of fetal size using the last ultrasound scan for all subjects revealed a significantly abnormal skewing of fetal biometrics with a smaller abdominal circumference vs femur length by either 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project or World Health Organization Fetal Growth Chart (P < .001 for both). A difference in distribution of fetal abdominal circumference compared to femur length was first apparent in the 24–27 6/7 week strata (2014 International Fetal and Newborn Growth Consortium for the 21st Century Project, P = .002; World Health Organization Fetal Growth Chart, P = .001). A significantly smaller head circumference compared to femur length was also observed by 2014 International Fetal and Newborn Growth Consortium for the 21st Century Project as early as the 28–33 6/7 week strata (2014 International Fetal and Newborn Growth Consortium for the 21st Century Project, P = .007). Overall, a femur‐sparing pattern of growth restriction was detected in 52% of pregnancies with either head circumference:femur length or abdominal circumference:femur length fetal body ratio <10th percentile (2014 International Fetal and Newborn Growth Consortium for the 21st Century Project Z‐score ≤–1.3). CONCLUSION: An unusual femur‐sparing pattern of fetal growth restriction was detected in the majority of fetuses with congenital Zika virus exposure. Fetal body ratios may represent a more sensitive ultrasound biomarker to detect viral injury in nonmicrocephalic fetuses that could impart long‐term risk for complications of congenital Zika virus infection.

Effect of Maternal Age and Fetal Number on the Risk of Hypertensive Disorders of Pregnancy

Abstract Objective Our primary objective was to compare the differential contribution of fetal number and maternal age to the risk of hypertensive disorders of pregnancy (HDP). Study Design This was a secondary analysis of a large study of primary cesarean delivery. Women with singleton, twin, or triplet gestations were included. Women were divided into groups based on fetal number and maternal age. The primary outcome was HDP. A logistic regression model was fit to adjust for confounders. The incidence of HDP was compared with the reference group and within exposure groups. Results Of the 70,417 women included, HDP occurred in 8,079 (12%) women. The frequency of HDP among the comparison groups ranged from 11 to 38%. Nearly all groups had significantly increased risk of HDP compared with young maternal age singletons. Twin and triplet gestations increased the risk of HDP over singletons irrespective of maternal age after adjusting for baseline disease and race. The risk of HDP did not significantly increase with maternal age when fetal number was similar. Conclusion Fetal number significantly increased the risk of HDP and contributed more to that risk than maternal age. Maternal age became significant in groups with age greater than 40 years.

96 – Placental Abruption

Placental abruption complicates a small fraction of pregnancies but has the potential to carry major maternal and fetal morbidity. As this entity is diagnosed clinically, imaging plays a limited role in diagnosis or management. Management varies based on gestational age and the severity of the abruption at the time of presentation.

101 – Placenta Circumvallata

Placenta circumvallate refers to a placental abnormality in which the membranous chorion transitions to a villous chorion in from the placental edges. The prevalence varies due to a lack of uniform criteria for diagnosis. Bleeding is the most commonly reported side effect, but the majority of pregnancies progress without complications. Serial assessment of fetal growth is recommended when diagnosed prenatally.

Authors' reply re: Trends in operative vaginal delivery, 2005–2013: a population‐based study

1 Patel JP, Roberts LN, Patel RK, Arya R. Re: Pregnancy outcomes in women with mechanical prosthetic heart valves – a prospective descriptive population-based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG 2017;125:96. 2 Vause S, Clarke B, Tower CL, Hay CRM, Knight M, on behalf of UKOSS. Pregnancy outcomes in women with mechanical prosthetic heart valves – a prospective descriptive populationbased study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG 2017;124:1411–9. 3 Elkayam U, Goland S. The search for a safe and effective anticoagulation regimen in pregnant women with mechanical prosthetic heart valves. J Am Coll Cardiol 2012;59:1116–8.