Blair J. Wylie

Twin chorionicity and the risk of stillbirth.

OBJECTIVE: To estimate the effect of chorionicity on the risk of stillbirth in twins. METHODS: A retrospective cohort analysis was performed of all twin deliveries of at least 24 weeks of gestation at a single tertiary care center from December 2000 to May 2007. The risk of fetal death with advancing gestation was calculated for monochorionic-diamniotic twins and for dichorionic-diamniotic twins. Overall in utero survival was compared by using Kaplan-Meier analysis and a hazards ratio with 95% confidence intervals estimated to assess the degree of difference. Pregnancies affected by growth abnormalities, anomalies, or twin-twin transfusion syndrome were subsequently excluded and survival by chorionicity similarly compared within these “apparently normal” gestations. RESULTS: Data from 1,000 consecutive twin pairs (196 monochorionic-diamniotic twins and 804 dichorionic-diamniotic twins) were analyzed. Stillbirths occurred in seven (3.6%) monochorionic-diamniotic and nine (1.1%) dichorionic-diamniotic twin pairs. Monochorionic-diamniotic twins had a higher risk of stillbirth compared with dichorionic-diamniotic twins, both overall (log-rank P=.004) and at each gestational age after 24 weeks, with this risk persisting in the subset of 771 (130 monochorionic-diamniotic twins and 641 dichorionic-diamniotic twins) “apparently normal” twins (log-rank P=.039). CONCLUSION: Monochorionicity has a negative effect on the in utero survival of twins, even among monochorionic-diamniotic twins without abnormalities. LEVEL OF EVIDENCE: II

Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic

The goals of this study were to define the uptake of H1N1 and seasonal influenza vaccination during pregnancy among women delivering during the 2009 H1N1 pandemic and explore barriers to vaccination. All postpartum women at the Massachusetts General Hospital from January 2010 through March 2010 were invited to complete an anonymous questionnaire about demographics, vaccination status, and attitudes about vaccination during pregnancy. Among 370 participants (53% response rate), 81% accepted both the H1N1 and seasonal influenza vaccines during pregnancy. Patients who declined one or both vaccines cited concerns over safety as a major deterrent. Of the 36% of participants who reported having flu-like symptoms during this pregnancy only 8.6% took oseltamivir. While a high vaccination rate was identified in this study, further education is needed to reassure patients regarding vaccine safety. Education for providers and patients emphasizing the benefits of early treatment of pregnant women with flu-like symptoms should be a priority.

Method of delivery and neonatal outcome in very low-birthweight vertex-presenting fetuses

OBJECTIVE This study was undertaken to compare neonatal outcome by method of delivery in very low-birthweight less than 1500 g vertex-presenting fetuses. STUDY DESIGN A retrospective cohort was conducted of 2466 very low-birthweight singleton liveborn vertex-presenting fetuses in Washington State (1994-2003). The exposure considered was cesarean delivery vs vaginal delivery. The risk of neonatal demise was estimated by logistic regression. Secondary outcomes included intraventricular hemorrhage, respiratory distress, and neonatal sepsis. Analyses were stratified by birthweight, gestational age, and growth restriction to assess subgroup differences. RESULTS Cesarean delivery offered no survival advantage to very low-birthweight infants when compared with vaginal delivery (adjusted odds ratio [95% confidence interval]: 1.08 [0.78-1.49]). Survival benefit was noted for growth-restricted infants (adjusted odds ratio [95% confidence interval]: 0.09 [0.02-0.47]) although only 12% of such infants delivered vaginally. CONCLUSION For very low-birthweight vertex-presenting fetuses at risk of preterm delivery, cesarean delivery does not improve neonatal survival. Further studies are warranted to assess the potential benefit of cesarean delivery to growth-restricted very low-birthweight infants.

Burden of malaria in pregnancy in Jharkhand State, India

BackgroundPast studies in India included only symptomatic pregnant women and thus may have overestimated the proportion of women with malaria. Given the large population at risk, a cross sectional study was conducted in order to better define the burden of malaria in pregnancy in Jharkhand, a malaria-endemic state in central-east India.MethodsCross-sectional surveys at antenatal clinics and delivery units were performed over a 12-month period at two district hospitals in urban and semi-urban areas, and a rural mission hospital. Malaria was diagnosed by Giemsa-stained blood smear and/or rapid diagnostic test using peripheral or placental blood.Results2,386 pregnant women were enrolled at the antenatal clinics and 718 at the delivery units. 1.8% (43/2382) of the antenatal clinic cohort had a positive diagnostic test for malaria (53.5% Plasmodium falciparum, 37.2% Plasmodium vivax, and 9.3% mixed infections). Peripheral parasitaemia was more common in pregnant women attending antenatal clinics in rural sites (adjusted relative risk [aRR] 4.31, 95%CI 1.84-10.11) and in those who were younger than 20 years (aRR 2.68, 95%CI 1.03-6.98). Among delivery unit participants, 1.7% (12/717) had peripheral parasitaemia and 2.4% (17/712) had placental parasitaemia. Women attending delivery units were more likely to be parasitaemic if they were in their first or second pregnancy (aRR 3.17, 95%CI 1.32-7.61), had fever in the last week (aRR 5.34, 95%CI 2.89-9.90), or had rural residence (aRR 3.10, 95%CI 1.66-5.79). Malaria control measures including indoor residual spraying (IRS) and untreated bed nets were common, whereas insecticide-treated bed nets (ITN) and malaria chemoprophylaxis were rarely used.ConclusionThe prevalence of malaria among pregnant women was relatively low. However, given the large at-risk population in this malaria-endemic region of India, there is a need to enhance ITN availability and use for prevention of malaria in pregnancy, and to improve case management of symptomatic pregnant women.

Cesarean Delivery in the Developing World

Two trends are apparent regarding cesarean delivery in the developing world. In the least developed countries, access to the procedure remains limited at levels much less than 5% of all births. This limited access is linked with increases in maternal and neonatal mortality. Safety concerns are equally valid when more than half of women in certain socioeconomic strata are having surgical delivery, as is evident in the more advanced developing economies of Latin America and China. The optimal minimum and maximum cesarean delivery rates continue to be a matter of debate and may never be resolved; however, these two extremes of cesarean delivery use evident in the developing world deserve critical examination.

Comparison of transverse and vertical skin incision for emergency cesarean delivery.

OBJECTIVE: To compare incision-to-delivery intervals and related maternal and neonatal outcomes by skin incision in primary and repeat emergent cesarean deliveries. METHODS: From 1999 to 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 hospitals comprising the Eunice Kennedy Shriver National Institute of Child Health and Human Developments Maternal–Fetal Medicine Units Network. This secondary analysis was limited to emergent procedures, defined as those performed for cord prolapse, abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate tracing, or uterine rupture. Incision-to-delivery intervals, incision-to-closure intervals, and maternal outcomes were compared by skin-incision type (transverse compared with vertical) after stratifying for primary compared with repeat singleton cesarean delivery. Neonatal outcomes were compared by skin-incision type. RESULTS: Of the 37,112 live singleton cesarean deliveries, 3,525 (9.5%) were performed for emergent indications of which 2,498 (70.9%) were performed by transverse and the remaining 1,027 (29.1%) by vertical incision. Vertical skin incision shortened median incision-to-delivery intervals by 1 minute (3 compared with 4 minutes, P<.001) in primary and 2 minutes (3 compared with 5 minutes, P<.001) in repeat cesarean deliveries. Total median operative time was longer after vertical skin incision by 3 minutes in primary (46 compared with 43 minutes, P<.001) and 4 minutes in repeat cesarean deliveries (56 compared with 52 minutes, P<.001). Neonates delivered through a vertical incision were more likely to have an umbilical artery pH of less than 7.0 (10% compared with 7%, P=.02), to be intubated in the delivery room (17% compared with 13%, P=.001), or to be diagnosed with hypoxic ischemic encephalopathy (3% compared with 1%, P<.001). CONCLUSION: In emergency cesarean deliveries, neonatal delivery occurred more quickly after a vertical skin incision, but this was not associated with improved neonatal outcomes. LEVEL OF EVIDENCE: II

Effects of twin gestation on maternal morbidity.

As the incidence of twin gestation increases, it is important to consider the maternal risks associated with carrying multiples. Compared with singleton gestation, there are increased risks to the mother during the antepartum, intrapartum, and postpartum periods. Certain pregnancy complications are more likely to occur during a twin gestation, including preeclampsia and other hypertensive disorders, antepartum hospitalization for preterm labor or abnormal bleeding, nutritional deficiencies, cesarean delivery, and postpartum hemorrhage. Women carrying twins may benefit from early education regarding these issues, close maternal monitoring as well as physical therapy sessions, and nutrition counseling during their pregnancies.

Attitudes, Knowledge, and Practices Regarding Malaria Prevention and Treatment among Pregnant Women in Eastern India

We explored views toward and use of malaria prevention and treatment measures among pregnant women in Jharkhand, India. We conducted 32 in-depth interviews and six focus group discussions (total = 73 respondents) with pregnant women in urban, semi-urban, and rural locations in a region with moderate intensity malaria transmission. Most respondents ranked malaria as an important health issue affecting pregnant women, had partially correct understanding of malaria transmission and prevention, and reported using potentially effective prevention methods, usually untreated bed nets. However, most conveyed misinformation and described using unproven prevention and/or treatment methods. Many described using different ineffective traditional malaria remedies. The majority also showed willingness to try new prevention methods and take medications if doctor-prescribed. Misconceptions and use of unproven prevention and treatment methods are common among pregnant women in eastern India. Policy makers should focus on improving knowledge and availability of effective malaria control strategies in this population.

Timing of Malaria Infection during Pregnancy Has Characteristic Maternal, Infant and Placental Outcomes

We conducted a clinical study of pregnant women in Blantyre, Malawi to determine the effect of the timing of malaria infection during pregnancy on maternal, infant and placental outcomes. Women were enrolled in their first or second trimester of their first or second pregnancy and followed every four weeks until delivery. Three doses of sulfadoxine-pyrimethamine were given for intermittent preventive treatment for malaria, and all episodes of parasitemia were treated according to the national guidelines. Placentas were collected at delivery and examined for malaria parasites and pigment by histology. Pregnant women had 0.6 episodes of malaria per person year of follow up. Almost all episodes of malaria were detected at enrollment and malaria infection during the follow up period was rare. Malaria and anemia at the first antenatal visit were independently associated with an increased risk of placental malaria detected at delivery. When all episodes of malaria were treated with effective antimalarial medication, only peripheral malaria infection at the time of delivery was associated with adverse maternal and infant outcomes. One quarter of the analyzed placentas had evidence of malaria infection. Placental histology was 78% sensitive and 89% specific for peripheral malaria infection during pregnancy. This study suggests that in this setting of high antifolate drug resistance, three doses of sulfadoxine-pyrimethamine maintain some efficacy in suppressing microscopically detectable parasitemia, although placental infection remains frequent. Even in this urban setting, a large proportion of women have malaria infection at the time of their first antenatal care visit. Interventions to control malaria early and aggressive case detection are required to limit the detrimental effects of pregnancy-associated malaria.

Maternal congenital cardiac disease: outcomes of pregnancy in a single tertiary care center.

OBJECTIVE: To evaluate contemporary perinatal and cardiac outcomes of pregnancies in women with major structural congenital heart disease. METHODS: Obstetric, neonatal, and cardiac outcomes were abstracted retrospectively from medical records of all women with congenital cardiac disease delivering at our institution from 2000–2007 and compared by type of structural defect. Predictors of adverse cardiac or obstetric events were identified. RESULTS: Over the 7-year study period, 74 deliveries occurred in 69 women with congenital heart disease, median age 28 years. There were three right-obstructive defects, 14 left-obstructive defects, four right-regurgitant defects, 19 conotruncal defects, 19 shunts, and four miscellaneous lesions. There were 21 adverse cardiac events in 15 pregnancies (20.2%); these were defined as maternal death, congestive heart failure, myocardial infarction, stroke, the need for urgent cardiac intervention, or arrhythmia requiring treatment. There were 44 adverse obstetric events in 34 pregnancies (45.9%), defined as preterm delivery, stillbirth, preeclampsia, small for gestational age, or neonatal intensive care unit admission. Patients with shunt morphology were more likely to experience adverse obstetric and cardiac outcomes. CONCLUSION: Pregnancy in women with underlying major congenital heart defects poses increased risks to both mother and fetus. Nonetheless, favorable maternal and neonatal outcomes occur in the majority of patients. LEVEL OF EVIDENCE: III