Calla Holmgren

Hyperemesis in pregnancy: An evaluation of treatment strategies with maternal and neonatal outcomes

OBJECTIVE The objective of the study was to evaluate the use of interventions such as a peripherally inserted central catheters (PICC) line or nasogastric (NG)/nasoduodenal (ND) tube with the use of medications alone in the management of pregnancies with hyperemesis. STUDY DESIGN Subjects were identified with confirmed intrauterine pregnancy, admitted with hyperemesis gravidarum (HEG) between 1998 and 2004. Medical records were then abstracted for information with regard to therapy. Subjects were assigned on the basis of the management plan: medication alone, PICC line, or NG/ND tube. Outcomes were compared between groups. RESULTS Ninety-four patients met study criteria and had complete outcome data available. Of those, 33 had a PICC line placed (35.1%), 19 had a NG/ND placed (20.2%), and 42 were managed with medication alone (44.7%). These groups were similar with respect to gestational age at delivery, Apgar score, and mean birthweight. Maternal complications were significantly higher among those with PICC lines. Of patients managed with PICC lines, 66.4% (P < .001) required treatment for infection, thromboembolism, or both. Adjusted odds ratio for a PICC line complication was 34.5 (5.09, 233.73). CONCLUSION Maternal complications associated with PICC line placement are substantial despite no difference in neonatal outcomes, suggesting that the use of PICC lines for treatment of HEG patients should not be routinely used.

Evaluation of the use of anti-TNF-α in an LPS-induced murine model

OBJECTIVE Tumor necrosis factor alpha (TNF-alpha) may play a critical role in inflammatory-mediated preterm labor. Medications blocking the activity of TNF-alpha have been shown to be effective in the treatment of conditions such as rheumatoid arthritis; however, the use of these medications for an event like preterm birth or fetal death is unknown. We hypothesized that treatment with anti-TNF-alpha may decrease the rate of fetal death and preterm birth in a LPS-induced murine model. METHODS Pregnant C57BL/6J mice received intraperitoneal (IP) injections of either vehicle or 2mg anti-TNF-alpha. After 24h, 10 microg of LPS was administered IP. Mice were sacrificed 24h later and outcomes between groups were assessed. A second set of experiments utilizing RT-PCR was performed to determine the influence of anti-TNF-alpha on production of inflammatory cytokines in response to LPS. RESULTS There were 72 resultant pups in the LPS+saline group, and 91 in the group receiving LPS+anti-TNF-alpha. Pretreatment with anti-TNF-alpha reduced the rate of fetal death and preterm birth after LPS administration (p<0.01). Expression of IL-6, IL-1beta, TLR-2, CD14 and COX-1 were found to be significantly reduced in mice treated with anti-TNF-alpha and LPS compared to LPS alone. CONCLUSION The use of anti-TNF-alpha decreased fetal deaths and preterm deliveries in an LPS-induced model of preterm birth. In addition, there were critical gene expression alterations in the group receiving anti-TNF-alpha. Further evaluation of TNF-alpha blockade as a potential treatment for preterm labor is warranted.

Frequency of fetal heart rate categories and short-term neonatal outcome.

OBJECTIVE: To estimate the time spent in each fetal heart rate category during labor and during the last 2 hours before delivery in term singleton pregnancy and to estimate the relationship between the time spent in each category and short-term neonatal outcomes. METHODS: This study reviewed fetal heart rate data and newborn outcomes of women in term labor in 10 hospitals over 28 months. Fetal heart rate characteristics were assessed by labor and delivery nurses, and categories were assigned by computer using definitions from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The duration of time in each category was calculated and correlated with newborn outcome. RESULTS: Forty-eight thousand four hundred forty-four patients were identified. Considering all of labor, category I was present 77.9% of the time, category II was present 22.1% of the time, and category III was present 0.004% of the time. In the last 2 hours before delivery, category I decreased to 60.9% of the duration, category II increased to 39.1%, and category III increased to 0.006%. Newborns of women whose last 2 hours were exclusively category I did well; only 0.6% had 5-minute Apgar scores less than 7, and 0.2% had low Apgar scores with neonatal intensive care unit (NICU) admission. When more than 75% of the last 2 hours was category II, low 5-minute Apgar score increased to 1.3% of patients, and low 5-minute Apgar score with NICU admission increased to 0.7% (both P<.001). CONCLUSION: Category I and category II fetal heart rate patterns are common in labor, and category III patterns are rare. Increasing time in category II in the last 2 hours of labor is associated with increased short-term newborn morbidity. LEVEL OF EVIDENCE: III

Uterine rupture with attempted vaginal birth after cesarean delivery: decision-to-delivery time and neonatal outcome.

OBJECTIVE: To estimate the time from the diagnosis of uterine rupture to delivery that would prevent adverse neonatal sequelae. METHODS: Cases of uterine rupture from January 1, 2000, to December 31, 2009, were identified in nine hospitals in the Intermountain Health Care system and at the University of Utah. Maternal demographics, labor characteristics, and neonatal outcomes were obtained. Primary adverse outcome was abnormal umbilical artery pH level less than 7.0 or 5-minute Apgar score less than 7. Adverse secondary outcome included fetal or neonatal death and neonatal neurologic injury attributed to uterine rupture. RESULTS: Thirty-six cases of uterine rupture occurred during 11,195 trials of labor after cesarean delivery. Signs of uterine rupture were fetal (n=24), maternal (n=8), or a combination of maternal and fetal (n=3). In one case, uterine rupture was not suspected. Mean time to delivery from the onset of symptoms or signs for the primary adverse outcome group (n=13) was 23.3 (±10.8) minutes compared with 16.0 (±7.7) minutes for those without an adverse outcome (P=.02). No neonate delivered in fewer than 18 minutes had an umbilical pH level below 7.0. Three neonates delivered at more than 30 minutes met criteria for an adverse secondary outcome. CONCLUSION: The frequency of uterine rupture was 0.32% in patients attempting a trial of labor after cesarean delivery. Neonates delivered within 18 minutes after a suspected uterine rupture had normal umbilical pH levels or 5-minute Apgar scores greater than 7. Poor long-term outcome occurred in three neonates with a decision-to-delivery time longer than 30 minutes. LEVEL OF EVIDENCE: II

Maternal and fetal morbidity associated with uterine rupture of the unscarred uterus

OBJECTIVE We sought to report obstetric and neonatal characteristics and outcomes following primary uterine rupture in a large contemporary obstetric cohort and to compare outcomes between those with primary uterine rupture vs those with uterine rupture of a scarred uterus. STUDY DESIGN This was a retrospective case-control study. Cases were defined as women with uterine rupture of an unscarred uterus. Controls were women with uterine rupture of a scarred uterus. Demographics, labor characteristics, and obstetric, maternal, and neonatal outcomes were compared. Primary rupture case outcomes were also compared by mode of delivery. RESULTS There were 126 controls and 20 primary uterine rupture cases. Primary uterine rupture cases had more previous live births than controls (3.6 vs 1.9; P < .001). Cases were more likely to have received oxytocin augmentation (80% vs 37%; P < .001). Vaginal delivery was more common among cases (45% vs 9%; P < .001). Composite maternal morbidity was higher among primary uterine rupture mothers (65% vs 20%; P < .001). Cases had a higher mean estimated blood loss (2644 vs 981 mL; P < .001) and higher rate of blood transfusion (68% vs 17%; P < .001). Women with primary uterine rupture were more likely to undergo hysterectomy (35% vs 2.4%; P < .001). Rates of major composite adverse neonatal neurologic outcomes including intraventricular hemorrhage, periventricular leukomalacia, seizures, and death were higher in cases (40% vs 12%; P = .001). Primary uterine rupture cases delivering vaginally were more likely to ultimately undergo hysterectomy than those delivering by cesarean (63% vs 9%; P = .017). CONCLUSION Although rare, primary uterine rupture is particularly morbid. Clinicians must remain vigilant, particularly in the setting of heavy vaginal bleeding and severe pain.

Maternal obesity and contraction strength in the first stage of labor

OBJECTIVE The purpose of this study was to determine whether maternal obesity is associated with cesarean delivery and decreased contraction strength in the first stage of labor. STUDY DESIGN We studied a retrospective cohort of women who delivered within a single healthcare system from 2007-2009; we included 5410 women with an intrauterine pressure catheter during the last 2 hours of the first stage of labor and who either had a vaginal delivery or cesarean delivery for dystocia. Logistic regression was used to determine how body mass index was associated with cesarean delivery or mean Montevideo units of ≥200. RESULTS Although obese women were at significantly greater odds of cesarean delivery than normal-weight women (odds ratio, 2.4; 95% confidence interval, 1.9-3.1), they were equally able to achieve Montevideo units of ≥200. Among women with a vaginal delivery, obese women had a longer first stage of labor compared with normal-weight women (597 vs 566 min; P = .003). CONCLUSION Obese women have longer labors but are equally able to achieve adequate Montevideo units as normal-weight women.

Simple, validated vaginal birth after cesarean delivery prediction model for use at the time of admission.

OBJECTIVE: To create a simple tool for predicting the likelihood of successful trial of labor after cesarean delivery (TOLAC) during the pregnancy after a primary cesarean delivery using variables available at the time of admission. METHODS: Data for all deliveries at 14 regional hospitals over an 8-year period were reviewed. Women with one cesarean delivery and one subsequent delivery were included. Variables associated with successful VBAC were identified using multivariable logistic regression. Points were assigned to these characteristics, with weighting based on the coefficients in the regression model to calculate an integer VBAC score. The VBAC score was correlated with TOLAC success rate and was externally validated in an independent cohort using a logistic regression model. RESULTS: A total of 5,445 women met inclusion criteria. Of those women, 1,170 (21.5%) underwent TOLAC. Of the women who underwent trial of labor, 938 (80%) had a successful VBAC. A VBAC score was generated based on the Bishop score (cervical examination) at the time of admission, with points added for history of vaginal birth, age younger than 35 years, absence of recurrent indication, and body mass index less than 30. Women with a VBAC score less than 10 had a likelihood of TOLAC success less than 50%. Women with a VBAC score more than 16 had a TOLAC success rate more than 85%. The model performed well in an independent cohort with an area under the curve of 0.80 (95% confidence interval 0.76–0.84). CONCLUSIONS: Prediction of TOLAC success at the time of admission is highly dependent on the initial cervical examination. This simple VBAC score can be utilized when counseling women considering TOLAC. LEVEL OF EVIDENCE: II

Uterine rupture associated with VBAC.

Uterine rupture during attempted vaginal birth after cesarean is a rare, but serious complication and can result in death or long-term disability. Several factors can increase the risk of uterine rupture during vaginal birth after cesarean and adequate counseling is necessary. Current literature suggests that timely diagnosis and delivery of the fetus is necessary for optimal outcome.

The Use of Prenatal Ultrasound for the Detection of Fetal Aneuploidy

Ultrasound is a noninvasive tool for early evaluation of the fetus and intrauterine environment. Its limitations include the lack of standardization of evaluation that patients receive, as well as varying sonologists experience and equipment. Further, many fetuses with aneuploidy will not demonstrate significant sonographic findings, making detection limited. With regard to aneuploidy screening, its utility is improved when used in conjunction with analyte screening. Early recognition of fetal compromise allows families time for preparation and informed management of the gestation.

A risk stratification model to predict adverse neonatal outcome in labor

Objective:The development and evaluation of a labor risk model consisting of a combination of antepartum risk factors and intrapartum fetal heart rate (FHR) characteristics that can reliably identify those infants at risk for adverse neonatal outcome in labor.Study design:A nested case–control study of term singleton deliveries at the nine hospitals between March 2007 and December 2009. Eligibility criteria included: gestational age ⩾37.0 weeks; singleton pregnancy; documented continuous FHR monitoring for ⩾2 h before delivery; assessment of FHR tracing at least every 20 min; and, available maternal and neonatal outcomes. Adverse neonatal outcome was defined as nonanomalous infants admitted to the newborn intensive care unit with either a 5 minute Apgar score <7 or an umbilical artery pH<7.1. Initial risk score was determined using data available at 1 h after admission. Patients with an initial risk score between 7 and 15 were considered high risk. Intrapartum risk scores were then created for these patients using FHR tracing data and labor characteristics.Result:A total of 51 244 patients were identified meeting study criteria. Of the antepartum variables evaluated (n=31), 10 were associated with an adverse outcome. The high-risk group made up 28% of the population and accounted for 59.8% of the adverse outcomes. Intrapartum characteristics were then evaluated in this high-risk group. Intrapartum evaluation identified the highest risk group with a C/S rate of 40% and adverse outcome rate of 11.3%.Conclusion:Incorporation of maternal and antepartum risk factors with FHR analysis can improve the ability to identify the fetus at risk in labor.