Catherine A. Bigelow

Risk Factors for New-onset Late Postpartum Preeclampsia in Women Without a History of Preeclampsia:

OBJECTIVE Risk factors for the development of new-onset late postpartum preeclampsia (LPP) in women without any history of preeclampsia are not known. Because identification of women who are at risk may lead to an earlier diagnosis of disease and improved maternal outcomes, this study identified risk factors (associated patient characteristics) for new-onset LPP. STUDY DESIGN A case-control study of 34 women with new-onset LPP and 68 women without new-onset LPP after normal delivery, who were matched on date of delivery, was conducted at Mount Sinai Hospital, New York, NY. Data were collected by chart review. Exact conditional logistic regression identified patient characteristics that were associated with new-onset LPP. RESULTS New-onset LPP was associated with age ≥40 years (adjusted odds ratio, 24.83; 95% confidence interval [CI], 1.43-infinity; P = .03), black race (adjusted odds ratio, 78.35; 95% CI, 7.25-infinity; P < .001), Latino ethnicity (adjusted odds ratio, 19.08; 95% CI, 2.73-infinity; P = .001), final pregnancy body mass index of ≥30 kg/m(2) (adjusted odds ratio, 13.38; 95% CI, 1.87-infinity; P = .01), and gestational diabetes mellitus (adjusted odds ratio, 72.91; 95% CI, 5.52-infinity; P < .001). As predictive tests for new-onset LPP, the sensitivity and specificity of having ≥1 of these characteristics was 100% and 59%, respectively, and the sensitivity and specificity of having ≥2 was 56% and 93%, respectively. CONCLUSION Older age, black race, Latino ethnicity, obesity, and a pregnancy complicated by gestational diabetes mellitus all are associated positively with the development of new-onset LPP. Closer observation may be warranted in these populations.

Timing of and outcomes after selective termination of anomalous fetuses in dichorionic twin pregnancies.

The objective of this article is to determine if selective termination (ST) of an anomalous dichorionic twin at early gestational age (GA) is associated with a decreased risk of fetal loss and prematurity.

Percutaneous umbilical blood sampling: current trends and outcomes

OBJECTIVES To report our contemporary experience with PUBS, including indications and complications, stratified by the presence of hydrops fetalis. STUDY DESIGN All PUBS performed from 1988 to 2013 at a single tertiary care center were identified using a comprehensive ultrasound database. We recorded patient demographics, relevant obstetric, fetal and neonatal data, indication for and success of PUBS and any complications. Data were analyzed using SAS, version 9.3 (SAS Institute Inc., Cary, NC). RESULTS 455 PUBS were performed on 208 pregnant women, 97.8% of which were successful. The average gestational age at the time of PUBS was 26.7 weeks (SD 5.1 weeks, range 17.5-41.3 weeks). Indications were available for 441: 245 (55.6%) isoimmunization, 77 (17.5%) non-immune hydrops fetalis (NIHF), 98 (22.2%) chromosomal diagnosis, and 21 (4.8%) other indications. Isoimmunization was a less common indication for PUBS in 2008-2013 as compared to 1988-1992 (51.7% vs 66.2%, p=0.07). Amongst PUBS performed in the setting of hydrops, isoimmunization was much less common in the later time period (61.1% vs 0%, respectively; p<0.01). The procedure complication rate (bradycardia or fetal demise at procedure) of 2.5% was stable over the study period and was most common with NIHF (2.0% without hydrops, 0% with immune hydrops and 6.3% with NIHF; p=0.04). Of the 208 women with a PUBS performed, 74 had more than one PUBS procedure (mean 2.2, max 18). Transfusions were performed in 233 of the 455 (51.2%). Overall, 10.2% of the pregnancies had an intrauterine fetal demise (IUFD) within 2 weeks of the procedure, which was most common in pregnancies with NIHF (3.2% without hydrops, 9.1% with immune hydrops and 31.7% with NIHF; p<0.01). The IUFD rate was 60% (3/5) in fetuses with parvovirus-mediated NIHF. CONCLUSIONS PUBS has a high likelihood of success with a relatively low complication rate. The complication rate is highest in pregnancies with NIHF, and these pregnancies are also at a significantly higher risk of IUFD, particularly those patients with parvovirus-mediated NIHF. Our findings can be used when counseling patients who are considering PUBS for diagnostic or therapeutic purposes.

Maternal clinical disease characteristics and maternal and neonatal outcomes in twin and singleton pregnancies with severe preeclampsia

OBJECTIVE Based on anecdotal observations, there is concern that severe preeclampsia leads to greater morbidity and mortality for mothers and neonates of twin pregnancies than for mothers and neonates of singleton pregnancies. Because few studies have been done, this study compared maternal disease characteristics and maternal/neonatal clinical outcomes of twin and singleton pregnancies complicated by severe preeclampsia. STUDY DESIGN An historical cohort study of patients hospitalized at the Mount Sinai Hospital in New York City, NY, USA, from 2006 to 2010, compared 63 twin and 339 singleton pregnancies complicated by severe preeclampsia via chart review. Women were analyzed in two groups: hospitalized ≤34 weeks gestational age (GA) and hospitalized >34 weeks GA. Univariable analysis (using Chi-square test, Fishers Exact test, Students t-test, or Wilcoxon Rank-Sum test, as appropriate) then multivariable analysis (using multivariable linear regression or multivariable logistic regression, as appropriate) compared maternal disease characteristics and maternal/neonatal clinical outcomes in twin and singleton pregnancies. RESULTS Women with twins were older [mean age 34.9 years (standard deviation (SD) 7.9 years) vs. 29.4 years (SD 7.4 years), P-value<.001] and women with singletons had a higher prevalence of chronic hypertension (21% vs. 8%, P=.02) and higher prevalence of history of preeclampsia (13% vs. 2%, P=.006). Women with twins were admitted for severe preeclampsia at an earlier gestational age (GA) [median twin 34.9 weeks GA (interquartile range, IQR, 32.7, 36.1) vs. median singleton 37.1 weeks GA (IQR 35.0, 38.9), P<.001]. Among women presenting ≤34 weeks GA (27 twins; 108 singletons), women with singletons had a higher mean systolic blood pressure (BP) (181.1 vs. 163.5, P<.001), higher mean diastolic BP (108.4 vs. 100.1, P=.002), and higher prevalence of headache (56% vs. 30%, P=.02). Among women presenting >34 weeks GA (36 twins; 231 singletons), women with singletons had a higher prevalence of headache (54% vs. 28%, P=.004). CONCLUSION Mothers and neonates of twin pregnancies complicated by severe preeclampsia do not appear to have greater morbidity and mortality compared to mothers and neonates of singleton pregnancies complicated by severe preeclampsia.

Emergent primary cesarean delivery and maternal operative morbidity

Abstract Background: It is unknown how variations in surgical entry time in primary cesarean delivery (CD) may affect operative outcomes and maternal morbidity. Objective: Determine whether performing a primary CD in labor emergently (“stat”) is associated with adverse maternal outcomes. Study design: Retrospective cohort study of patients who underwent primary CD at The Mount Sinai Hospital during the years of 2011–2016. Women with a singleton pregnancy and without a prior uterine scar attempting a trial of labor were included. An emergent CD was defined as a skin-to-uterine incision (I-U) time of ≤3 minutes. Subjects were dichotomized into those with an I-U time of ≤3 minutes or ≥5 minutes. Results: 1722 patients underwent primary CD and met eligibility criteria. 72 patients with an I-U time of 4 minutes were removed from the analysis. 196 patients (11.9%) had an I-U time ≤3 minutes and 1454 patients (88.1%) had an I-U time ≥5 minutes. There were no differences in any outcomes between groups. The likelihood of transfusion, hysterectomy, or admission to the intensive care unit (ICU) was 1.5% in the emergent group and 1.0% in the control group (p = .334). Postpartum length of stay was also similar between the groups (3.3 versus 3.2 days, p = .259). When 384 patients with I-U times >10 minutes were excluded, surgical outcomes remained similar between groups. Among the subgroup of patients who reached the second stage of labor, surgical outcomes were also similar between groups. Conclusions: Emergent primary CD is not associated with increased maternal morbidity.