Chad K. Klauser

Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: interobserver variability

OBJECTIVE We determined interobserver variability in the classification of fetal heart rate (FHR) tracing with periodic deceleration as being reassuring or nonreassuring and in the ability to predict emergency cesarean delivery (ECD) or umbilical arterial pH < 7.00. STUDY DESIGN Five clinicians reviewed 100 FHR tracings 1 hour before abnormalities and, if applicable, the hour before delivery. We calculated weighted Kappa coefficients (WKC) to assess interobserver variability and likelihood ratio of FHR tracing to identify ECD and low pH. RESULTS Among 100 parturients, 46% of the women had ECD, and 2% of the women had low pH. The WKC for the classification of the FHR tracing as reassuring or nonreassuring in early labor was -0.12 and before delivery was 0.15. The WKC for ECD was 0.26 and for low pH was 0.21. The likelihood ratio for these 2 outcomes was < 2.0. CONCLUSION There was poor agreement among the clinicians who classified FHR as reassuring vs nonreassuring; they could not identify which parturient would have ECD or a newborn infant with low pH.

Progesterone does not prevent preterm births in women with twins.

Objective: To compare preterm birth rate and neonatal outcome in twin gestations randomized to either 17 alpha-hydroxyprogesterone caproate (17P) or placebo. Materials and Methods: Women with twin gestations between 20–30 weeks were randomized to receive weekly injections of either 250mg 17P injection (Group I), or placebo (Group II). Maternal and neonatal outcome data was recorded. Results: Thirty twin intrauterine pregnancies were randomized; 16 received 17P and 14 received placebo. Demographic data as well as past history and gestational age at randomization were equivalent between groups (P = 0.286–0.847). All patients in both groups were Medicaid recipients. The incidence of preterm labor (P = 0.980), and premature rupture of the membranes (P = 0.525) were the same between groups. Gestational age at delivery was also similar between 17P (33.9 weeks) versus placebo (33.1 weeks, P = 0.190) as was the incidence of preterm birth <35 weeks (44% vs 79%, P = 0.117). Infant weight (P = 0.641), Apgar score at 5 minutes (P = 0.338) as well as neonatal morbidity such as respiratory distress syndrome (P = 0.838), patent ductus arteriosus (P = 0.704), intraventricular hemorrhage (P = 0.851) and necrotizing enterocolitis (P = 0.946) showed no difference. Days spent in the NICU among 17P (18.4) versus placebo (17.3, P = 0.155), neonatal death (P = 0.359) and those infants discharged with neurologic handicap (P = 0.594) were not different between groups. Conclusion: Amongst this group of twin gestations weekly 17HP injections did not reduce the incidence of preterm birth or the complications associated with prematurity.

Active Second-Stage Management in Twin Pregnancies Undergoing Planned Vaginal Delivery in a U.S. Population

OBJECTIVE: To estimate neonatal morbidity and delivery outcomes according to planned mode of delivery in twin pregnancies with active second-stage management. METHODS: This was an historic cohort of twin pregnancies delivered in one practice between June 2005 and September 2009 using a strict protocol of second-stage management, including breech extraction of a second noncephalic twin and internal version of a nonengaged cephalic second twin followed by breech extraction. Primary outcome was a 5-minute Apgar score less than 7 for twin B. Secondary outcomes were 5-minute Apgar score less than 7 for twin A and 1-minute Apgar score less than 7 and arterial cord pH below 7.20 for each twin. RESULTS: A total of 287 twin pregnancies were included. There were 157 patients (54.7%) in the planned cesarean group and 130 patients (45.3%) in the planned vaginal delivery group. There was no significant difference in the rates of twin B having a 5-minute Apgar score lower than 7 or an arterial cord pH below 7.20. Among the patients in the planned vaginal delivery group, the cesarean delivery rate was 15.4%. No patients had a vaginal delivery of twin A followed by cesarean delivery of twin B. Among the patients in the planned vaginal delivery group, patients who had a successful vaginal delivery were more likely to be younger (31.56±6.6 compared with 36.88±6.1 years, P=.001) and were more likely to have a prior vaginal delivery (47.3% compared with 15.0%, P=.007). CONCLUSION: Planned vaginal delivery of twin pregnancies seems to be associated with neonatal outcomes similar to those with planned cesarean delivery. Active second-stage management is associated with good neonatal outcomes and a low risk of combined vaginal-cesarean delivery. LEVEL OF EVIDENCE: II

The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes.

Objective. To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM). Methods. Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI ≥ 30 kg/m2) and non-obese (pre-pregnancy BMI < 30 kg/m2) women and for women across five increasing pre-pregnancy BMI categories. Results. A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes. Conclusion. In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

Weight gain in twin pregnancies and adverse outcomes: examining the 2009 Institute of Medicine guidelines.

OBJECTIVE: To estimate whether the weight gain recommendations for twin pregnancies in the 2009 Institute of Medicine (IOM) guidelines are associated with improved perinatal outcomes. METHODS: A cohort of 297 twin pregnancies was identified from a single practice with measured prepregnancy body mass index (BMI) and weight gain during pregnancy. Recommended IOM guidelines were applied to our cohort based on prepregnancy BMI categories (normal weight, overweight, obese). Pregnancy outcomes were compared between patients whose weight gain met or exceeded the IOM recommendations and patients who did not meet these recommendations. RESULTS: Patients with normal prepregnancy BMIs whose weight gain met the IOM recommendations had significantly improved outcomes compared with patients who did not meet the IOM recommendations. They were less likely to have preterm birth before 32 weeks (5.0% compared with 13.8%) and spontaneous preterm birth before 32 weeks (3.4% compared with 11.5%). They also delivered significantly larger neontates (larger twin birth weight 2,582.1±493.4 g compared with 2,370.3±586.0 g; smaller twin birth weight 2,277.0±512.1 g compared with 2,109.3±560.9 g) and were significantly more likely to have both neonates weigh more than 2,500 g (38.8% compared with 22.5%) and more than 1,000 g (97.5% compared with 91.2%) and were less likely to deliver any twin with a birth weight lower than the fifth percentile for gestational age (21.5% compared with 35.0%). CONCLUSION: In women with twin pregnancies and normal starting BMIs, weight gain during pregnancy is significantly associated with improved outcomes, including a decreased risk of prematurity and larger birth weights. LEVEL OF EVIDENCE: II

Intrauterine Growth Restriction in Twin Pregnancies: Incidence and Associated Risk Factors

We sought to estimate the association of several maternal risk factors with intrauterine growth restriction (IUGR) in twin pregnancies. This is a case-control study of 313 patients with twin pregnancies delivered greater than 24 weeks between June 2005 and January 2010. We used three definitions of IUGR: (1) either twin with a birth weight < 10th percentile for gestational age; (2) either twin with a birth weight < 5th percentile for gestational age; and (3) birth-weight discordance ≥ 20%. Using each definition of IUGR, we estimated the association between IUGR and maternal age, weight, monochorionicity, in vitro fertilization, pregnancy reduction, thrombophilia, hypertension, and diabetes. Overall, 47% of patients delivered at least one twin with a birth weight <10th percentile, 27% of patients delivered at least one twin with a birth weight <5th percentile, and 16% of patients had birth-weight discordance of ≥20%. Using any of these three definitions for IUGR in twin pregnancies, there was no significant association between IUGR and any of the risk factors examined. This remained true when we excluded all patients who delivered <34 weeks. IUGR is very common in twin pregnancies. However, in twin pregnancies, IUGR cannot be predicted by maternal risk factors.

Prediction of placenta accreta by ultrasonography and color doppler imaging

Objective. To determine the accuracy of ultrasound and color flow Doppler to diagnose placenta accreta. Methods. Respectively, ultrasound images consistent with signs of placenta accreta (concomitant previa, numerous vascular lacunae, absent lower uterine segment between bladder–placenta, turbulent or complicated blood flow at the uteroplacental interface) were correlated with findings at the time of surgery and pathologic examination. Results. Over 64 months, 12 cases with suspected placenta accreta by ultrasound were studied. The median gestational age at first diagnosis was 25 weeks and 92% had a previa while all had at least one previous cesarean delivery. At surgery, 83% (10/12) had an adherent placenta requiring hysterectomy (eight accreta, one increta, and one percreta). There were two false positives (one complete previa, one low-lying placenta with vasa previa). Nine of 12 women (75%) required blood transfusions due to a mean hematocrit nadir of 22.7 ± 4.6%. The mean number of packed red blood cell units transfused was 4.9 ± 4.7 units (range 2–17 units). Conclusion. Sonography coupled with color-flow Doppler appears helpful in allowing antenatal diagnosis of accreta.

Natural History of Vasa Previa Across Gestation Using a Screening Protocol

The purpose of this study was to estimate the prevalence and persistence rate of vasa previa in at‐risk pregnancies using a standardized screening protocol.

Outcomes of emergency or physical examination-indicated cerclage in twin pregnancies compared to singleton pregnancies.

OBJECTIVE To report the obstetrical outcomes in patients with twin pregnancies who underwent an emergency/physical exam-indicated cerclage and to compare them to patients with singleton pregnancies undergoing the same procedure. STUDY DESIGN Patients who underwent emergency/physical exam-indicated cerclage in the second trimester in one maternal-fetal medicine practice from July 1997 to March 2012 were reviewed. We defined an emergency/physical exam-indicated cerclage as any cerclage placed in a patient with a dilated cervix on examination or membranes visible at the external cervical os on speculum examination. We compared outcomes between patients with singleton and twin pregnancies using non-parametric testing. RESULTS There were 43 patients (12 twin and 31 singleton pregnancies) who underwent emergency/physical exam-indicated cerclage placement. The median gestational age at cerclage placement, cervical dilation, maternal age, and cerclage type were similar between the groups. Comparing twins to singletons, the median time from cerclage placement to delivery was similar (92 vs. 106 days, p=0.330), as was the median gestational age at delivery (33.5 vs. 35.0 weeks, p=0.244). The likelihood of delivery at >32 weeks (75.0% vs. 71.0%, p>0.999) and the likelihood of neonatal survival to discharge (83.3% vs. 83.9%, p>0.999) were also similar. CONCLUSIONS Emergency/physical exam-indicated cerclage in twin pregnancies can be associated with favorable outcomes, including a high likelihood of delivery at >32 weeks and a high likelihood of survival. Their outcomes appear similar to singleton pregnancies. Cerclage should be considered an option for patients with twin pregnancies and a dilated cervix in the second trimester.

Cervical Pessary and Vaginal Progesterone in Twin Pregnancies With a Short Cervix.

OBJECTIVE: To evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix. METHODS: This was a retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2015. We included patients at 28 weeks of gestation or less who were diagnosed with a cervical length less than 20 mm. At the time of diagnosis, all patients were prescribed vaginal progesterone. Starting in 2013, they were also offered pessary placement in addition to vaginal progesterone. We compared outcomes between patients who received a pessary and matched women in a control group in a one-to-three ratio. Women in the control group were matched to women in the case group according to cervical length and gestational age (within 5 mm and 1 week, respectively, of the case patient at the time of pessary placement). We excluded patients with cerclage, monochorionic–monoamniotic placentation, major fetal congenital anomalies discovered before or after birth, patients with twin-twin transfusion syndrome, and patients for whom there were no appropriate controls. Chi-square, Fisher exact, and Students t tests were used, as appropriate. Regression analysis was performed to control for significant differences at baseline. RESULTS: Twenty-one patients received a cervical pessary, and they were compared with 63 matched women in the control group. As expected (as a result of matching), baseline gestational age (25.7±2.1 compared with 25.9±2.1 weeks of gestation, P=.671) and cervical length (10.9±3.6 mm compared with 11.9±4.5 mm, P=.327) were similar between the groups. Patients with a pessary had a significantly lower incidence of delivery at less than 32 weeks of gestation (1/21 [4.8%] compared with 18/63 [28.6%], adjusted P=.05), longer interval to delivery (65.2±16.8 compared with 52.1±24.3 days, adjusted P=.025), and a lower incidence of severe neonatal morbidity (2/21 [9.5%] compared with 22/63 [34.9%], adjusted P=.04). CONCLUSION: For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.