Christina Davidson

Genes in Glucose Metabolism and Association With Spina Bifida

The authors test single nucleotide polymorphisms (SNPs) in coding sequences of 12 candidate genes involved in glucose metabolism and obesity for associations with spina bifida. Genotyping was performed on 507 children with spina bifida and their parents plus anonymous control DNAs from Hispanic and Caucasian individuals. The transmission disequilibrium test was performed to test for genetic associations between transmission of alleles and spina bifida in the offspring (P < .05). A statistically significant association between Lys481 of HK1 (G allele), Arg109Lys of LEPR (G allele), and Pro196 of GLUT1 (A allele) was found ( P = .019, .039, and .040, respectively). Three SNPs on 3 genes involved with glucose metabolism and obesity may be associated with increased susceptibility to spina bifida.

Association of copper-zinc superoxide dismutase (SOD1) and manganese superoxide dismutase (SOD2) genes with nonsyndromic myelomeningocele †‡

BACKGROUND A common and severe neural tube defect (NTD) phenotype, myelomeningocele (MM), results from the defective closure of the caudal end of the neural tube with herniation of the spinal cord and meninges through the vertebral column. The exact mechanisms for NTDs are unknown, but excessive oxidative stress, particularly in association with maternal diabetes, has been postulated as a mechanism for MM. METHODS The SNPlex Genotyping (ABI, Foster City, CA) platform was used to investigate single nucleotide polymorphisms (SNPs) across the superoxide dismutase (SOD) 1 and 2 genes to assess their association with MM risk. The study population included 329 trio (affected child and both parents) and 281 duo (affected child and one parent) families. Only cases with documented MM were studied. Seventeen SNPs across the SOD1 and SOD2 genes met the quality-control criteria to be considered for statistical analysis. Genetic association was assessed using the family-based transmission disequilibrium test in PLINK (a genome association analysis toolset). RESULTS Four SNPs in the SOD1 gene (rs 202446, rs202447, rs4816405, and rs2070424) and one SNP in the SOD2 gene ( rs5746105) [corrected] appeared to be associated with MM risk in our population. After adjusting for multiple testing, these SNPs remained significant. CONCLUSION This study provides the first genetic evidence to support association of myelomeningocele with superoxide scavenging. The rare alleles of the five specific SNPs within SOD1 and SOD2 appear to confer a protective effect on the susceptibility for MM risk in the MM population tested. Further evaluation of the roles of superoxide scavenging and neural tube development is warranted.

Evaluation of outcomes associated with trial of labor after cesarean delivery after a change in clinical practice guidelines in an academic hospital

Abstract Objective: To evaluate maternal–neonatal morbidity for women undergoing trial of labor after cesarean (TOLAC) following clinical practice changes based upon ACOG’s 2010 VBAC guideline. Study design: Four-year retrospective cohort analysis around implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 weeks and ≥1 prior cesarean. Maternal–neonatal outcomes pre- and post-guideline implementation were compared. Primary outcome was composite maternal morbidity (uterine rupture or dehiscence, hysterectomy, transfusion, thromboembolism, operative/delivery injury, chorioamnionitis/endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity. Results: Four hundred and fifty women underwent TOLAC before and 781 after guideline implementation. Post-guideline, there was a significant increase in age, body mass index, labor length, women with >1 cesarean, comorbid condition and induced labor. Composite maternal morbidity was significantly higher after the guideline (13.78% versus 18.82%, p = 0.02), possibly due to an increased rate of chorioamnionitis/endometritis, which was no longer significant after control for potential confounders in multivariable analysis. There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were unchanged (78.9% before versus 78.1% after, p = 0.75), however hospital VBAC rates increased after the guideline (26% versus 33%, p < 0.0001). Conclusions: Adoption of ACOG’s TOLAC practice changes can increase VBAC rates without increasing maternal–neonatal morbidity from TOLAC.

Comparison of induction of labor methods for unfavorable cervices in trial of labor after cesarean delivery

Abstract Objective: To compare induction of labor methods in patients attempting a trial of labor after cesarean (TOLAC) with an unfavorable cervix. Methods: This is a retrospective cohort study from patients attempting TOLAC from 2009 to 2013. Patients with a simplified Bishop score of three or less where labor was initiated with either a Cook balloon or oxytocin were included. Our primary outcome was mode of delivery. Our secondary outcomes included duration of labor and multiple maternal and neonatal morbidities. Results: Two-hundred and fourteen women met inclusion criteria: 150 received oxytocin and 64 had the Cook balloon placed. The vaginal birth after cesarean delivery rate was significantly higher in the oxytocin group at 70.7% versus 50.0% in the Cook balloon group (p = 0.004). In the multivariable analysis, odds for cesarean delivery were two times higher with the Cook balloon than with oxytocin (Adjusted OR = 2.09, 95% CI = 1.05-4.18, p = 0.036). The duration of labor was longer with the Cook balloon versus oxytocin (21.9 versus 16.3 hours, p = 0.0002). There were no significant differences in maternal and neonatal health outcomes. Conclusion: Oxytocin induction of labor was associated with a higher rate of vaginal delivery and a shorter duration of labor compared to the Cook balloon in women undergoing TOLAC with an unfavorable cervix.

Utilization of obstetrical ultrasound in a referral population

Objective. To determine the number of ultrasounds performed prior to presentation to a maternal-fetal medicine (MFM) sub-specialist and the patients perceived reason for referral. Study design. Women presenting for their first targeted ultrasound at an MFM unit in an urban center between November 2003 and April 2004 reported the number, location, and gestational age (GA) of prior ultrasounds and whether their insurance company had been billed for these studies. They also reported their current GA, insurance type, and perceived reason for referral. Pearson correlation and Kruskal–Wallis were used where appropriate; p < 0.05 was considered significant. Results. Six hundred fifty-five women were invited to participate; 207 declined, leaving 448 available for the final analysis. The median number of prior ultrasounds was two (range 0–11). Twelve percent reported no prior ultrasound, 30% reported having had one, 28% reported having had two, and 29% reported having had three or more. Women presented at a mean GA of 21.3 ± 5.4 weeks. They reported having had their first ultrasound at 9.9 ± 2 weeks and their most recent prior ultrasound at 16.9 ± 6.7 weeks. GA at presentation did not correlate with the number of prior ultrasounds (r = 0.17). Of 396 women with at least one prior ultrasound, 336 had at least one performed in their doctors office and 74 had at least one performed in an ultrasound clinic; 183 stated that their insurance had been billed and 168 did not know if their insurance had been billed. The majority, 60%, had private insurance, 37% had Medicaid, and 2% had no insurance. Women with private insurance had a higher number of prior ultrasounds than women with Medicaid (2.3 ± 1.4 vs. 1.5 ± 1.3, p < 0.001). In response to the perceived reason for referral, 280 women stated their reason for referral to the MFM unit was for a routine ultrasound or to determine gender, 158 women reported that they were referred because their doctor was concerned about ‘something’, and 10 were unsure of their indication. Conclusion. Most women have at least one ultrasound prior to presenting to an MFM unit for a targeted scan. Many, especially those with private insurance, have had several prior ultrasounds. Patient education is needed about reasons for referral to an MFM unit for ultrasound and the possible increased financial burden of multiple ultrasounds.

Outcomes associated with trial of labor after cesarean in women with one versus two prior cesarean deliveries after a change in clinical practice guidelines in an academic hospital

Abstract Objective: In 2010, the American College of Obstetricians & Gynecologists (ACOG) published a new clinical practice guideline on trial of labor after cesarean (TOLAC) that was considered less restrictive. It allowed for offering TOLAC to women with two prior cesarean deliveries, even without a prior vaginal delivery, and for labor induction. As a result, our hospital, a public tertiary care academic center, updated our TOLAC practice guideline to reflect ACOG’s new recommendations. We thus aim to evaluate maternal and neonatal outcomes for women undergoing TOLAC with 1 versus 2 prior cesareans, with and without a prior vaginal delivery, following these clinical practice changes at our hospital. Study design: This was a secondary analysis of a 2-year retrospective cohort following implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 0/7 weeks and 1 or 2 prior cesarean deliveries. Maternal and neonatal outcomes in women with one prior cesarean were compared to women with two prior cesareans. The primary outcome was composite maternal morbidity (uterine rupture, uterine dehiscence, hysterectomy, transfusion, postpartum venous thromboembolism, delivery/surgical injury, chorioamnionitis or endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity. The analysis was performed in SAS; p < .05 was considered significant. Results: Seven hundred women with one prior cesarean and 73 women with two prior cesareans underwent TOLAC after the 2011 guideline implementation. Post guideline maternal demographics, labor length, comorbid conditions, simplified Bishop score, and induced labor were similar between groups. Composite maternal morbidity was similar between groups (18.3 versus 23.3%, p = .30 for women with 1 versus 2 prior cesarean deliveries, respectively). The same was true when comparing women with 1 versus 2 prior cesareans who had never had a prior vaginal delivery (25.5 versus 33.3%, p = .28 for 1 versus 2 prior cesarean deliveries, respectively). There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were similar between groups (78.9% in women with 1 prior cesarean versus 74.0% in women with 2 prior cesareans, p=.33), even when only analyzing women without a prior vaginal delivery (69.4% in women with 1 prior cesarean versus 71.4% in women with 2 prior cesareans, p = .78). Conclusion: Adoption of ACOG’s TOLAC practice changes, specifically offering TOLAC to women with two prior cesareans even without a prior vaginal delivery, and offering induction of labor regardless of cervical favorability, may increase VBAC rates without increasing maternal or neonatal morbidity from TOLAC.

A Standardized Approach to Cesarean Surgical Technique and Its Effect on Operative Time and Surgical Morbidity

Objective To evaluate the impact of a standardized surgical technique for primary cesarean deliveries (CDs) on operative time and surgical morbidity. Materials and Methods Two‐year retrospective chart review of primary CD performed around the implementation of a standardized CD surgical technique. The primary outcome was total operative time (TOT). Secondary outcomes included incision‐to‐delivery time (ITDT), surgical site infection, blood loss, and maternal and fetal injuries. Results When comparing pre‐ versus postimplementation surgical times, there was no significant difference in TOT (76.5 vs. 75.9 minutes, respectively; p = 0.42) or ITDT (9.8 vs. 8.8 minutes, respectively; p = 0.06) when the entire cohort was analyzed. Subgroup analysis of CD performed early versus late in an academic year among the pre‐ and postimplementation groups showed no significant difference in TOT (79.3 early vs. 73.8 minutes late; p = 0.10) or ITDT (10.8 early vs. 8.8 minutes late; p = 0.06) within the preimplementation group. In the postimplementation group, however, there was significant decrease in TOT (80.5 early vs. 71.3 minutes late; p = 0.02) and ITDT (10.6 early vs. 6.8 minutes late; p < 0.01). Secondary outcomes were similar for both groups. Conclusion A standardized surgical technique combined with surgical experience can decrease TOT and ITDT in primary CD without increasing maternal morbidity.

Maternal and Fetal Death on Weekends

Background Higher mortality rates have been reported in patients admitted to the hospital on weekends. This study aimed to compare maternal mortality ratio (MMR), fetal mortality ratio, and other maternal and neonatal outcomes by day of death or delivery in the United States. Methods Our database consisted of a population‐level analysis of live births and maternal and fetal deaths between 2004 and 2014 in the United States from the Centers for Disease Control and Preventions National Center for Health Statistics. We also examined the relationship between these deaths and various documented maternal and fetal clinical conditions. Results A total of 2,061 maternal deaths occurred on weekends and 5,510 deaths on weekdays. During the same period of time, 65,063 and 210,851 cases of fetal demise were delivered on weekends and on weekdays, respectively. Maternal mortality was significantly higher on weekends than weekdays (22.9 vs. 15.3/100,000 live births, p < 0.001) as was fetal mortality (7.21 vs. 5.85/100,000, p < 0.001), despite a lower frequency of serious comorbidities among women delivering on weekends. Conclusion Our data demonstrate a significant increase in the U.S. MMR and stillbirth delivery on weekends. Relative representation of antepartum, intrapartum, and postpartum deaths cannot be ascertained from these data.

Comparison of Induction of Labor Methods for Unfavorable Cervices in Trial of Labor After Cesarean Delivery [27J]

INTRODUCTION: To compare induction of labor methods with the Cook balloon versus oxytocin in patients attempting a trial of labor after cesarean delivery with an unfavorable cervix. METHODS: This is a retrospective cohort study from patients attempting trial of labor after cesarean from 2009–2013 at one institution. Patients with a simplified Bishop score of three or less where labor was initiated with either Cook balloon or oxytocin alone were included. Our primary outcome was mode of delivery of vaginal delivery versus repeat cesarean delivery. Our secondary outcomes included duration of labor and multiple maternal and neonatal morbidities. RESULTS: 214 women met inclusion criteria, of which 150 received oxytocin for induction and 64 had the Cook balloon placed. The vaginal birth after cesarean delivery rate was significantly higher in the oxytocin group at 70.7% versus 50.0% in the Cook balloon group (P=.004). This difference remained significant in the multivariable analysis where odds for cesarean delivery were two times higher with the Cook balloon than with oxytocin induction (Adjusted OR=2.09, 95% CI=1.05–4.18, P=.036). The duration of labor was significantly longer with the Cook balloon versus oxytocin induction (21.9 versus 16.3 hours, P=.0002). There were no significant differences in uterine rupture or maternal and neonatal health outcomes between the two groups. CONCLUSION: Oxytocin induction of labor was associated with a higher rate of vaginal delivery and a shorter duration of labor as compared to the Cook balloon in women undergoing trial of labor after cesarean with an unfavorable cervix.

Uncertainty in evidence synthesis limits clinical applicability of a clinical and cost-effectiveness analysis of induction of labour methods

Commentary on: Alfirevic Z, Keeney E, Dowswell T, et al. Methods to induce labour: a systematic review, network meta-analysis and cost-effectiveness analysis. BJOG 2016;123:1462–70[OpenUrl][1]. The goal of induction of labour (IOL) is to achieve vaginal delivery by stimulation of uterine contractions before the spontaneous onset of labour. Variations in the management of IOL likely affect rates of caesarean delivery (CD), particularly the use of cervical ripening agents for the unfavourable cervix. This systematic review and meta-analysis looks at the various methods of labour induction and compares them from a clinical and cost-effectiveness perspective. This was a review of randomised controlled trials (RCTs) examining pharmacological, mechanical and complementary (ie, acupuncture) interventions to induce labour. Outcomes included were vaginal delivery not achieved within 24 hours (VD24); uterine hyperstimulation with fetal heart rate (FHR) changes; CD; serious maternal and neonatal morbidity or … [1]: {openurl}?query=rft.jtitle%253DBJOG%26rft.volume%253D123%26rft.spage%253D1462%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx