Dana Henry

Perinatal outcomes in the setting of active phase arrest of labor

OBJECTIVE: To examine the association between active phase arrest and perinatal outcomes. METHODS: This was a retrospective cohort study of women with term, singleton, cephalic gestations diagnosed with active phase arrest of labor, defined as no cervical change for 2 hours despite adequate uterine contractions. Women with active phase arrest who underwent a cesarean delivery were compared with those who delivered vaginally, and women who delivered vaginally with active phase arrest were compared with those without active phase arrest. The association between active phase arrest, mode of delivery, and perinatal outcomes was evaluated using univariable and multivariable logistic regression models. RESULTS: We identified 1,014 women with active phase arrest: 33% (335) went on to deliver vaginally, and the rest had cesarean deliveries. Cesarean delivery was associated with an increased risk of chorioamnionitis (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 2.21–5.15), endomyometritis (aOR 48.41, 95% CI 6.61–354), postpartum hemorrhage (aOR 5.18, 95% CI 3.42–7.85), and severe postpartum hemorrhage (aOR 14.97, 95% CI 1.77–126). There were no differences in adverse neonatal outcomes. Among women who delivered vaginally, women with active phase arrest had significantly increased odds of chorioamnionitis (aOR 2.70, 95% CI 1.22–2.36) and shoulder dystocia (aOR 2.37, 95% CI 1.33–4.25). However, there were no differences in the serious sequelae associated with these outcomes, including neonatal sepsis or Erbs palsy. CONCLUSION: Efforts to achieve vaginal delivery in the setting of active phase arrest may reduce the maternal risks associated with cesarean delivery without additional risk to the neonate. LEVEL OF EVIDENCE: II

Maternal and neonatal outcomes after antenatal corticosteroid administration for PPROM at 32 to 33 6/7 weeks gestational age*

Abstract Background: Preterm Premature Rupture of Membranes (PPROM) precedes many deliveries and experts agree with expectant management until 34 weeks gestation. However, there is controversy regarding the gestational age (GA) for administration of corticosteroids. Study design: We performed a retrospective cohort study in the University of California Fetal Consortium (UCfC). We searched available charts of singleton pregnancies with PPROM between 32 and 33 6/7 weeks GA. Outcomes from the groups were analyzed. Results: Of 191 women with PPROM at 32 to 33 6/7 weeks, 150 received corticosteroids. The median GA at admission was earlier for the exposed versus unexposed group (32 4/7 versus 33 0/7 weeks, respectively, p = 0.001). The mean GA at delivery in the exposed was 33 2/7 (32 0/7 to 35 0/7) weeks versus 33 5/7 (32 0/7 to 36 1/7) weeks in the unexposed (p = 0.001). There was no difference in chorioamnionitis or RDS. Conclusion: In women with PPROM at 32 to 33 6/7 weeks, our data suggests that corticosteroids are associated with similar outcomes despite earlier GA at delivery and no differences in major morbidities. A larger prospective study is needed to determine if the benefit of corticosteroids outweighs the potential risks in PPROM.

The association between nitroglycerin use and adverse outcomes in women undergoing cesarean delivery in the second stage of labor

Abstract Objective: To identify predictors of hysterotomy extension in women undergoing cesarean delivery (CD) in the second stage of labor, and whether use of nitroglycerin (NTG) during CD has a protective effect. Methods: We conducted a retrospective cohort study of women undergoing CD in the second stage of labor from 2012 to 2015. Some women received NTG at the obstetrician’s request. Logistic regression was used to examine the relationship between second stage duration and NTG administration on maternal and neonatal outcomes. Results: Of the 391 women in the sample, 27% had an extension and 12% received NTG. Second stage ≥4 h was associated with a 2.14-fold higher risk of extension (95% CI 1.22–3.75), a 2.00-fold higher risk of hemorrhage (95% CI: 1.20–3.33) and 2.42-fold higher risk of blood transfusion during delivery hospitalization (95% CI: 0.99–5.91). Intravenous (IV) and sublingual-spray (SL-spray) NTG administration were not associated with an increased risk of hemorrhage or extension. SL-NTG was associated with 4.68-fold increased odds of 5-min Apgar <7 (95% CI 1.42–15.41) and 3.36-fold greater odds of NICU admission (95% CI 1.20–9.41). Conclusion: We found no evidence that NTG protects against extension, and SL-NTG use was associated with adverse neonatal outcomes. Clinical trials should be conducted to evaluate risk and benefits of NTG use.

Maternal and neonatal outcomes among scheduled versus unscheduled deliveries in women with prenatally diagnosed, pathologically proven placenta accreta

Abstract Objective: To evaluate maternal and neonatal outcomes among scheduled versus unscheduled deliveries in cases of prenatally diagnosed, pathologically proven placenta accreta. Study design: Retrospective cohort of placenta accreta cases delivered in five University of California hospitals. Results: Of 151 cases of histopathologically proven placenta accreta, 82% were prenatally diagnosed. Sixty-seven percent of women underwent scheduled deliveries and 33% were unscheduled. There were no differences in demographics between groups except a higher rate of antepartum bleeding in the unscheduled delivery group (81 versus 53%; p = .003). Scheduled deliveries were associated with a later gestational age at delivery (34.6 versus 32.6 weeks; p = .001), lower blood loss (2.0 versus 2.5 l; p = .04), higher birth weight (2488 versus 2010 g; p < .001), shorter postpartum length of stay (4 versus 5 d; p = .03) and neonatal length of stay (12 versus 20 d; p = .005). Conclusion: Despite a prenatal diagnosis of placenta accreta, 1/3 of these cases require unscheduled delivery, portending poorer maternal and neonatal outcomes.

Maternal Arrhythmia and Perinatal Outcomes: A Pregnancy and Cardiac Disease Treatment Program

INTRODUCTION: Maternal cardiac diseases can be severely compromised in the setting of arrhythmias. We compared perinatal outcomes among women with a cardiac arrhythmia with women with other types of cardiac disease. METHODS: This is a retrospective cohort study of pregnant women with cardiac disease who delivered from 2008 to 2013. Perinatal outcomes among women with an arrhythmia were compared with those with other types of maternal cardiac disease (congenital, structural, or cardiomyopathy). RESULTS: A cohort of 143 women was identified; 37 (26%) had a diagnosis of an arrhythmia. Compared with women without arrhythmias, those with an arrhythmia were more likely to have a spontaneous vaginal delivery (62% compared with 43%, P<.05) and required fewer operative vaginal births (11% compared with 26%, P=.05). Pregnancies were more likely to be complicated by intrauterine growth restriction (IUGR) (16% compared with 5%, P<.05) and placental abruption (5% compared with 0%, P<.05). The risk of IUGR remained increased in multivariable model controlling for confounding (adjusted odds ratio 6.9, 95% confidence interval 1.6–30.4, P=.01). There were no differences in rates of other maternal complications including gestational diabetes, postpartum hemorrhage, chorioamnionitis, or intensive care unit admission. Neonatal outcomes including gestational age at delivery, birth weight, 5-minute Apgar, umbilical artery pH less than 7, and neonatal intensive care unit admission were not different. CONCLUSIONS: Patients with arrhythmias were more likely to have a successful vaginal delivery compared with those other maternal cardiac diseases. However, the pregnancy had an increased risk for IUGR and placental abruption. The rates of adverse neonatal outcomes were similar between the groups.

Perinatal Outcomes in the Setting of Active Phase Arrest of Labor

ABSTRACT Diagnosis of active phase arrest has been defined as no cervical change for a minimum of 2 hours in the setting of an adequate uterine contraction pattern. However, cesarean deliveries performed for active phase arrest often fail to meet these criteria. Previous studies have demonstrated that a majority of women diagnosed with active phase arrest will achieve a vaginal delivery if given at least 4-hours before a diagnosis of active phase arrest is made. These studies also showed low rates of maternal and neonatal complications among all women with active phase arrest, and similar rates for cesarean and vaginal deliveries. To confirm these findings, this retrospective cohort study evaluated perinatal outcomes in Californian women with a live, term, cephalic, singleton birth who were diagnosed with active phase arrest of labor for at least 2-hours and delivered between 1991 and 2001 (n = 1014). Two comparisons were made. In the first, rates of adverse perinatal outcomes among women with active phase arrest were compared by mode of delivery: vaginal or cesarean. In the second, outcomes of women who delivered vaginally were compared in those with or without active phase arrest. Of the 1014 women identified with active phase arrest, 33% (335) went on to deliver vaginally, and 68% (679) underwent cesarean deliveries. Among these women, multivariable logistic regression analysis showed that cesarean delivery was associated with an increased risk of chorioamnionitis (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 2.21–5.15), endomyometritis (aOR 48.41, 95% CI 6.61–354), postpartum hemorrhage (aOR 5.18, 95% CI 3.42– 7.85), and severe postpartum hemorrhage (aOR 14.97, 95% CI 1.77–126). There was no significant association between cesarean delivery and adverse neonatal outcomes in women with active phase arrest. Women with active phase arrest who delivered vaginally had significantly increased odds of chorioamnionitis (aOR 1.78, 95% CI 1.22–2.36) and shoulder dystocia (aOR 2.37, 95% CI 1.33– 4.25). There were no differences in rates of other adverse neonatal outcomes and active phase arrest, including sepsis, neonatal intensive care unit admission, clavicular fracture, Erb’s palsy, and acidemia. These findings suggest to the investigators that an attempt to achieve vaginal delivery in women diagnosed with active phase arrest should be made because it poses no additional risk to the neonate and may reduce the maternal risks associated with cesarean delivery.