David Garry

Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries.

OBJECTIVE: To estimate the differences in immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. METHODS: We conducted a medical record review of all forceps and vacuum-assisted deliveries that occurred from January 1, 1998, to August 30, 1999, at Winthrop-University Hospital. Maternal demographics and delivery characteristics were recorded. Maternal outcomes, such as use of episiotomy and presence of lacerations, were studied. Neonatal outcomes evaluated were Apgar scores, neonatal intensive care unit admissions, cephalohematomas, instrument marks and bruising, and caput and molding. RESULTS: Of 508 operative vaginal deliveries, 200 were forceps and 308 were vacuum assisted. Forceps were used more often than vacuum for prolonged second stage of labor (P = .001). There was a higher rate of epidural (P = .02) and pudendal (P < .001) anesthesia, episiotomies (P = .01), maternal third- and fourth-degree perineal (P < .001) and vaginal lacerations (P = .004) with the use of forceps, whereas periurethral lacerations were more common in vacuum-assisted (P = .026) deliveries. More instrument marks and bruising (P < .001) were found in the neonates delivered by forceps, whereas there was a greater incidence of cephalohematomas (P = .03) and caput and molding (P < .001) in the neonates delivered with vacuum. Multivariable logistic regression analysis showed that forceps use was associated with an increase in major perineal and vaginal tears (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.27, 2.69; P = .001), an increase in instrument marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P < .001) and a decrease in cephalohematomas (OR 0.49; 95% CI 0.29, 0.83; P = .007) compared with the vacuum. CONCLUSIONS: Maternal injuries are more common with the use of forceps. Neonates delivered with forceps have more facial injuries, whereas neonates delivered with vacuum have more cephalohematomas. LEVEL OF EVIDENCE: II-3

A comparison of rapid amniotic fluid markers in the prediction of microbial invasion of the uterine cavity and preterm delivery

OBJECTIVE The purpose of this study was to evaluate amniotic fluid lactate dehydrogenase level in comparison with other rapid markers in prediction of microbial invasion of the uterine cavity and preterm delivery < or = 36 hours after amniocentesis. STUDY DESIGN One hundred thirty-one women in preterm labor with intact membranes underwent transabdominal amniocentesis. Amniotic fluid was analyzed for leukocyte count, glucose level, lactate dehydrogenase level, and Gram stain. Cultures for aerobes, anaerobes, and Mycoplasma sp. were performed. Amniocentesis-to-delivery interval was calculated. The study group was divided and the findings compared according to amniotic fluid culture results and according to amniocentesis-to-delivery interval. Sensitivity, specificity, and positive and negative predictive value were calculated for lactate dehydrogenase, leukocyte count, glucose, and Gram stain in the prediction of positive amniotic fluid culture and preterm delivery < or = 36 hours after amniocentesis. Receiver-operator characteristic curve analysis, logistic regression analysis, t tests, and nonparametric tests were used. RESULTS The prevalence of positive amniotic fluid cultures was 12% (16 of 131). The median lactate dehydrogenase level (1084 U/L) was significantly greater for women with a positive amniotic fluid culture than for those with a negative culture (median lactate dehydrogenase level 194 U/L; p < 0.0002). The critical values calculated for optimal performance in prediction of a positive amniotic fluid culture were a lactate dehydrogenase level > or = 419 U/L, leukocyte count > or = 50 cells/mm3 (50 x 10(6)/L) and glucose < or = 17 mg/dl (0.94 mmol/L). Lactate dehydrogenase, leukocyte count, glucose, and Gram stain were equally sensitive and specific in prediction of a positive amniotic fluid culture. Thirty-nine women (29.8%) gave birth < or = 36 hours after amniocentesis. The median lactate dehydrogenase level (414 U/L) was significantly greater among women giving birth < or = 36 hours after amniocentesis than among women giving birth > 36 hours after amniocentesis (median lactate dehydrogenase, 173 U/L; p < 0.001). Critical values of lactate dehydrogenase > or = 225 U/L, leukocyte count > or = 10 cells/mm3 (10 x 10(6)/L) and glucose < or = 34 mg/dl (1.9 mmol/L) were selected for optimal performance in prediction of amniocentesis-to-delivery interval < or = 36 hours. Lactate dehydrogenase level had the best sensitivity (74%) in prediction of delivery < or = 36 hours after amniocentesis in contrast to leukocyte count (49%), glucose (62%), and positive Gram stain (26%). Amniotic fluid lactate dehydrogenase values > or = 225 U/L were associated with a fivefold greater risk for delivery < or = 36 hours after amniocentesis (odds ratio 5.46, 95% confidence interval 2.00 to 14.87; p = 0.0006). CONCLUSION Amniotic fluid lactate dehydrogenase level has diagnostic value in prediction of a positive amniotic fluid culture and delivery < or = 36 hours after amniocentesis. Lactate dehydrogenase is a readily available, inexpensive, rapid amniotic fluid marker that can be measured in any hospital laboratory.

Antenatal Betamethasone Compared With Dexamethasone (betacode Trial): A Randomized Controlled Trial

OBJECTIVE: To compare betamethasone with dexamethasone in terms of effectiveness in reducing perinatal morbidities and mortality among preterm infants. METHODS: We enrolled 299 women at risk for preterm delivery in a double-blind, placebo-controlled, randomized trial of antenatal betamethasone compared with dexamethasone at Stony Brook University Hospital from August 2002 through July 2004. We excluded women with clinical chorioamnionitis, fetal structural and chromosomal abnormalities, prior antenatal steroid exposure, and steroid use for other indications. Statistical analysis was performed in accordance of the intention-to-treat principle. RESULTS: There were no significant differences between the groups with regard to baseline characteristics. The rate of respiratory distress syndrome, need for vasopressor therapy, necrotizing enterocolitis, retinopathy of prematurity, patent ductus arteriosus, neonatal sepsis, and neonatal mortality were not significant different between the groups. However, the rates of intraventricular hemorrhage (6 of 105 [5.7%] compared with 17 of 100 [17.0%], relative risk [RR] 2.97, 95% confidence interval [CI] 1.22–7.24, P=.02) and any brain lesion (7 of 105 [6.7%] compared with 18 of 100 [18.0%], RR 2.7, 95% CI 1.18–6.19, P=.02) were significantly lower in neonates exposed to dexamethasone compared with betamethasone. The absolute risk reduction in the rate of intraventricular hemorrhage was 11.3 % ( 95% CI 2.7–11.9%), and the number needed to treat was 9 (95% CI 5–37) in favor of dexamethasone. CONCLUSION: Betamethasone and dexamethasone are comparable in reducing the rate of most major neonatal morbidities and mortality in preterm neonates. However, dexamethasone seems to be more effective in reducing the rate of intraventricular hemorrhage compared with betamethasone. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00418353 LEVEL OF EVIDENCE: I

Stress and Preterm Labor and Birth in Black Women

OBJECTIVE To examine (a) 3 commonly used measures of stress during pregnancy, (b) changes in stress over time to determine when stress is highest, and (c) whether any of the stress measures predict who will deliver preterm in pregnant Black women. DESIGN Prospective descriptive study. SETTING Perinatal evaluation center and outpatient clinics of a teaching hospital in the northeast. PARTICIPANTS Fifty-nine Black women: 39 were recruited in preterm labor from a Perinatal Evaluation Center, and 20 experiencing healthy pregnancies were recruited from the prenatal clinic. MEASURES Stress was measured using 2 paper and pencil tests (the Prenatal Distress Questionnaire and the Perceived Stress Scale) and corticotropin-releasing hormone. RESULTS There was not a high correlation between stress measures. Stress at 28 weeks as measured by Prenatal Distress Questionnaire and Perceived Stress Scale was at its highest, but corticotropin-releasing hormone increased to 32 weeks and then decreased. CONCLUSIONS Perceived stress, prenatal distress, and corticotropin-releasing hormone do not all appear to be measuring the same phenomenon. Screening for stress in Black women at 28 weeks requires further research as perceived stress levels in Black women experiencing preterm labor around 28 weeks differentiated women who delivered preterm infants from Black women who delivered at term.

Outcomes after an excisional procedure for cervical intraepithelial neoplasia in HIV-infected women.

OBJECTIVE To determine predictors of treatment failure and recurrence after surgical excisional procedures for CIN in HIV-infected women. METHODS A retrospective cohort study was conducted in which 136 eligible HIV-infected women treated for CIN between 1999 and 2005 were included. Data were abstracted from charts and computer databases. Treatment failures were defined as the presence of CIN 1+ at initial follow-up. Recurrences were defined as the presence of CIN 1+ subsequent to initial normal follow-up. RESULTS Treatment failure at initial follow-up was common, occurring in 51% of CIN 1 and 55% of CIN 2+. Most lesions detected at treatment failure were high grade (>70%), regardless of the grade of initial lesion. Significant risk factors for treatment failure were loop electrosurgical excision procedure (LEEP) compared to cold knife conization (RR=1.76; 95% CI: 1.15-2.64), and low CD4+ count (p=0.04). Among those with an initial normal clinical evaluation, 55% eventually recurred. As with treatment failure, most lesions detected at recurrence were high grade. Risk factors for recurrence included use of LEEP (hazard ratio [HR]=3.38; 95% CI: 1.55-7.39), higher HIV RNA level, and the presence of positive margins at treatment (HR=6.12; 95% CI: 1.90-19.73). CONCLUSIONS Most CIN treatment of HIV-infected women studied either failed or resulted in recurrence. Of particular concern, many of these subsequent lesions were high grade. Conization, however, was associated with significantly less failure/recurrence than LEEP. Clinicians treating CIN in HIV-infected women should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention until there are better therapies for this patient population.

Rapid and novel prenatal molecular assay for detecting aneuploidies and microdeletion syndromes

To develop a targeted aneuploidy and microdeletion detection platform for use in the prenatal setting, to assess the integrity of the platform with a robust validation system, and to prospectively determine the performance of the platform under routine clinical conditions.

Correlation of neonatal nucleated red blood cell counts in preterm infants with histologic chorioamnionitis

OBJECTIVE The aim of this study was to compare the neonatal nucleated red blood cell counts in preterm infants in the presence and absence of clinical and histologic chorioamnionitis while controlling for gestational age and birth weight percentile. STUDY DESIGN Nucleated red blood cell counts were obtained from preterm infants delivered after preterm labor or preterm premature rupture of membranes. Patients were divided on the basis of clinical and histologic chorioamnionitis. Nucleated red blood cell counts between groups were compared, and regression analysis controlling for gestational age and birth weight percentile was performed. RESULTS Of 359 patients, both measures of infection status were significantly associated with increased nucleated red blood cell counts. In the regression analysis histologic chorioamnionitis retained significance, whereas clinical chorioamnionitis did not. CONCLUSIONS Histologic chorioamnionitis produces an erythropoietic response in the fetus. Whether fetal erythropoiesis is a direct response to mediators of inflammation or whether it is the result of a rise in erythropoietin is unknown.

Commercial Laboratory IgM Testing for Toxoplasma gondii in Pregnancy: A 20-Year Experience

OBJECTIVE: This study was performed to review the clinical utility of commercial laboratory Toxoplasmosis-specific IgM testing during pregnancy and outcomes of the gestation at our institution. METHODS: A retrospective review of all women referred for suspected acute Toxoplasma gondii infection during pregnancy from 1984 through 2004 was performed. Women were diagnosed with suspected acute toxoplasmosis based on commercial laboratory serologic antibody testing. All women had blood sent to a recognized reference laboratory for antibody testing within 2 weeks of the commercial laboratory results. The study protocol was approved by the Institutional Review Board. Chi-square analysis were used with a significance of P < .05. RESULTS: A total of 130 women were evaluated during the study period with 116 IgM positive results from the commercial laboratories. The commercial laboratory antibodies were as follows: IgM positive with IgG negative (n = 20), IgM positive with IgG positive (n = 96), and IgM negative with IgG positive (n = 14). There was a significant reduction in the IgM positive results when comparing commercial laboratory (n = 116) with the reference laboratory results (n = 28; p < .001). Acute toxoplasmosis infection was diagnosed in 7 (5%) of the women. All cases of acute toxoplasmosis infection had a positive commercial laboratory IgM result. The false positive rate for the commercial laboratory IgM was 88.6% and the diagnostic indices were sensitivity 100%, specificity 11.4%, positive predictive value 6% and negative predictive value 100%. CONCLUSION: Commercial laboratory Toxoplasmosis-specific IgM is associated with a high false positive rate. The commercial and reference laboratory IgM results identified all cases of acute toxoplasmosis infection. Commercial laboratories reflexively obtaining reference laboratory confirmation of positive results could reduce costs associated with testing, referrals, retesting, and invasive procedures.

Skin Preparation for Prevention of Surgical Site Infection After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To compare chlorhexidine with alcohol, povidone–iodine with alcohol, and both applied sequentially to estimate their relative effectiveness in prevention of surgical site infections after cesarean delivery. METHODS: Women undergoing nonemergent cesarean birth at greater than 37 0/7 weeks of gestation were randomly allocated to one of three antiseptic skin preparations: povidone–iodine with alcohol, chlorhexidine with alcohol, or the sequential combination of both solutions. The primary outcome was surgical site infection reported within the first 30 days postpartum. Based on a surgical site infection rate of 12%, an anticipated 50% reduction for the combination group relative to either single skin preparation group, with a power of 0.90 and an &agr; of 0.05, 430 women per group were needed to detect a difference. RESULTS: From January 2013 to July 2014, 1,404 women were randomly assigned to one of three groups: povidone–iodine with alcohol (n=463), chlorhexidine with alcohol (n=474), or both (n=467). The groups were similar with respect to demographics, medical disorders, indication for cesarean delivery, operative time, and blood loss. The overall rate of surgical site infection—4.3%—was lower than anticipated. The skin preparation groups had similar surgical site infection rates: povidone–iodine 4.6%, chlorhexidine with alcohol 4.5%, and sequential 3.9% (P=.85). CONCLUSION: The skin preparation techniques resulted in similar rates of surgical site infections. Our study provides no support for any particular method of skin preparation before cesarean delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01870583. LEVEL OF EVIDENCE: I

Second-trimester sonographic comparison of the lower uterine segment in pregnant women with and without a previous cesarean delivery

Objective. To compare measurements of the lower uterine segment during a second‐trimester sonographic examination in women with and without a previous cesarean delivery. Methods. Women undergoing second‐trimester sonographic examination, 24 with a history of cesarean delivery and 30 control subjects with no history of cesarean delivery, were recruited for transvaginal sonographic evaluation of the lower uterine segment with a high‐frequency probe. The uterine niche or previous cesarean scar site was defined as a small triangular anechoic defect in the anterior wall of the uterus. The uterine wall thickness was measured successively at the level where the bladder dome meets the lower uterine segment. Measurements were obtained with cursors at the interface of the urine‐bladder and the amniotic fluid‐decidua. The study was approved by the Institutional Review Board, and P < .05 was considered significant. Results. The uterine niche was identified in 14 (58%) of 24 women with a previous cesarean delivery. The lower uterine segment was significantly thinner in women with a previous cesarean delivery compared with control subjects (mean ± SD, 4.7 ± 1.1 versus 6.6 ± 2.0 mm; P < .001). In the previous cesarean group, the mean lower uterine segment thickness was similar in the 5 women with 2 cesarean deliveries when compared with those with 1 cesarean delivery (4.6 ± 1.0 versus 4.7 ± 1.4 mm; P = .91). In a linear regression model, the only variable retaining significance in the prediction of uterine wall thickness was previous cesarean delivery (P = .002). Maternal age, parity, number of previous cesarean deliveries, and gestational age did not attain significance in the model. Conclusions. The lower uterine segment during a second‐trimester sonographic examination is significantly thinner in women with a previous cesarean delivery. Identification of the scar niche is possible in most of these women.