Debra A. Guinn

Value of perinatal autopsy

OBJECTIVE To determine how often a perinatal autopsy identified the cause of death, and how frequently this information changed recurrence risk estimates or altered parental counseling. METHODS We reviewed all autopsies of fetal stillbirths and briefly viable neonates performed by one perinatal pathologist at the University of Alabama Hospital from 1992 to 1994. RESULTS Four hundred sixteen fetal and early neonatal deaths occurred at our hospital from January 1, 1992, to June 1, 1994. Consent for an autopsy examination was granted for 139 of these (33%), and all autopsies were performed by a single perinatal pathologist. Abnormalities likely to be the cause of death were identified in 130 of 139 cases (94%). Ninety-one subjects did not have structural anomalies: In 14 cases autopsy revealed previously unsuspected pathology that altered parental counseling; in 68 cases autopsy findings were consistent with the clinical obstetrical diagnosis; and in nine cases the cause of death could not be identified. Forty-eight subjects were anomalous. Thirty-seven of these (79%) had been evaluated by antenatal ultrasonography, and autopsy identified additional abnormalities in 51% (19 of 37). In the 11 deaths evaluated neonatally, a previously unsuspected diagnosis likely to be the cause of death was identified in three. Overall, autopsy findings changed recurrence risk estimates and/or parental counseling in 36 of 139 cases (26%). CONCLUSION The cause of fetal or perinatal death was determined by autopsy in 94% of cases in our series. Counseling and recurrence risk estimates were altered by autopsy findings in 26%.

Subcutaneous Tissue Reapproximation, Alone or in Combination With Drain, in Obese Women Undergoing Cesarean Delivery

OBJECTIVE: To compare the efficacy of subcutaneous suture reapproximation alone with suture plus subcutaneous drain for the prevention of wound complications in obese women undergoing cesarean delivery. METHODS: We conducted a multicenter randomized trial of women undergoing cesarean delivery. Consenting women with 4 cm or more of subcutaneous thickness were randomized to either subcutaneous suture closure alone (n = 149) or suture plus drain (n = 131). The drain was attached to bulb suction and removed at 72 hours or earlier if output was less than 30 mL/24 h. The primary study outcome was a composite wound morbidity rate (defined by any of the following: subcutaneous tissue dehiscence, seroma, hematoma, abscess, or fascial dehiscence). RESULTS: From April 2001 to July 2004, a total of 280 women were enrolled. Ninety-five percent of women (268/280) had a follow-up wound assessment. Both groups were similar with respect to age, race, parity, weight, cesarean indication, diabetes, steroid/antibiotic use, chorioamnionitis, and subcutaneous thickness. The composite wound morbidity rate was 17.4% (25/144) in the suture group and 22.7% (28/124) in the suture plus drain group (relative risk 1.3, 95% confidence interval 0.8–2.1). Individual wound complication rates, including subcutaneous dehiscence (15.3% versus 21.8%), seroma (9.0% versus 10.6%), hematoma (2.2% versus 2.4%), abscess (0.7% versus 3.3%), fascial dehiscence (1.4% versus 1.7%), and hospital readmission for wound complications (3.5% versus 6.6%), were similar (P > .05) between women treated with suture alone and those treated with suture plus drain, respectively. CONCLUSION: The additional use of a subcutaneous drain along with a standard subcutaneous suture reapproximation technique is not effective for the prevention of wound complications in obese women undergoing cesarean delivery. LEVEL OF EVIDENCE: I

Risk factors for the development of preterm premature rupture of the membranes after arrest of preterm labor

OBJECTIVE Our purpose was to determine risk factors predictive of preterm premature rupture of the membranes in women treated for preterm labor with intact membranes. STUDY DESIGN Women with intact membranes participating in a National Institute of Child Health and Human Development multicenter randomized trial of adjunctive antibiotic therapy for preterm labor (24 to 34 weeks) were studied (n = 275). After randomization, 22 women continued to have contractions and were delivered of their infants. The remaining 253 women whose contractions had ceased composed our study population. Preterm premature rupture of the membranes was diagnosed if ruptured membranes occurred > or = 1 hour before the onset of recurrent preterm labor. As part of the study protocol, most women underwent amniocentesis on admission. RESULTS Preterm premature rupture of the membranes developed in 44% women (17.4%). Women who had preterm premature rupture of the membranes were more likely to be black (p = 0.004), to be multiparous (p = 0.014), to have a history of abortion(s) (p = 0.001), to have had a preterm birth(s) (p = 0.036), to have early onset preterm labor (p = 0.04), to have more advanced cervical dilatation (p = 0.0001), to have one or more amniotic fluid markers suggestive of infection (p = 0.01, odds ratio 4.2), and to have positive amniotic fluid cultures (p = 0.0007, odds ratio 27). Assignment to antibiotic therapy did not prevent preterm premature rupture of the membranes in the 253 women randomized or in the 16 women with a positive amniotic fluid marker(s) of infection. CONCLUSION Black race, multiparity, a history of abortion or preterm birth, advanced dilatation, and a positive amniotic fluid marker(s) are associated with preterm premature rupture of the membranes in women with preterm labor. Antibiotic treatment did not prevent preterm premature rupture of the membranes.

Single versus weekly courses of antenatal corticosteroids in preterm premature rupture of membranes

OBJECTIVE: This study was performed to evaluate the efficacy of weekly courses of antenatal corticosteroids compared with a single course in women with preterm premature rupture of membranes (PROM). METHODS: A planned secondary analysis of women with preterm PROM who participated in a multicenter, randomized trial of weekly courses of antenatal corticosteroids versus single-course therapy was performed. After their first course of standard antenatal steroid therapy, administered between 24 to 32–6/7 weeks of gestation, consenting women were randomly assigned to receive betamethasone versus placebo injections weekly until 34–0/7 weeks of gestation. Maternal and neonatal morbidities were compared between the 2 groups. RESULTS: Of the 161 women with preterm PROM, 81 women were assigned to receive weekly courses of steroids and 80 to the single-course group. There were no significant differences in composite morbidity between the groups (27 [34.2%] of 81 patients versus 33 [41.8%] of 80 patients, P = .41). Chorioamnionitis was higher in patients who received weekly courses of antenatal steroids (39 [49.4%] of 81 patients versus 25 [31.7%] of 80 patients, P = .04). CONCLUSION: Weekly courses of antenatal steroids in women with preterm PROM did not improve neonatal outcomes beyond that achieved with single-course therapy and was associated with an increased risk of chorioamnionitis. Antenatal steroid therapy should not be routinely repeated in patients with preterm PROM. LEVEL OF EVIDENCE: I

Necrotizing fasciitis after cesarean delivery.

Objective: To review our experience with the diagnosis and management of necrotizing fasciitis after cesarean delivery. Methods: We reviewed medical records of women with serious post-cesarean wound infections at the University of Alabama at Birmingham between 1987 and 1994 to identify women with necrotizing fasciitis. The diagnosis of necrotizing fasciitis required intraoperative identification of necrotic fascia in febrile women undergoing post-cesarean wound debridement. Results: During the study period, 5048 women had cesarean deliveries, nine of which were complicated by necrotizing fasciitis. The mean (± standard deviation) maternal age was 27 ± 6 years, and the mean maternal weight was 199 ± 64 lb. None of the patients had insulin-dependent diabetes mellitus, and none had known peripheral vascular disease. There were no intraoperative complications at cesarean delivery. The mean time from cesarean delivery to the diagnosis of necrotizing fasciitis and reoperation was 10 ± 4 days (range 5–17). All patients had surgical debridement upon consideration of the diagnosis, and all received broadspectrum antimicrobial therapy. Results of wound cultures were available in seven of the women, and all seven were found to have polymicrobial infections. There were two mortalities, one as a result of metastatic breast cancer and another with complications of sepsis. Conclusion: Necrotizing fasciitis is infrequent (1.8 per 1000 women) after cesarean delivery at our institution, but it does result in appreciable morbidity and mortality.

Extra-amniotic saline, laminaria, or prostaglandin E2 gel for labor induction with unfavorable cervix : A randomized controlled trial

Objective To determine which of three methods of cervical ripening resulted in the lowest cesarean rate in women with unfavorable cervices and indications for labor induction. Methods Consenting women with singleton gestations, vertex presentations, and unfavorable cervices (dilatation under 2 cm and effacement under 75%) were randomly assigned to laminaria and standard intravenous oxytocin, serial doses of intracervical prostoglandin (PG) E2 gel (Prepidil, Pharmacia & Upjohn, Inc., Kalamazoo, MI) 0.5 μg every 6 hours for two doses followed by oxytocin if indicated, or extra-amniotic saline infusion and oxytocin. Results An interim analysis after recruitment of 321 subjects, 67% of the planned sample, found similar cesarean rates for the three groups (laminaria 36%; gel 33%; PGE2 saline infusion 29%; P = .59); however, the mean randomization-to-delivery interval was significantly longer in the PGE2 group. Stochastic curtailment, as part of the interim analysis, indicated a low likelihood of achieving a statistically significant difference in cesarean rates between PGE2 gel and the other two groups. Therefore, we completed the study with saline infusion and laminaria. The saline infusion and laminaria groups had similar preinduction characteristics. The cesarean rates were similar (saline infusion 25.4% versus laminaria 30.3%; P = .32), but the mean interval from randomization to delivery was shorter in the saline infusion group (18.0 versus 21.5 hours, P = .002). There were no significant differences in selected maternal and neonatal morbidities. Conclusion Cervical ripening with extra-amniotic saline infusion, PGE2, or laminaria resulted in comparable cesarean rates in women with an unfavorable cervix and indications for labor induction. Extra-amniotic saline infusion had the shortest randomization-to-delivery interval without increasing maternal or neonatal morbidity.

The effectiveness of a verbal opt-out system for human immunodeficiency virus screening during pregnancy

OBJECTIVE: We sought to evaluate the use of human immunodeficiency virus (HIV) screening during pregnancy in a health care system using the verbal opt-out method, in which HIV screening was recommended during all pregnancies and women were given an opportunity to refuse testing. METHODS: This was a retrospective cohort study of pregnancies resulting in delivery from 1998 through 2001 at Denver Health Medical Center, an urban public hospital. The main outcome measure was the proportion of documented HIV screening within 9 months before the delivery date. RESULTS: Of 12,221 pregnancies resulting in delivery, HIV screening was completed in 12,000 (98.2%, 95% confidence interval 97.9–98.4%). Of the 221 women not screened for HIV, only 24 (10.9% of those not screened, 0.2% of all women in the study) were documented as refusing HIV testing. Patients not screened for HIV presented late in pregnancy, a median of 1 day before delivery, compared with a median of 176 days for those who were screened (P < .001). CONCLUSION: A verbal opt-out system was very effective in promoting HIV screening during pregnancy. Late presentation in pregnancy was associated with not having HIV screening performed. LEVEL OF EVIDENCE: II-3

Repeat prenatal corticosteroid prior to preterm birth: a systematic review and individual participant data meta-analysis for the PRECISE study group (prenatal repeat corticosteroid international IPD study group: assessing the effects using the best level of evidence) - study protocol

BackgroundThe aim of this individual participant data (IPD) meta-analysis is to assess whether the effects of repeat prenatal corticosteroid treatment given to women at risk of preterm birth to benefit their babies are modified in a clinically meaningful way by factors related to the women or the trial protocol.Methods/DesignThe Prenatal Repeat Corticosteroid International IPD Study Group: assessing the effects using the best level of Evidence (PRECISE) Group will conduct an IPD meta-analysis. The PRECISE International Collaborative Group was formed in 2010 and data collection commenced in 2011. Eleven trials with up to 5,000 women and 6,000 infants are eligible for the PRECISE IPD meta-analysis. The primary study outcomes for the infants will be serious neonatal outcome (defined by the PRECISE International IPD Study Group as one of death (foetal, neonatal or infant); severe respiratory disease; severe intraventricular haemorrhage (grade 3 and 4); chronic lung disease; necrotising enterocolitis; serious retinopathy of prematurity; and cystic periventricular leukomalacia); use of respiratory support (defined as mechanical ventilation or continuous positive airways pressure or other respiratory support); and birth weight (Z-scores). For the children, the primary study outcomes will be death or any neurological disability (however defined by trialists at childhood follow up and may include developmental delay or intellectual impairment (developmental quotient or intelligence quotient more than one standard deviation below the mean), cerebral palsy (abnormality of tone with motor dysfunction), blindness (for example, corrected visual acuity worse than 6/60 in the better eye) or deafness (for example, hearing loss requiring amplification or worse)). For the women, the primary outcome will be maternal sepsis (defined as chorioamnionitis; pyrexia after trial entry requiring the use of antibiotics; puerperal sepsis; intrapartum fever requiring the use of antibiotics; or postnatal pyrexia).DiscussionData analyses are expected to commence in 2011 with results publicly available in 2012.

Necrotizing Fasciitis After Cesarean Delivery

Objective To review our experience with the diagnosis and management of necrotizing fasciitis after cesarean delivery. Methods We reviewed medical records of women with serious post-cesarean wound infections at the University of Alabama at Birmingham between 1987 and 1994 to identify women with necrotizing fasciitis. The diagnosis of necrotizing fasciitis required intraoperative identification of necrotic fascia in febrile women undergoing post-cesarean wound debridement. Results During the study period, 5048 women had cesarean deliveries, nine of which were complicated by necrotizing fasciitis. The mean (± standard deviation) maternal age was 27 ± 6 years, and the mean maternal weight was 199 ± 64 Ib. None of the patients had insulin-dependent diabetes mellitus, and none had known peripheral vascular disease. There were no intraoperative complications at cesarean delivery. The mean time from cesarean delivery to the diagnosis of necrotizing fasciitis and reoperation was 10 ± 4 days (range 5–17). All patients had surgical debridement upon consideration of the diagnosis, and all received broad-spectrum antimicrobial therapy. Results of wound cultures were available in seven of the women, and all seven were found to have polymicrobial infections. There were two mortalities, one as a result of metastatic breast cancer and another with complications of sepsis. Conclusion Necrotizing fasciitis is infrequent (1.8 per 1000 women) after cesarean delivery at our institution, but it does result in appreciable morbidity and mortality.