Elizabeth Langen

Poor Prognosis with In Vitro Fertilization in Indian Women Compared to Caucasian Women Despite Similar Embryo Quality

Background Disease prevalence and response to medical therapy may differ among patients of diverse ethnicities. Poor outcomes with in vitro fertilization (IVF) treatment have been previously shown in Indian women compared to Caucasian women, and some evidence suggests that poor embryo quality may be a cause for the discrepancy. In our center, only patients with the highest quality cleavage stage embryos are considered eligible for extending embryo culture to the blastocyst stage. We compared live birth rates (LBR) between Indian and Caucasian women after blastocyst transfer to investigate whether differences in IVF outcomes between these ethnicities would persist in patients who transferred similar quality embryos. Methodology/Principal Findings In this retrospective cohort analysis, we compared IVF outcome between 145 Caucasians and 80 Indians who had a blastocyst transfer between January 1, 2005 and June 31, 2007 in our university center. Indians were younger than Caucasians by 2.7 years (34.03 vs. 36.71, P = 0.03), were more likely to have an agonist down regulation protocol (68% vs. 43%, P<0.01), and were more likely to have polycystic ovarian syndrome (PCOS), although not significant, (24% vs. 14%, P = 0.06). Sixty eight percent of Indian patients had the highest quality embryos (4AB blastocyst or better) transferred compared to 71% of the Caucasians (P = 0.2). LBR was significantly lower in the Indians compared to the Caucasians (24% vs. 41%, P<0.01) with an odds ratio of 0.63, (95%CI 0.46–0.86). Controlling for age, stimulation protocol and PCOS showed persistently lower LBR with an adjusted odds ratio of 0.56, (95%CI 0.40–0.79) in the multivariate analysis. Conclusions/Significance Despite younger age and similar embryo quality, Indians had a significantly lower LBR than Caucasians. In this preliminary study, poor prognosis after IVF for Indian ethnicity persisted despite limiting analysis to patients with high quality embryos transferred. Further investigation into explanations for ethnic differences in reproduction is needed.

High rate of preterm birth in pregnancies complicated by rheumatoid arthritis.

OBJECTIVE To describe the outcomes of pregnancies complicated by rheumatoid arthritis (RA) and to estimate potential associations between disease characteristics and pregnancy outcomes. STUDY DESIGN We reviewed all pregnancies complicated by RA delivered at our institution from June 2001 through June 2009. Fisher exact tests were used to calculate odds ratios. Univariable regression was performed using STATA 10.1 (StataCorp, College Station, TX). A p value of ≤ 0.05 was considered statistically significant. RESULTS Forty-six pregnancies in 40 women were reviewed. Sixty percent of pregnancies had evidence of disease flare and 28% delivered prior to 37 weeks. We did not identify associations between preterm birth and active disease at conception or during pregnancy. In univariate analysis, discontinuation of medication because of pregnancy was associated with a significantly earlier gestational age at delivery (362/7 versus 383/7 weeks, p = 0.022). CONCLUSION Women with RA may be at higher risk for preterm delivery.

Asian ethnicity and poor outcomes after in vitro fertilization blastocyst transfer.

OBJECTIVE: To estimate the effect of ethnicity on in vitro fertilization (IVF) outcomes after blastocyst transfer. METHODS: We conducted a review of fresh blastocyst transfer IVF cycles from January 1, 2005, to December 31, 2006. Data collection included demographic information, infertility history, treatment protocol details, and treatment outcomes. Statistics were performed using the Student t test and &khgr;2 test. To establish the independent contribution of Asian ethnicity, a multivariable logistic regression analysis was performed. RESULTS: We reviewed 180 blastocyst transfer cycles among white (62%) and Asian (38%) women. The groups were similar in most baseline characteristics. Asian women, however, had a lower body mass index (22.6 compared with 24.2, P=.02), were more likely to be nulligravid (53% compared with 35%, P=.03), and were more likely to have had at least one prior IVF cycle (37% compared with 20%, P=.02) The groups were similar in treatment characteristics, number of oocytes retrieved, fertilization rate, and number of blastocysts transferred. However, Asian women had a thicker endometrial lining (10.9 compared with 10.2, P=.02). Despite these similarities, Asian women had a lower implantation rate (28% compared with 45%, P=.01), clinical pregnancy rate (43% compared with 59%, P=.03), and live birthrate (31% compared with 48%, P=.02). In multivariable analysis, the decreased live birthrate among Asian women persisted (adjusted odds ratio 0.48, 95% confidence interval 0.24–0.96, P=.04). CONCLUSION: When compared with white women, Asian women have lower clinical pregnancy and live birthrates after blastocyst transfer. LEVEL OF EVIDENCE: II

The effect of preterm premature rupture of membranes on neonatal mortality rates

OBJECTIVE: To estimate the effect of preterm premature rupture of membranes (PROM) on neonatal mortality. METHODS: A cross-sectional study using a state perinatal database (California Perinatal Quality Care Collaborative) was performed. Prenatal data, including ruptured membranes, corticosteroid administration, maternal age, maternal race, maternal hypertension, mode of delivery, and prenatal care, were recorded. Mortality rates were compared for neonates born between 24 and 34 weeks of gestation without preterm PROM to those with recent (less than 18 hours before delivery) and prolonged (more than 18 hours before delivery) preterm PROM. Neonatal sepsis rates were also examined. RESULTS: Neonates born between 24 0/7 and 34 0/7 weeks of gestation from 127 California neonatal intensive care units between 2005 and 2007 were included (N=17,501). When analyzed by 2-week gestational age groups, there were no differences in mortality rates between those born with and without membrane rupture before delivery. The presence of prolonged preterm PROM was associated with decreased mortality at 24 to 26 weeks of gestation (18% compared with 31% for recent preterm PROM; odds ratio [OR] 1.79; confidence interval [CI] 1.25–2.56) but increased mortality at 28 to 30 weeks of gestation (4% compared with 3% for recent preterm PROM; OR 0.44; CI 0.22, 0.88) when adjusted for possible confounding factors. Sepsis rates did not differ between those with recent or prolonged preterm PROM at any gestational age. CONCLUSION: The presence of membrane rupture before delivery was not associated with increased neonatal mortality in any gestational age group. The effects of a prolonged latency period were not consistent across gestational ages. LEVEL OF EVIDENCE: III

Running habits of competitive runners during pregnancy and breastfeeding.

Background: Running is a popular sport that may be performed safely during pregnancy. Few studies have characterized running behavior of competitive female runners during pregnancy and breastfeeding. Hypothesis: Women modify their running behavior during pregnancy and breastfeeding. Study Design: Observational, cross-sectional study. Level of evidence: Level 2. Methods: One hundred ten female long-distance runners who ran competitively prior to pregnancy completed an online survey characterizing training attitudes and behaviors during pregnancy and postpartum. Results: Seventy percent of runners ran some time during their pregnancy (or pregnancies), but only 31% ran during their third trimester. On average, women reduced training during pregnancy, including cutting their intensity to about half of their nonpregnant running effort. Only 3.9% reported sustaining a running injury while pregnant. Fewer than one third (29.9%) selected fetal health as a reason to continue running during pregnancy. Of the women who breastfed, 84.1% reported running during breastfeeding. Most felt that running had no effect on their ability to breastfeed. Women who ran during breastfeeding were less likely to report postpartum depression than those who did not run (6.7% vs 23.5%, P = 0.051), but we did not detect the same association of running during pregnancy (6.5% vs 15.2%, P = 0.16). Conclusion: Women runners reported a reduction in total training while pregnant, and few sustained running injuries during pregnancy. The effect of running on postpartum depression was not clear from our findings. Clinical Relevance: We characterized running behaviors during pregnancy and breastfeeding in competitive runners. Most continue to run during pregnancy but reduce total training effort. Top reasons for running during pregnancy were fitness, health, and maintaining routine; the most common reason for not running was not feeling well. Most competitive runners run during breastfeeding with little perceived impact.

The effects of respiratory failure on delivery in pregnant patients with H1N1 2009 influenza.

BACKGROUND: The majority of hospitalizations for H1N1 complications have been in people with high-risk comorbidities, including pregnancy. Here we describe the obstetric and critical care treatment of three patients with confirmed H1N1 influenza virus infection complicated by acute respiratory failure. CASES: We describe the clinical and therapeutic courses of three patients with confirmed H1N1 2009 influenza virus infection complicating singleton, twin, and triplet gestations, each of which were complicated by respiratory failure. CONCLUSION: These three cases illustrate that a high index of suspicion, prompt treatment, timing and mode of delivery considerations, and interdisciplinary treatment are integral to the care of pregnant patients with H1N1 influenza infections complicated by acute respiratory failure.

Maternal glucose response to betamethasone administration.

OBJECTIVE This study aims to describe the pattern of maternal glucose response to betamethasone administration using a continuous glucose monitoring system. STUDY DESIGN A prospective observational trial was conducted among women receiving clinically indicated betamethasone between 24 and 34 weeks gestation. At the time of initial betamethasone administration, a continuous glucose monitoring device was inserted which measured interstitial fluid glucose levels every 5 minutes. Glucose levels were monitored for 7 days, until delivery, or until hospital discharge, whichever came first. We recorded the percentage of time women spent above three glucose thresholds: 110, 144, and 180 mg/dL, respectively. RESULTS A total of 17 women were enrolled at the time of betamethasone administration and data were available for 15 patients. There were 11 nondiabetic and 4 diabetic women. Both diabetic and nondiabetic women had the highest recorded blood glucose readings between 24 and 48 hours after the first injection of betamethasone. In that period, nondiabetic women spent 73, 40, and 17% of the time with blood glucose levels above the 110, 144, and 180 mg/dL thresholds, respectively. CONCLUSION Nondiabetic women receiving betamethasone manifest significant hyperglycemia after betamethasone administration. If delivery is imminent, maternal glucose response to betamethasone may need to be monitored to prevent possible neonatal hypoglycemia.

Association of Cervical Effacement With the Rate of Cervical Change in Labor Among Nulliparous Women.

OBJECTIVE: To assess the association of cervical effacement with the rate of intrapartum cervical change among nulliparous women. METHODS: We conducted a secondary analysis of a prospective trial of intrapartum fetal pulse oximetry. For women who had vaginal deliveries, interval-censored regression was used to estimate the time to dilate at 1-cm intervals. For each given centimeter of progressive cervical dilation, women were divided into those who had achieved 100% cervical effacement and those who had not. The analysis was performed separately for women in spontaneous labor and those who were given oxytocin. RESULTS: A total of 3,902 women were included in this analysis, 1,466 (38%) who underwent labor induction, 1,948 (50%) who underwent labor augmentation (combined for the analysis), and 488 (13%) who labored spontaneously. For women in spontaneous labor, the time to dilate 1 cm was shorter for those who were 100% effaced starting at 4 cm of cervical dilation (P=.01 to <.001). For women who received oxytocin, the time to dilate 1 cm was shorter for those who were 100% effaced throughout labor (P<.001). CONCLUSION: The rate of cervical dilation among nulliparous women is associated with not only the degree of cervical dilation, but also with cervical effacement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00098709.

A Double-Blind, Randomized, Placebo-Controlled Trial of 17 Alpha-hydroxyprogesterone Caproate in the Management of Preterm Premature Rupture of Membranes

Objective The objective of this study was to evaluate whether weekly administration of 17 &agr;‐hydroxyprogesterone caproate (17‐OHPC) increases the number of women who achieve 34 weeks of gestation after preterm premature rupture of membranes (PPROM). Study Design We conducted a multicenter double‐blind, randomized controlled trial of 17‐OHPC versus placebo among women with PPROM. Women with singleton pregnancy, clinically confirmed PPROM, and without evidence of active infection or major fetal malformation between 240/7 and 320/7 weeks of pregnancy were offered enrollment. Women received weekly injections of 17‐OHPC versus placebo until 340/7 weeks of gestation or delivery. The remainder of care was per hospital protocol. The primary outcome was achievement of 34 weeks of gestation. Secondary outcomes included length of latency and maternal and fetal outcomes. Results In this study, 21 women were enrolled. Eleven women received placebo and 10 received 17‐OHPC. The study was closed prematurely secondary to poor enrollment. None of the women remained pregnant until 34 weeks of gestation. The median latency periods were 8 and 14.5 days for the placebo and 17‐OHPC groups, respectively (p = 0.14). There were no differences in maternal or neonatal outcomes. Conclusion We did not identify any benefit from administration of 17‐OHPC in pregnancies complicated by PPROM.

Outcomes in oligohydramnios: the role of etiology in predicting pulmonary morbidity/mortality

Abstract Objective Early-onset oligohydramnios is typically secondary to renal-urinary anomalies (RUA) or preterm premature rupture of membranes (PPROM). We compared neonatal pulmonary outcomes between these etiologies. Methods We conducted a retrospective cohort study of women with oligohydramnios identified before 24 completed weeks of gestation attributed to either PPROM or RUA. Patients were excluded if other fetal anomalies were noted. Respiratory morbidity was assessed by the need for oxygen at 36 corrected weeks or at hospital discharge. Results Of 116 eligible patients, 54 chose elective pregnancy termination. A total of 39.5% of PPROM (n=17/43) and 36.8% of RUA (n=7/19) pregnancies experienced pre-viable loss (P=1.00). Significantly fewer PPROM live births resulted in neonatal mortality (26.9% vs. 75.0%, P<0.01). There was no difference in respiratory morbidity (57.9% vs. 66.6%, P=1.00). The collective incidence of respiratory mortality and morbidity was not different between etiologies (P=0.06). Conclusion This analysis suggests that the prognoses for oligohydramnios due to pre-viable PPROM vs. renal anomalies are similarly grave, though RUA infants experienced a higher rate of neonatal respiratory mortality.