Emmanuelle Paré

Adverse neonatal outcomes: examining the risks between preterm, late preterm, and term infants

OBJECTIVE There is a relative paucity of data regarding neonatal outcomes in the late preterm cohort (34 to 36 6/7 weeks). This study sought to assess differences in adverse outcomes between infants delivering 32 to 33 6/7, 34 to 36 6/7 weeks, and 37 weeks or later. STUDY DESIGN Data were collected as part of a retrospective cohort study of preterm labor patients (2002-2005). Patients delivering 32 weeks or later were included (n = 264). The incidence of adverse outcomes was assessed. Significant associations between outcomes and gestational age at delivery were determined using chi(2) analyses and Poisson regression modeled cumulative incidence and controlled for confounders. RESULTS Late preterm infants have increased risk of adverse outcomes, compared with term infants. Controlling for confounders, there was a 23% decrease in adverse outcomes with each week of advancing gestational age between 32 and 39 completed weeks (relative risk 0.77, P < .001, 95% confidence interval, 0.71-0.84). CONCLUSION Further investigation regarding obstetrical management and long-term outcomes for this cohort is warranted.

Evaluation of fetuses in a study of intravenous immunoglobulin as preventive therapy for congenital heart block: Results of a multicenter, prospective, open-label clinical trial†

OBJECTIVE The recurrence rate of anti-SSA/Ro-associated congenital heart block (CHB) is 17%. Sustained reversal of third-degree block has never been achieved. Based on potential reduction of maternal autoantibody titers as well as fetal inflammatory responses, intravenous immunoglobulin (IVIG) was evaluated as preventive therapy for CHB. METHODS A multicenter, prospective, open-label study based on Simons 2-stage optimal design was initiated. Enrollment criteria included the presence of anti-SSA/Ro antibodies in the mother, birth of a previous child with CHB/neonatal lupus rash, current treatment with < or = 20 mg/day of prednisone, and <12 weeks pregnant. IVIG (400 mg/kg) was given every 3 weeks from week 12 to week 24 of gestation. The primary outcome was the development of second-degree or third-degree CHB. RESULTS Twenty mothers completed the IVIG protocol before the predetermined stopping rule of 3 cases of advanced CHB in the study was reached. CHB was detected at 19, 20, and 25 weeks; none of the cases occurred following the finding of an abnormal PR interval on fetal Doppler monitoring. One of these mothers had 2 previous children with CHB. One child without CHB developed a transient rash consistent with neonatal lupus. Sixteen children had no manifestations of neonatal lupus at birth. No significant changes in maternal titers of antibody to SSA/Ro, SSB/La, or Ro 52 kd were detected over the course of therapy or at delivery. There were no safety issues. CONCLUSION This study establishes the safety of IVIG and the feasibility of recruiting pregnant women who have previously had a child with CHB. However, IVIG at low doses consistent with replacement does not prevent the recurrence of CHB or reduce maternal antibody titers.

Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery.

OBJECTIVE: To investigate whether short or long interpregnancy interval is associated with uterine rupture and other major maternal morbidities in women who attempt vaginal birth after cesarean delivery (VBAC). METHODS: We performed a secondary analysis of a U.S. multi-center, record-based, retrospective cohort study of 13,331 pregnant women, identified by a validated International Classification of Disease, 9th Revision, code search, with at least one prior cesarean delivery, who attempted VBAC between 1995 and 2000. We performed univariable and multivariable logistic regression analyses to evaluate the association between long or short interpregnancy interval and three maternal outcomes: 1) uterine rupture, 2) composite major morbidity (including rupture, bladder or bowel injury, and uterine artery laceration), and 3) blood transfusion. We evaluated short interpregnancy interval with cutoffs at less than 6, less than 12, and less than 18 months between prior delivery and conception and defined long interval as 60 months or more. RESULTS: A total of 128 cases (0.9%) of uterine rupture occurred, and 286 (2.2%), 1,109 (8.3%), 1,741 (13.1%), and 2,631 (19.7%) women had interpregnancy intervals of less than 6, 6–11, 12–17, and 60 months or more, respectively. An interval less than 6 months was associated with increased risk of uterine rupture (adjusted odds ratio [aOR] 2.66, 95% confidence interval [CI] 1.21–5.82), major morbidity (aOR 1.95, 95% CI 1.04–3.65), and blood transfusion (aOR 3.14, 95% CI 1.42–6.95). Long interpregnancy interval was not associated with an increase in major morbidity. CONCLUSION: Short interpregnancy interval increases risk for uterine rupture and other major morbidities twofold to threefold in VBAC candidates. LEVEL OF EVIDENCE: II

Cerebroplacental Doppler Ratio and Adverse Perinatal Outcomes in Intrauterine Growth Restriction Evaluating the Impact of Using Gestational Age–Specific Reference Values

The purpose of this study was to compare the impact of using gestational age–specific reference levels of the cerebroplacental Doppler ratio (CPR) with categorical threshold in the prediction of adverse perinatal outcomes in growth‐restricted pregnancies.

Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes

Objective  To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section.

Vaginal birth after caesarean section versus elective repeat caesarean section

Objective  To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section.

Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks of Gestation

OBJECTIVE: To compare rates of vaginal birth after cesarean (VBAC) failure and major complications in women attempting VBAC before and after the estimated date of delivery (EDD) METHODS: This was a 5-year retrospective cohort study in 17 university and community hospitals of women with at least 1 prior cesarean delivery. Women who attempted VBAC before the EDD were compared with those at or beyond 40 weeks of gestation. Logistic regression analyses were performed to assess the relationship between delivery beyond the EDD and VBAC failure or complication rate. RESULTS: A total of 11,587 women in the cohort attempted VBAC. Women past 40 weeks of gestation were more likely to have a failed VBAC. After controlling for confounders, the increased risk of a failed VBAC beyond 40 weeks remained significant (31.3% compared with 22.2%, odds ratio 1.36, 95% confidence interval 1.24–1.50). The risk of uterine rupture (1.1% compared with 1.0%) or overall morbidity (2.7% compared with 2.1%) was not significantly increased in the women attempting VBAC beyond the EDD. When the cohort was defined as 41 weeks or more of gestation, the risk of a failed VBAC was again significantly increased (35.4% compared with 24.3%, odds ratio 1.35, 95% confidence interval 1.20–1.53), but the risk of uterine rupture or overall morbidity was not increased. CONCLUSION: Women beyond 40 weeks of gestation can safely attempt VBAC, although the risk of VBAC failure is increased. LEVEL OF EVIDENCE: II-2

An Open Label Pilot Study of Transcranial Magnetic Stimulation for Pregnant Women with Major Depressive Disorder

OBJECTIVE Despite the data that major depressive disorder (MDD) is common during pregnancy and that pregnant women prefer nonmedication treatment options, there is a paucity of research examining alternative treatments for this special population. We present the results of an open label pilot study examining treatment with transcranial magnetic stimulation (TMS) in pregnant women with MDD. METHODS Ten women with MDD in the second or third trimester of pregnancy were treated with 20 sessions of 1-Hz TMS at 100% of motor threshold (MT) to the right dorsolateral prefrontal cortex. The total study dose was 6000 pulses. Antenatal monitoring was performed during treatment sessions 1, 10, and 20. RESULTS Seven of ten (70%) subjects responded (decrease ≥50% in Hamilton Depression Rating Scale [HDRS-17] scores). No adverse pregnancy or fetal outcomes were observed. All infants were admitted to the well baby nursery and were discharged with the mother. Mild headache was the only common adverse event and was reported by 4 of 10 (40%) subjects. CONCLUSIONS TMS appears to be a promising treatment option for pregnant women who do not wish to take antidepressant medications.

The effect of prematurity on vaginal birth after cesarean delivery: success and maternal morbidity.

OBJECTIVE: We sought to compare vaginal birth after cesarean (VBAC) success and uterine rupture rates between preterm and term gestations in women with a history of one prior cesarean delivery. Our hypothesis was that preterm women undergoing VBAC were more likely to be successful and have a lower rate of complications than term women undergoing VBAC. METHODS: We reviewed medical records of women with a history of a cesarean delivery who either attempted a VBAC or underwent a repeat cesarean delivery from 1995 through 2000 in 17 community and university hospitals. We collected information on demographics, medical and obstetric history, complications, and outcome of the index pregnancy. The primary analysis was limited to women with singleton gestations and one prior cesarean delivery. Statistical analysis consisted of bivariate and multivariable techniques. RESULTS: Among the 20,156 patients with one prior cesarean delivery, 12,463 (61%) attempted a VBAC. Mean gestational ages for the term and preterm women were 39.2 weeks and 33.9 weeks of gestation, respectively. The VBAC success rates for the term and preterm groups were 74% and 82%, respectively (P < .001). Multivariable analysis showed that the VBAC success was higher (adjusted odds ratio 1.54, 95% confidence interval 1.27–1.86) in preterm gestations. A decreased risk of rupture among preterm gestations was suggested in these results (adjusted odds ratio 0.28, 95% confidence interval 0.07–1.17; P = .08). CONCLUSION: Preterm patients undergoing a VBAC have higher success rates when compared with term patients undergoing a VBAC. Preterm patients undergoing VBAC may have lower uterine rupture rates. LEVEL OF EVIDENCE: II-2

Is Sonographic Assessment of Fetal Weight Influenced by Formula Selection

Objective. Several published formulas exist for the determination of estimated fetal weight (EFW), with limited data on their comparative accuracies. The aims of our study were to assess and compare the performance of different EFW formulas in predicting actual birth weight (BW) in an urban population. Methods. Patients with an EFW determined within 7 days of delivery were considered eligible for the study. Fourteen published formulas, derived from populations comparable to ours, were used to recalculate EFWs from the same initial measurements. The accuracy of the EFWs obtained from the different formulas were compared by percentage error methods using bias and precision and Bland‐Altman limits of agreement methods. Sensitivity and specificity for prediction of being small for gestational age (SGA) were calculated. Results. Eighty‐one fetuses were included in the study. Formula C of Hadlock et al [Hadlock C; log10 BW = 1.335 − 0.0034(abdominal circumference [AC])(femur length [FL]) + 0.0316(biparietal diameter) + 0.0457(AC) + 0.1623(FL); Am J Obstet Gynecol 1985; 151:333–337] had the best performance according to the bias and precision method. Bland‐Altman limits of agreement confirmed these results. Among the formulas, the sensitivity for detection of SGA ranged from 72% to 100%, and specificity was 41% to 88%. Hadlock C had the optimal sensitivity/specificity trade‐off for detection of SGA. Conclusions. Fourteen formulas showed considerable variation of bias and precision in our population as well as a wide range of sensitivities and specificities for SGA. The choice of the appropriate formula for EFW in a given population should be based on objective and explicit criteria. Consideration of bias and precision for the formula in the population being assessed is critical and may affect clinical care.