Eran Ashwal

Episiotomy – risk factors and outcomes*

Abstract Objective: To identify risk factors for mediolateral episiotomy, and evaluate the risk of obstetrical anal sphincter injury (OASI) among women with an episiotomy. Methods: A retrospective cohort study of all singletons vaginal deliveries at term between 2007 and 2014. Spontaneous and operative vaginal deliveries were compared separately, as well as nulliparous and multiparous women. Results: Overall, 41,347 women were included in the spontaneous vaginal delivery group: 12,585 (30.4%) nulliparous and 28,762 (69.6%) multiparous women. Risk factors for episiotomy (nulliparous) were maternal age (aOR 0.98), gestational age (GA, aOR 1.07), regional analgesia (RA, aOR 1.18), labor induction (aOR 1.17), meconium (aOR 1.37) and birth weight (BW, aOR 1.04). Episiotomy was associated with PPH (aOR 1.49). Among multiparous, risk factors were maternal age (aOR 1.04), previous vaginal delivery (aOR 0.38), GA (aOR 1.06), RA (aOR 1.22), meconium (aOR 1.22) and BW (aOR 1.05). Episiotomy was associated with 3rd degree perineal tear (aOR 2.26, 95% CI 1.03-4.97). Only birth weight (nulliparous) and previous vaginal deliveries (multiparous) were contributors for episiotomy in the OVD group. Conclusion: Several risk factors for mediolateral episiotomy exist. Episiotomy does not protect nulliparous women, and may be associated with an increased risk for multiparous, for OASI. Therefore, the practice of routine episiotomy should be abandoned, and the practice of selective episiotomy reconsidered.

Perinatal outcomes of vacuum assisted versus cesarean deliveries for prolonged second stage of delivery at term

Abstract Introduction: To compare perinatal outcomes of interventions for prolonged second stage of labor. Materials and methods: Retrospective cohort study, in a single, university-affiliate, medical center (2007–2014). Eligibility: singleton gestations at term, diagnosed with prolonged second stage of labor and head station of Su2009+u20091 and lower. We compared perinatal outcomes of cesarean deliveries (CD) with vacuum assisted deliveries (VAD). Results: Of 62 102 deliveries, 3449 (5.6%) were eligible: 356 (10.3%) underwent CD and 3093 (89.7%) underwent VAD. The rate of five-minute Apgar scores <7 was higher in the CD group as well as rates of NICU admission, neonatal asphyxia and composite neonatal adverse outcome. After adjusting for different confounders, CD was associated with adverse neonatal composite outcome (aOR 1.57, 95% CI 1.21–2.05, pu2009=u20090.001) and VAD with cephalhematoma (aOR 4.06, 95% CI 2.64–6.25, pu2009<u20090.001). No other differences were found between the groups with regards to other traumatic outcomes. Conclusion: Our data suggests that in deliveries complicated by prolonged second stage, CD yield poorer neonatal outcome than VAD, with no apparent major difference in traumatic composite outcome.

Gestational weight gain among nutritionally treated GDM patients

Abstract Objective: We aimed to evaluate pregnancy outcome in diet-treated gestational diabetes mellitus (GDM) patients according to the 2009 Institute of Medicine (IOM) guidelines concerning gestational weight gain (GWG). Design and patients: This was a retrospective cohort study, limited to women with singleton pregnancies and diet-treated GDM. Women with preexisting diabetes or women with pharmaceutical treatment were excluded. We compared patients with adequate GWG with patients with excess GWG according to the 2009 IOM guidelines. Results: Overall, 142 women were evaluated, of which 99 (69.7%) had adequate GWG and 43 (30.3%) had excess GWG. All demonstrated good glycemic control. Patients in the excess GWG group had higher mean pre-pregnancy weight and body mass index (BMI). No other obstetrical or perinatal statistically significant differences were demonstrated, although there was a trend for higher birth weight percentile and higher rate of respiratory distress among the excess GWG group. Conclusions: Higher pre-pregnancy BMI is a risk factor for failing to comply with the 2009 IOM GWG guidelines. However, it seems that in pregnancies complicated by diet-treated GDM, GWG is not a reliable marker for adverse pregnancy outcome if glycemic control is adequate.

Is there an association between subclinical hypothyroidism and preterm uterine contractions? A prospective observational study*

Abstract Objective: To investigate the association between subclinical hypothyroidism and preterm contractions. Methods: Prospective observational study among women at 23u2009+u20090/7 and 34u2009+u20096/7 weeks of gestation, with no known thyroid function abnormality, and preterm uterine contractions (PTC). All patients underwent laboratory evaluation of Thyroid Stimulating Hormone (TSH) and Free Thyroxin (FT4). Patients with and without PTC were compared. Results: No association was found between PTC and subclinical hypothyroidism. Rate of spontaneous preterm delivery (PTD) was comparable between women with abnormal and normal thyroid function tests. Excluding indicated PTD, patients in the study group had a higher rate of spontaneous PTD (24.7% versus 9.6%, pu2009=u20090.03). Patients with past PTD and preterm contractions had higher rates of hypothyroxinemia compared with patients without past PTD (54.6% versus 19.0% and 31.2%, pu2009=u20090.001), and patients with past PTD (regardless of the presence or absence of PTC) had higher rate of subclinical hypothyroidism compared with patients with PTC and without PTD (59.1% and 66.7% versus 31.6%, pu2009=u20090.017). Conclusions: No association was found between PTC and subclinical hypothyroidism in the entire cohort, except for patients with preterm contractions and a history of past PTD. This specific group of patients might benefit from thyroid function evaluation.

Transient Isolated Polyhydramnios and Perinatal Outcomes

PURPOSEnu2002To evaluate labor and perinatal outcomes of transient isolated polyhydramnios.nnnMATERIALS AND METHODSnu2002A retrospective cohort study (2008u200a-u200a2013) at a university-affiliated, tertiary medical center. Eligibility was limited to patients with singleton gestations, no maternal diabetes or known structural/chromosomal anomalies, and no rupture of the membranes prior to delivery, at >u200a34 weeks of gestation. All women underwent routine sonogram for estimation of fetal weight (sEFW) between 28u200a-u200a34 weeks of gestation, and a second routine sonogram at admission. We compared women diagnosed with polyhydramnios at the time of the sEFW which later resolved, with women who had normal AFI during the sEFW.nnnRESULTSnu2002Overall, 44u200a263 women delivered during this time period, of which 292 (0.7u200a%) with transient polyhydramnios (study group) and 29u200a682 with a normal amniotic fluid level (control group) were eligible for analysis. Women with transient polyhydramnios had a higher risk for assisted vaginal delivery (AVD), mainly due to abnormal/intermediate fetal heart rate tracings (aOR 2.3, 95u200a% CI 1.2u200a-u200a5.5), and a higher risk for cesarean delivery (CD), mostly because of labor dystocia (aOR 2.5, 95u200a% CI 1.2u200a-u200a5.1 for 1st stage arrest and aOR 3.4, 95u200a% CI 1.6u200a-u200a7.2) for 2nd stage arrest), suspected macrosomia (aOR 3.2, 95u200a% CI 1.6u200a-u200a6.6) and malpresentation (aOR 6.6, 95u200a% CI 2.0u200a-u200a21.1).nnnCONCLUSIONnu2002Transient isolated polyhydramnios detected during the sonogram at 28u200a-u200a32 weeks of gestation is an independent risk factor for the need for obstetrical intervention during labor.

Sonographic appearance of the uterus in the early puerperium in vaginal versus cesarean deliveries: a prospective study

Abstract Purpose: The purpose of this study is to compare uterine sonographic characteristics in early puerperium, following vaginal versus cesarean deliveries; and in women with abnormal third stage of labor, compared to uncomplicated vaginal delivery. Materials and methods: This is a prospective study of women after delivery of singleton, appropriate-for-gestational-age weight, term neonates; 66 women delivered vaginally and 33 delivered by cesarean section. Sonographic uterine dimensions (height, length, and width), intracavitary thickness and its echogenicity (at level of fundus, midcavity and cervix) were recorded at less than and after 24u2009h from delivery, and compared between women delivered vaginally and by cesarean section. Among women delivered vaginally, data were further analyzed according to whether women underwent manual revision of the uterine cavity. Results: Sonographic evaluations were taken at 15.4 (4.3–24.0) and 39.5 (28.8–108.8) hours after delivery (median, range). We found no clinically significant differences in uterine characteristics according to mode of delivery or according to manual revision of the uterine cavity. The sonographic appearance of the uterus was similar when performed at less than or after 24u2009h from delivery. Conclusions: Postpartum sonographic evaluation of the uterus appears similar after vaginal and cesarean deliveries.

The impact of maternal epilepsy on perinatal outcome in singleton gestations

Abstract Objective: We sought to evaluate perinatal outcomes in women with epilepsy. Methods: We performed a retrospective cohort study between 2007 and 2014, at a tertiary, university-affiliated medical center. All women with singleton gestation who delivered during the study period were included, except for pregnancies in which fetuses with chromosomal or structural anomalies were diagnosed. Perinatal outcome was compared between two groups: women diagnosed with epilepsy and women without epilepsy. Results: Out of 62,102 deliveries during the study period, 61,455 met the inclusion criteria, of whom 206 (0.3%) had epilepsy. The only difference found in maternal demographics was higher rate of nulliparity in the epilepsy group (pu2009=u2009.02). As for maternal adverse outcome, higher rates of placental abruption and longer postpartum admission were found in women with epilepsy (pu2009=u2009.02 and pu2009<u2009.001, respectively). Comparing neonatal outcomes between the two groups, higher rates of neonatal intensive care unit admission (16.5 versus 9.2%), seizures (1.9 versus 0.4%), transient tachypnea of the newborn (2.4 versus 1.0%) and respiratory distress syndrome (1.9 versus 0.4%) were significantly higher to newborns of women with epilepsy (pu2009<u2009.05 for all). On multivariable logistic regression, epilepsy was found to be independently and significantly associated with placental abruption (OR 4.04, 95%CI 1.27–12.83, pu2009=u2009.02), neonatal intensive care unit (NICU) admissions (OR 1.84, 95%CI 1.25–2.70, pu2009=u2009.002), seizures (OR 4.33, 95%CI 1.60–11.77, pu2009=u2009.004), transient tachypnea of the newborn (OR 2.47, 95%CI 1.005–6.05, pu2009=u2009.049) and respiratory distress syndrome (OR 7.16, 95%CI 2.47–20.76, pu2009<u2009.001). Conclusions: Epilepsy in pregnant women is associated with adverse perinatal outcomes, including neonatal seizures, placental abruption and respiratory problems.

Outcomes of vacuum-assisted vaginal deliveries of mothers with gestational diabetes mellitus

Abstract Objective: To evaluate the outcomes of vacuum-assisted vaginal deliveries (VAD) among neonates of mothers with gestational diabetes mellitus (GDM). Study design: Retrospective cohort study of women with singleton gestation ≥37u2009+u20090 weeks of gestation who underwent VAD at a single, tertiary, medical center (2007–2014). Women with GDM and their neonates were compared to women without diabetes and their neonates. Composite neonatal outcome was defined as ≥1 of the following: shoulder dystocia, 5-min Apgar score <7, asphyxia, seizure, subgaleal, subarachnoid or subdural hemorrhage, fracture of the clavicle, humerus or skull, or Erb’s palsy. Results: Overall, 251 (5.2%) women with GDM were compared with 4534 (94.8%) women without GDM. Women with GDM were older, delivered earlier, with higher rates of mild preeclampsia and induction of labor. Their neonates had higher mean birth weight percentile, and higher rates of hypoglycemia, phototherapy, fracture of the humerus (3.2 versus 1.1%, aOR 2.95, 95%CI 1.38–6.30), and subarachnoid hemorrhage (1.2 versus 0.3%, aOR 4.56, 95%CI 1.28–16.26). No difference was found with regards to the composite neonatal outcome (9.2 versus 11.1%, pu2009=u2009.34). Conclusions: GDM is associated with a higher risk for certain birth injuries in VAD at ≥37u2009+u20090 weeks of gestation, yet the overall risk of adverse neonatal outcomes is comparable to women without GDM.

Perioperative noninvasive cardiac output monitoring in parturients undergoing cesarean delivery with spinal anesthesia and prophylactic phenylephrine drip: a prospective observational cohort study

Abstract Introduction: Spinal anesthesia for cesarean delivery is associated with high incidence of hypotension and is most often prevented by a prophylactic phenylephrine infusion (PPI). In this study, we aimed to identify maternal hemodynamic changes both intraoperatively and postoperatively with the use of the NICaS noninvasive cardiac output monitor in healthy singleton parturients undergoing cesarean delivery (CD) with spinal anesthesia and PPI. Methods: Healthy term women undergoing spinal anesthesia for singleton CD were enrolled. The following data were collected – cardiac output (CO), mean arterial pressure (MAP), stroke volume (SV), and total peripheral resistance (TPR). Measurements were measured at five time points: (1) before arrival in OR, (2) after spinal anesthesia with pi, (3) after delivery of baby and beginning of oxytocin infusion, (4) in post anesthesia care room (5) 24u2009hours postoperatively, and (6) 48u2009hours postoperatively. All parturients received standardized spinal solution consisting of 12u2009mg hyperbaric, 20 µg fentanyl, and 100-µg preservative-free morphine. PPI was titrated to preserve blood pressure to 20% of baseline and stopped at the end of surgery. Oxytocin was administered as a continuous infusion (20-units/1000u2009cc Ringer lactate) at a rate of 100u2009cc/h. Results: One hundred thirty-seven women completed the study. Average age was 34.9u2009±u20095.7 and average BMI was 30.1u2009±u20095.1. One hour after delivery in the post anesthesia care unit (PACU), there were significant decreases in stroke volume, heart rate, blood pressure, and CO with a concomitant increase in TPR. Within 48u2009hours the TPR decreased, and CO and stroke volume increased. Conclusions: Significant hemodynamic changes were documented at all time points both intraoperatively and postoperatively with the most significant changes occurring 1u2009hour postoperatively. Further studies need to be performed to discover hemodynamic changes of spinal anesthesia and PPI in different parturient populations.

Uterine electrical activity, oxytocin and labor: translating electrical into mechanical

PurposeUterine activity plays a crucial role in labor, especially when utero-tonic materials are administered. We aimed to determine the electrical responsiveness of the uterine musculature to labor augmentation with oxytocin using electrical uterine myography (EUM) technology, and to assess whether the kinetics of the EUM device may serve as a predictor for successful vaginal delivery.MethodsEUM prospectively measured electrical uterine activity in women with singleton gestations at term (≥xa037xa0+xa00xa0weeks) undergoing labor augmentation by oxytocin administration. The results were reported as the EUM index, which represented the mean electrical activity in 10-min intervals and measured in units of microwatt per second (mW/s). Measurements were performed at least 30xa0min before oxytocin initiation and until at least four contractions per 10xa0min were recorded by standard tocodynamometry. The delta EUM index was defined as the difference between the mean EUM index before and after the initiation of oxytocin.ResultsThe mean EUM index increased significantly during oxytocin augmentation in all the parturients (Pxa0<xa00.001). Mean and minimum (but not maximum) uterine electrical activity during oxytocin infusion correlated with the baseline uterine activity. The delta EUM index was not significantly affected by demographic or obstetric parameters. There was no correlation between the delta EUM index and time to delivery or the mean EUM index during oxytocin administration and time to delivery.ConclusionsUterine electrical activity as evaluated by EUM is significantly intensified following oxytocin administration, regardless of obstetrical characteristics, and is correlated with the baseline uterine electrical activity prior to oxytocin infusion.