Eyal Krispin

Effect of Meconium-Stained Amniotic Fluid on Perinatal Complications in Low-Risk Pregnancies at Term.

OBJECTIVE This study aims to determine the impact of meconium-stained amniotic fluid (MSAF) in low-risk pregnancies at term on pregnancy outcome. STUDY DESIGN A retrospective cohort study of women with MSAF during labor who delivered in a tertiary hospital at 37 to 41(+6) weeks of gestation (2007-2013). Exclusion criteria included: multiple gestations, noncephalic presentation, fetal structural/chromosomal anomalies, hypertensive disorders, diabetes, oligohydramnios, or small for gestational age. Pregnancy outcome of women with MSAF (N = 4,893) was compared with a control group of women without MSAF (N = 39,651). Neonatal respiratory morbidity was defined as the presence of any of the following: respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, or need for ventilatory support. RESULTS Overall, 10.9% of low-risk pregnancies at term were diagnosed with MSAF. Compared with the controls, women with MSAF had higher rates of nulliparity, gestational age at delivery ≥ 41 weeks, induction of labor, nonreassuring fetal heart rate, and operative deliveries. In multivariate analysis MSAF was associated with operative delivery (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.63-2.09; p < 0.001), cesarean section (OR, 1.48; 95% CI, 1.31-1.69; p < 0.001), respiratory morbidity (OR, 4.74; 95% CI, 3.87-5.82; p < 0.001), and increased risk for short-term neonatal morbidity. CONCLUSIONS MSAF is associated with a higher rate of adverse perinatal outcome even in low-risk pregnancies at term.

The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial

Abstract Objective: Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity. Methods: Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4 cm dilation). The primary measured outcome was the length of second stage of labor. Results: Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery. Conclusion: Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.

Association between prior vaginal birth after cesarean and subsequent labor outcome

Abstract Objective: To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean. Methods: A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007–2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes. Results: Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p = .036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p < .001). In multivariate analysis, previous VBAC was associated with decreased risk of uterine rupture (OR = 0.46, 95% CI 0.21–0.97, p = .04). Conclusions: In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth.

Predictors for prolonged interval from premature rupture of membranes to spontaneous onset of labor at term

Abstract Objective: To identify predictors for prolonged interval from premature rupture of membranes (PROM) to spontaneous onset of labor in women presenting with PROM and low Bishop score at term. Methods: A retrospective study of women presenting with PROM and Bishop score < 7 at term (≥37weeks) in a tertiary hospital (2013–14). Spontaneous onset of labor was defined as presence of regular uterine contractions and Bishop score ≥ 7. Women with interval from PROM to spontaneous onset of labor of <24hours (short interval group) were compared to those with interval ≥ 24 hours (prolonged interval group). Women who underwent induction of labor at < 24 hours from PROM were excluded. Results: Among 625 women who met inclusion criteria, 155 (24.8%) had a prolonged interval to onset of labor. In multivariate analysis, prolonged PROM was associated with (OR, 95%CI) cervical dilatation (0.35, 0.24–0.52, p < 0.001), effacement (0.97, 0.96–0.99, p < 0.001) and uterine contraction (0.51, 0.32–0.80, p = 0.004). A multivariable prediction model including maternal age, parity, cervical dilatation and effacement, gestational age and neonatal birthweight was associated with an AUC of receiver–operator characteristic curve of 0.739 (0.631–0.847, p < 0.001) for predicting prolonged PROM. Conclusion: Uterine contractions and cervical examination parameters can be used for prediction of prolonged interval to spontaneous onset of labor in women with term PROM.

The association of different progesterone preparations with preterm birth prevention

Abstract Objective: We aimed to compare the efficacy of commonly available progesterone preparations for preterm birth prevention. Methods: A retrospective cohort study of all women treated with progesterone to prevent preterm birth and delivered in a single university-affiliated tertiary medical-center. Four progesterone preparations were compared: vaginal Endometrin 100 mg twice daily, vaginal Crinone 8% gel 90 mg daily, vaginal Utrogestan 200 mg daily, and intramuscular 17α-hydroxyprogesterone caproate (17-OHPC) 250 mg weekly. All women were considered at risk for preterm birth according to: prior preterm birth or cervical length below 25 mm measured during the second trimester. Significant maternal morbidity, pregnancy achieved by artificial reproductive technique and cerclage placement were excluded. Primary outcome was the rate of preterm birth prior to 37 weeks of gestation. Results: Overall, 422 women were allocated to four study groups according to progesterone preparation: Endometrin 175 (41.5%), Crinone 73 (17.3%), Utrogestan 154 (36.5%), and 17-OHPC 20 (4.7%). Rates of preterm birth prior to 37 gestational weeks were lowest on the Endometrin treatment group (12.6 versus 20.5, 17.5, and 35% in the rest, p = .05). Multivariate analysis revealed that the progesterone preparation was associated with preterm birth prior to 37 gestational weeks (LR = 8.3, p = .004). The need for maternal red blood cells transfusion was significantly higher in the Endometrin subgroup (4% versus 0 in all others, p = .018). This finding remained significant after adjustment to potential confounders (LR 16.44, p < .001). Neonatal outcomes did not differ between groups. Conclusions: Different progesterone preparations prescribed to women at risk, may possess different efficacy in preventing preterm delivery prior to 37 weeks of gestation.

Updating the amniotic fluid index nomograms according to perinatal outcome

Abstract Background: The two most commonly used nomograms for amniotic fluid index (AFI) were developed by Moore and Cayle and Magann et al. However, there are several inconsistencies between the two methods. Objective: The aim of the study was to determine whether these differences carry clinical significance. Methods: A retrospective cohort of women with singleton pregnancies evaluated for AFI during pregnancy at a tertiary medical center in 2007–2014 were divided into five groups: group A, definite oligohydramnios—AFI below the fifth percentile according to the nomograms of both Moore and Cayle and Magann et al.; group B, intermediate oligohydramnios—AFI below the fifth percentile according to only one nomogram (Moore and Cayle); group C, euhydramnios—normal AFI according to both nomograms; group D, intermediate polyhydramnios—AFI above the 95th percentile according to one nomogram (Magann et al.); group E, definite polyhydramnios—above the 95th percentile according to both nomograms. The association of group by maternal and perinatal outcomes was analyzed. Results: A total of 6987 women were included: group A, 996 (14%); group B, 1344 (19%); group C, 2561 (37%); group D, 1051 (15%); group E, 1034 (15%). Group B (intermediate oligohydramnios) was characterized by significantly lower rates of adverse perinatal outcomes than group A (definite oligohydramnios): small for gestational age neonate (12.3 versus 15.2%, p = .05), neonatal intensive care unit admission (11.1 versus 21.5%; p < .001), composite respiratory outcome (4.8 versus 9.8%; p < .001), and neonatal sepsis (6.4 versus 10.8%; p < .001). No such differences were found between groups B and C. Group D (intermediate polyhydramnios) differed from group E (definite polyhydramnios) by lower rates of 5 minutes Apgar score <7 (1.3 versus 3.2%; p = .003), neonatal intensive care unit admission (10.9 versus 14.4%; p = .02), and major congenital anomalies (1.7 versus 5.6%; p = .02). There was no difference in these parameters between groups D and C. Conclusion: This study suggests that intermediate oligohydramnios and intermediate polyhydramnios are not associated with adverse perinatal outcomes. Outcome in these pregnancies is similar to pregnancies with euhydramnios. Commonly used AFI nomograms should be updated.

The association between pre-pregnancy impaired fasting glucose and adverse perinatal outcome

AIMS To evaluate the association between impaired fasting glucose (IFG) prior to pregnancy with maternal and neonatal outcome. METHODS A retrospective cohort study of singleton deliveries in a single, tertiary, university-affiliated medical center between August 2007 and December 2012. We included women who had a fasting glucose test done up to 26 weeks prior to pregnancy. We excluded women with diabetes mellitus and women carrying a fetus with structural or chromosomal anomalies. Maternal and neonatal outcome were compared between two groups: women with pre-pregnancy IFG (defined as fasting glucose ≥100 mg/dl and <126 mg/dl) versus those with normoglycemia (fasting glucose <100 mg/dl). RESULTS Overall, 1945 women met inclusion criteria. Of whom, 1790 had pre-pregnancy glucose <100 mg/dl and 155 had IFG. There were no differences between groups in basic characteristics. As for maternal outcome, IFG was associated with higher rates of mild preeclampsia (5.16% vs. 0.67%), abnormal glucose challenge test (21.94% vs. 13.46%) and gestational diabetes (13.55 vs. 2.85%), p < 0.05 for all. There were no significant differences in neonatal outcome. After adjusting for potential confounders, on multivariable logistic regression, pre-pregnancy IFG remained significantly and independently associated with mild preeclampsia (aOR 6.92, 95% CI 2.68-18.05, p < 0.001). CONCLUSIONS Pre-pregnancy IFG is associated with increased risk for abnormal glucose challenge test and gestational diabetes, and it is an independent risk factor for adverse pregnancy outcome including mild preeclampsia.