Hadar Rosen

Maternal Obesity Class as a Predictor of Induction Failure: A Practical Risk Assessment Tool

OBJECTIVE To assess the impact of body mass index (BMI) on the rate of cesarean section (rCS) in induction of labor (IOL). STUDY DESIGN A total of 7,543 singleton term pregnancies undergoing IOL (cervical dilatation at admission, CDA ≤ 3 cm) were divided according to BMI: underweight (n = 325); normal weight (NW) (n = 4,633); overweight (OW) (n = 1,610); and obese (n = 975). Age, parity, macrosomia, gestational age (GA), gestational weight gain (GWG), CDA, and IOL indications were considered. RESULTS A higher rate of macrosomia (15.0 vs. 11.1%; p < 0.0001), earlier induction (GA 39.7 ± 1.3 vs. 40.1 ± 1.3 weeks; p < 0.0001) for maternal indications (39.1 vs. 21.1%; p < 0.001), and lower CDA (≤1cm; 66.4 vs. 61.4%; p < 0.005) were observed in obese versus NW. The rate of weight gain above the recommended range was higher in obese (obese 70.6% vs. NW 43.9%; p < 0.001), despite a significantly lower mean GWG compared with NW (14 ± 7.5 vs. 16.5 ± 5.6 kg; p < 0.001). Compared with NW, OW and obese demonstrated a significantly higher rCS (OW 31.1% and obese 36.9% vs. NW 24.7%; p < 0.001). BMI represented an independent factor affecting the rCS (vs. NW; OW odds ratio [OR] 1.4; confidence interval [CI] 1.2-1.7; p < 0.001; obese OR 2.3; CI 1.9-2.7 p < 0.001). CONCLUSION In the case of IOL, obesity represents an independent factor associated with a significant increase of CS to be considered during induction counselling.

The Likelihood of Change in Fetal Presentation During the Third Trimester in Twin Pregnancies.

OBJECTIVE: To estimate the likelihood and identify predictors of spontaneous fetal version during the third trimester in twins using data from a multicenter randomized controlled trial on mode of delivery in twin pregnancies. METHODS: Women with twin pregnancies after 32 weeks of gestation in which twin A was vertex were randomized to planned cesarean or planned vaginal delivery. In the current study we analyzed the likelihood of a spontaneous version of any of the twins between ultrasound assessment at the time of randomization and delivery. RESULTS: A total of 2,603 women were analyzed. Twin A tended to persist in the vertex presentation after 32 weeks of gestation with a spontaneous version rate to nonvertex presentation of 3.0% (95% confidence interval [CI] 2.3–3.7%). Twin B was less stable and underwent spontaneous version in 24.8% (95% CI 23.1–26.5%) of cases; the rate remained higher than 20% even after 34 weeks of gestation. On multivariable analysis, twin A was more likely to undergo version when twin B was smaller (adjusted odds ratio [OR] 2.0, 95% CI 1.04–3.3), when twin B was breech (adjusted OR 3.7, 95% CI 2.2–6.4) or transverse (adjusted OR 2.9, 95% CI 1.6–5.5), and when the interval to delivery exceeded 4 weeks (adjusted OR 2.5, 95% CI 1.3–5.0). Twin B was more likely to undergo version when it was in the breech presentation (adjusted OR 1.7, 95% CI 1.4–2.1) or transverse lie (adjusted OR 3.1, 95% CI 2.5–3.9) compared with vertex presentation, when it was smaller (adjusted OR 1.7, 95% CI 1.1–2.0), when the interval to delivery exceeded 4 weeks (adjusted OR 1.7, 95% CI 1.3–2.4), and in multiparous women (adjusted OR 1.3, 95% CI 1.04–1.5). CONCLUSION: The likelihood of spontaneous version of twin A after 32 weeks of gestation is low when twin A is in the vertex presentation but is much higher for twin B, even late during the third trimester. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00187369. LEVEL OF EVIDENCE: II

The role of serial measurements of cervical length in asymptomatic women with triplet pregnancy

Abstract Objective: To assess the predictive accuracy of serial measurements of cervical length (CL) for preterm birth in asymptomatic women with triplet pregnancy. Methods: A retrospective study of women with triplets who underwent serial sonographic measurements of CL until 28–32 weeks of gestation. The predictive accuracy of CL for preterm birth was determined at 4 periods along gestation: 18–20 weeks (period 1), 21–24 weeks (period 2), 25–27 weeks (period 3) and 28–32 weeks (period 4). Results: A total of 431 measurements of CL from were analyzed. CL decreased in a linear manner across gestation: 40.8 ± 7.1 mm, 36.5 ± 8.4 mm, 29.9 ± 11.4 mm and 25.0 ± 11.8 mm in periods 1, 2, 3 and 4, respectively. The difference in CL between women who did and did not deliver prematurely was small before 25 weeks (periods 1&2) but became more pronounced later in pregnancy (periods 3&4), mainly due to a rapid cervical shortening between periods 2 and 3 (shortening rate −29.0 ± 20.0% vs. −12.6 ± 20.5%, respectively, p = .01). The best predictors of preterm birth were either a single measurement of CL during period 3 or the degree of cervical shortening between periods 2 and 3. Conclusions: Care providers should be aware of the limited predictive value of cervical length before 25 + 0 weeks in triplet pregnancies.

Operative Vaginal Delivery

Operative vaginal delivery is defined as a procedure performed in the final part of the second stage of labor in which the operator uses either forceps or a vacuum device to promote the extraction of the fetus from the birth canal. The goal of operative vaginal delivery is to facilitate vaginal birth, hence speeding up delivery with a minimum of maternal or neonatal morbidity (Keriakos et al. J Obstet Gynaecol 33(8):781–786, 2013).