Hector Mendez-Figueroa

Evidence-based surgery for cesarean delivery: an updated systematic review

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.

Neonatal characteristics and outcomes of pregnancies complicated by influenza infection during the 2009 pandemic.

The purpose of this study was to describe the neonatal characteristics and outcomes of infants who were born during the 2009 H1N1 influenza pandemic. A prospective cohort of pregnant women with influenza-like illness (ILI) was enrolled between the months of June 2009 and March 2010. Neonatal characteristics, complications, and outcomes were recorded. Forty-five women were included in the study. Birth outcomes were available in 41 cases; 16 women had 2009 H1N1 infection, and the remaining 25 women who tested negative were included in the ILI group. Live births were similar in both groups. Average gestational age at delivery was >39 weeks; Apgar scores and cord gas pH values were similar. Birthweights in the 2009 H1N1 group were on average 285 g lower (3186 vs 3471 g; P = .04). Three infants were admitted to the neonatal intensive care unit. In this cohort, 2009 H1N1 infection during pregnancy was associated with a lower birthweight when compared with ILI in pregnancy.

Management of ornithine transcarbamylase deficiency in pregnancy

Ornithine transcarbamylase (OTC) deficiency is the most common enzymatic deficiency in the urea cycle. In catabolic states, such as the intrapartum and immediate postpartum periods, hyperammonemic comas with permanent neurological damage and death can develop. We report six cases of OTC deficiency during pregnancy managed at our institution and review the literature on OTC deficiency during pregnancy. Using the patient database from our Metabolic Clinic, pregnant OTC deficiency carriers were identified. The antenatal, intrapartum, and postpartum periods were analyzed. Corresponding literature was reviewed and an extensive multidisciplinary management plan developed. All six pregnant women had favorable outcomes. No hyperammonemic episodes occurred, and intensive care unit admissions and hemodialysis were not required. Although risk to women with OTC deficiency during the intra- and postpartum period exists, multidisciplinary management and a coherent plan usually result in successful labor, delivery, and postpartum. A comprehensive plan for patients who develop hyperammonemia is recommended.

Pregnancy-induced changes in immune protection of the genital tract: defining normal

OBJECTIVE Both the state of pregnancy as well as disruption of vaginal flora and immune mediators may increase the risk of human immunodeficiency virus-1 acquisition. The objective of this study was to define immune changes in lower genital and systemic immunity associated with normal pregnancy. STUDY DESIGN This prospective cohort enrolled low-risk pregnant and nonpregnant women ages 18-35 years. Pregnant women at <14 weeks and nonpregnant women in follicular phase of the menstrual cycle were included. Cervical and vaginal fluid was collected. Concentrations of immune mediators were measured using enzyme-linked immunosorbent assay-based methods or multiplex immunoassay. Samples were inoculated onto various culture media allowing for growth of Lactobacillus species, Gardnerella vaginalis, Escherichia coli, Enterococcus species, anaerobic gram-negative rods, Candida, Staphylococcus aureus, Ureaplasma species, and Mycoplasma hominis. Concentrations of immune mediators and vaginal colonization frequencies were compared between the pregnant and nonpregnant groups. RESULTS Genital tract concentration of interleukin-1β was higher during pregnancy compared to nonpregnant participants. Serum C-reactive protein concentrations were higher in all trimesters of pregnancy. Concentrations of secretory leukocyte protease inhibitor did not differ between groups. Lactobacillus was more commonly isolated from vaginal cultures of nonpregnant participants (100% vs 70.2%, P = .02). Identification of Candida, G vaginalis, M hominis, and S aureus was common and not different between groups. Ureaplasma species was isolated from >60% pregnant participants. CONCLUSION The proinflammatory cytokine, interleukin-1β, as well as the systemic marker of inflammation, C-reactive protein, are increased during pregnancy. The impact of these proinflammatory changes during pregnancy deserves further study.

Endoscopic laser coagulation following amnioreduction for the management of a large placental chorioangioma

Hector Mendez-Figueroa1, Ramesha Papanna1, Edwina J. Popek2, Robert H. Byrd2, Kenneth Goldaber3, Kenneth J. Moise Jr1 and Anthony Johnson1* 1Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and the Texas Children’s Fetal Center, Houston, TX, USA 2Department of Pathology, Texas Children’s Hospital, Houston, TX, USA 3Arlington Perinatology Associates, Arlington, TX, USA

Rate of Gestational Diabetes Mellitus and Pregnancy Outcomes in Patients with Chronic Hypertension

Objective This study aims to determine the rate of gestational diabetes mellitus (GDM) in pregnancies complicated by chronic hypertension and to compare the adverse outcomes in chronic hypertensive pregnancies with and without GDM. Study Design A secondary analysis from a multicenter trial of low-dose aspirin for preeclampsia prevention in women with chronic hypertension. The rate of GDM was evaluated among singleton pregnancies complicated with chronic hypertension and grouped according to their GDM status. Pregnancy outcomes and rates of preterm delivery < 35 weeks and < 32 weeks, preeclampsia, indicated preterm birth, small for gestational age, abruptio placentae, and perinatal death were compared between those with and without GDM. A subgroup analysis comparing women who developed superimposed preeclampsia with and without GDM was studied. Multivariate logistic-regression analysis was used to adjust for potentially confounding factors. Results A total of 763 women met the inclusion criteria: 129 (17%) developed GDM. Parity, race, maternal baseline blood pressure, antihypertensive drug use, and assignment to low-dose aspirin were not significantly different between the groups with and without GDM. Using univariate analysis, maternal age (33 vs. 24%, p = 0.03) and body mass index (88 vs. 57%, p < 0.001) were higher in those who had GDM, whereas the rate of preterm delivery < 32 weeks (12 vs. 5%, p = 0.02) was higher among those without GDM. Using logistic-regression analysis, the rate of composite adverse outcomes (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.41-1.47) that included indicated preterm birth, small for gestational age, abruptio placentae, and perinatal death showed no significant differences.Superimposed preeclampsia developed in 34 (26%) women with GDM and in 182 (29%) without GDM. When superimposed preeclampsia was present, it developed at an earlier gestational age among the group without GDM (35 ± 5 vs. 37 ± 3 weeks, p = 0.003), and had higher rates of small for gestational age infants (18 vs. 3%, p = 0.03). After adjustment for confounders, only length of stay in neonatal intensive care unit was longer for those without GDM who developed superimposed preeclampsia (aOR, 0.42; 95% CI, 0.2-0.93). Conclusion Women with chronic hypertension are at a high risk for developing GDM. Outcomes in patients with chronic hypertension and GDM are not significantly different from those with chronic hypertension only.

Morbidity and Mortality in Small-for-Gestational-Age Infants: A Secondary Analysis of Nine MFMU Network Studies

Objective To compare the neonatal morbidity and mortality among small‐for‐gestational‐age (SGA; birth weight < 10% for estimated gestational age [EGA]) versus appropriate‐for‐gestational‐age (AGA; birth weight at 10‐89%) newborns. Methods Data from nine Maternal‐Fetal Medicine Units Network studies were used and included nonanomalous singletons at 24 weeks or more and birth weight < 90% for EGA. Using multivariable analysis, we compared the morbidity and mortality between SGA and AGA. Random‐effect logistic regressions were utilized with adjustment for 10 variables. Results Among the nine studies 71,744 singletons met the inclusion criteria, with 13% (n = 9,415) SGA and 87% (n = 62,329) AGA. Among SGA, the likelihood of stillbirth (8.8 vs. 2.5 per 1,000 births; adjusted odds ratio [aOR] 3.98, 95% confidence interval [CI]: 2.92‐5.42) and neonatal mortality (14.0 vs. 5.5 per 1,000 births; aOR 3.18, 95% CI: 2.55‐3.95) was threefold higher compared with AGA. For the subgroup of newborns of EGA of 32 weeks or more, SGA, compared with AGA, had significantly higher risk of stillbirth (aOR 3.32, 95% CI: 2.16‐5.12) and neonatal mortality (aOR 2.50; 95% CI: 1.38‐4.54). From 35 weeks onward, the risk of stillbirth among SGA is almost four times higher than for AGA. Conclusion The risk of stillbirth and neonatal mortality is significantly higher with SGA than with AGA. Modification in practice or new management schema may be warranted.

Dysregulation of Npas2 leads to altered metabolic pathways in a murine knockout model

In our primate model of maternal high fat diet exposure, we have described that fetal epigenomic modifications to the peripheral circadian Npas2 are associated with persistent alterations in fetal hepatic metabolism and non-alcoholic fatty liver. As the interaction of circadian response with metabolism is not well understood, we employed a murine knockout model to characterize the molecular mechanisms with which Npas2 reprograms the fetal hepatic metabolic response. cDNA was generated from Npas2-/- and +/+ (wild type) livers at day 2 (newborn) and at 25 weeks (adult) of life. Newborn samples were analyzed by exon array (n = 3/cohort). Independent pathway analysis software determined that the primary dysregulated pathway(s) in the Npas2-/- animals uniformly converged on lipid metabolism. Of particular interest, Ppargc1a, which integrates circadian and metabolism pathways, was significantly (p < .01) over expressed in newborn (1.7 fold) and adult (1.8 fold) Npas2-/- animals. These findings are consistent with an essential role for Npas2 in programming the peripheral circadian response and hepatic metabolism, which has not been previously described.

Comparing daily versus less frequent blood glucose monitoring in patients with mild gestational diabetes.

Abstract Objective: The prevalence of gestational diabetes mellitus (GDM) is increasing. This study was designed to determine if different frequencies in blood glucose (BG) monitoring, without regard to other variables, would allow timely detection of hyperglycemia requiring pharmacologic treatment in mild GDMs. Methods: Retrospective chart review, limited to self-glucose monitoring values, of 120 mild GDM patients who required pharmacologic therapy. Three data sets were constructed from each patient’s BG log: (1) all available BG; (2) every other day’s BG blocked; (3) only every third day’s BG available for review. The blocked BG datasets were compared with daily values. Results: 95% and 97% of subjects were started on pharmacologic therapy before or within 7 d of the reference date using every other day and every third day BG logs, respectively. Conclusions: Based exclusively on BG values, without regard to other clinical information, every other day or every third day BG monitoring in mild GDM does not delay the initiation of pharmacologic therapy.

Perinatal outcomes with normal compared with elevated umbilical artery systolic-to-diastolic ratios in fetal growth restriction.

OBJECTIVE: To compare the composite neonatal morbidity of pregnancies with fetal growth restriction (estimated fetal weight less than the 10th percentile) and normal compared with elevated umbilical artery systolic-to-diastolic ratios. METHODS: This was a retrospective cohort study of all pregnancies complicated by fetal growth restriction with normal compared with elevated umbilical artery systolic-to-diastolic ratios from January 2008 to July 2012 at a single center. Exclusions were multiple gestation, prenatally diagnosed fetal anomalies, delivery at outside institution, and absent or reversed end diastolic flow. Maternal characteristics and perinatal outcomes including composite neonatal morbidity were compared between groups. RESULTS: Of 11,785 pregnancies evaluated, 789 (7%) were diagnosed with fetal growth restriction. Among 512 that met inclusion criteria, 394 (77%) had normal and 118 (23%) had elevated umbilical artery systolic-to-diastolic ratios. When fetal growth–restricted pregnancies with elevated umbilical artery systolic-to-diastolic ratios were delivered at 37 weeks of gestation were compared with those with normal umbilical artery systolic-to-diastolic ratios delivered at 39 weeks of gestation, there was no difference in the rate of neonatal intensive care unit admission (101 [25.7%] compared with 51 [43.2%]; crude odds ratio [OR] 2.5, 95% confidence interval 1.5–4.0; adjusted OR 1.37, 95% CI 0.69–2.71) or composite neonatal morbidity (60 [15.2%] compared with 24 [20.3%]; crude OR 1.42, 95% CI 0.84–2.40; adjusted OR 0.91, 95% CI 0.45–1.84). CONCLUSION: Composite neonatal morbidity is comparable in fetal growth–restricted pregnancies with elevated compared with normal umbilical artery systolic-to-diastolic ratios when delivered at 37 and 39 weeks of gestation, respectively. Planning delivery of pregnancies with fetal growth restriction and elevated systolic-to-diastolic ratios and without other complications at 37 weeks of gestation results in good outcomes. LEVEL OF EVIDENCE: II