Heidi Leftwich

Fetal Hydronephrosis as a Predictor of Neonatal Urologic Outcomes

The ability to predict surgically relevant fetal renal hydronephrosis is limited. We sought to determine the most efficacious second‐ and third‐trimester fetal renal pelvis anteroposterior diameter cutoffs to predict the need for postnatal surgery.

Outcomes With Cerclage Alone Compared With Cerclage Plus 17α-hydroxyprogesterone Caproate.

OBJECTIVE: To examine the differences in perinatal outcomes among women with a prior preterm birth who received cerclage compared with cerclage plus 17&agr;-hydroxyprogesterone caproate. METHODS: Women with transvaginal cerclage placement and a prior delivery between 16 and 36 weeks of gestation were identified over a 10-year period (July 2002 to May 2012) in this retrospective cohort study. Exclusion criteria were delivery at another institution, abdominal cerclage, multiple gestations, and major fetal anomalies. Maternal demographics, gestational age at cerclage, gestational age at delivery, preterm prelabor rupture of membranes (PROM), and birth weight were compared between women with a cerclage and cerclage plus 17&agr;-hydroxyprogesterone caproate. The primary outcome was delivery at less than 24 weeks of gestation. RESULTS: Of the 411 women who had a cerclage, 260 met inclusion criteria. Of these, 171 received a cerclage alone and 89 received cerclage plus 17&agr;-hydroxyprogesterone caproate. The two groups were not different with respect to maternal demographics and gestational age at cerclage. There was a significant difference among those who received indomethacin at the time of cerclage, betamethasone administration, and history of a loop electrosurgical excision procedure–cold knife cone and cerclage. Delivery at less than 24 weeks of gestation occurred in 6% of women receiving both 17&agr;-hydroxyprogesterone caproate and cerclage compared with 16% in the cerclage only group (odds ratio [OR] 0.31, 95% confidence interval 0.10–0.78, P=.01). In the multivariate analysis controlling for indomethacin use, prior cerclage, and loop electrosurgical excision procedure–cold knife cone there was a 73% reduction in delivery in the combined treatment group compared with cerclage alone (adjusted OR 0.26, P=.02). A multivariant analysis was conducted with correction for indomethacin at the time of cerclage, prior cerclage, and loop electrosurgical excision procedure–cold knife cone and cerclage surgery. Even after controlling for significant variables, there remained a 73% reduction in delivery at less than 24 weeks of gestation in the cerclage plus 17&agr;-hydroxyprogesterone caproate cohort (adjusted OR 0.26, P=.02). CONCLUSION: Women receiving transvaginal cerclage plus 17&agr;-hydroxyprogesterone caproate had a 69% relative reduction in delivery at less than 24 weeks of gestation when compared with women receiving cerclage alone. We found no difference in overall preterm delivery or preterm PROM. In this cohort, compared with cerclage alone, the likelihood of a viable neonate improves with both treatments.

Does increase in birth weight change the normal labor curve

OBJECTIVE This study is designed to assess the effect of birth weight on the duration of labor. STUDY DESIGN Retrospective review of the electronic database created by the Consortium on Safe Labor, reflecting labor and delivery information from 12 clinical centers from 2002 to 2008. Population included all laboring women in the 19 participating hospitals, excluding those with malpresentation, fetal anomalies, elective repeat cesarean, multiple gestations, gestational age less than 34 weeks, and delivery with less than two cervical examinations. Birth weight categories include less than 2,500 g, 2,500 to 3,000 g, 3,000 to 3,500 g, 3,500 to 4,000 g, and greater than 4,000 g. Interval censored regression analysis was used to determine distribution of times for cervical dilation progression in centimeters. RESULTS A total of 146,904 maternal records were reviewed. In nulliparous, traverse times increased as birth weight increased, both in successful trial of labor and also those who ultimately required cesarean delivery (p < 0.01). In multiparous with successful trial of labor, traverse times increased as birth weight increased from 5 to 8 cm (p < 0.01). From 8 to 10 cm, traverse times increased by birth weight, though this was not statistically significant. CONCLUSION We have shown that in a large cohort of contemporary laboring women, as birth weight increases, progression in labor is, in fact slower.

Growth restriction: identifying fetuses at risk

Abstract Purpose: Examine risks of intrauterine growth restriction (IUGR) and composite perinatal outcomes with estimated fetal weights (EFW) 10–20th%, and compare outcomes using umbilical artery Doppler (UAD). Materials and methods: Retrospective, cohort evaluating ultrasound (US) EFW 10–20th%, between 2002 and 2012. Cases were identified with EFW % 10–20. Controls, EFW >20th% were obtained for each case, matched by gestational age, and US date. Unadjusted and adjusted logistic regression was used for outcomes. Results: Seven hundred and sixty-seven cases met criteria with matched controls. Fetuses having EFW 10–20th% (GA 33.6 ± 3.7 weeks) had increased IUGR on follow up ultrasound (OR 26.5[10.2–68.7], p < .01), small for gestational age (SGA) (OR 9.2 [6.9–12.3], p < .01), neonatal intensive care unit (NICU) admissions (OR 2.4 [1.6–3.6], p < .01), and composite perinatal morbidity (OR 7.8 [6.0–10.1], p < .01) on adjusted analyses. Abnormal UAD in cases had greater rates of 5 min Apgar <7, NICU admission and composite morbidity (p < .05). Conclusions: Pregnancies with EFW 10–20th% at the time of initial US are at increased risk for developing IUGR and being SGA at birth, with more NICU admissions and composite perinatal outcomes; abnormal UAD evaluation in cases conveyed further increase in outcomes.

Intracervical Ripening Bulb for Induction of Labor in a Trial of Labor After Cesarean Delivery

INTRODUCTION: We aimed to evaluate the perinatal outcomes associated with induction of labor using an intracervical ripening bulb in trial of labor after cesarean delivery (TOLAC). METHODS: Retrospective cohort study of women undergoing a TOLAC between 2002 and 2012. Women requiring induction of labor for a TOLAC who had either an intracervical ripening bulb with oxytocin (study group) or oxytocin alone (control group) as the method of induction were included. Pregnancies complicated by fetal demise, lethal anomalies, or previable or multiple gestations were excluded. Maternal outcomes included uterine rupture, dehiscence, and composite defined as chorioamnionitis, hemorrhage, transfusion, uterine rupture, or dehiscence. Neonatal composite was defined as 5-minute Apgar less than 7, arterial pH less than 7, respiratory distress syndrome, intraventricular hemorrhage, asphyxia, or neonatal intensive care unit admission. &khgr;2 compared categorical variables and t test continuous. Multivariate logistic regression controlled for potential confounders. RESULTS: Four hundred seventh women met inclusion and exclusion criteria. One hundred forty-nine (31.7%) women received an intracervical ripening bulb with oxytocin and 321 (68.3%) received oxytocin alone. Women undergoing induction with an intracervical ripening bulb were less likely to develop chorioamnionitis (adjusted odds ratio [OR] 0.29, 95% confidence interval 0.10–0.83). No difference was demonstrated in hemorrhage, transfusion, uterine rupture, dehiscence, or composite maternal or neonatal outcomes (Table 1). Rate of vaginal delivery was 50% in the intracervical ripening bulb group compared with 68% in the oxytocin group (OR 0.46 [0.31–0.69]). Table 1 Perinatal Outcomes for an Intracervical Ripening Bulb in a Trial of Labor After Cesarean Delivery CONCLUSIONS: With less rates of chorioamnionitis and no increase in adverse pregnancy outcomes, an intracervical ripening bulb appears to be an appropriate choice for use in a TOLAC; however, the high repeat cesarean delivery rate is concerning and gravidas desiring a TOLAC should be counseled regarding decreased success rate compared with oxytocin only.

Doppler Ultrasonography: More Than Just for Intrauterine Growth Restriction?

INTRODUCTION: Fetuses with growth delay at risk for complications may not be identified if further evaluation is limited to fetuses with an estimated fetal weight less than the 10th percentile. We assessed umbilical artery Doppler in fetuses at the 10–20th percentile to identify those at risk for poor perinatal outcomes. METHODS: Retrospective cohort evaluating fetuses with estimated fetal weight 10th–20th percentile on ultrasonography, January 2002 to January 2012. Exclusion criteria were delivery at an outside hospital, multiple gestations fetal anomalies, and lack of umbilical artery evaluation. Ultrasound reports were reviewed and perinatal outcomes ascertained from medical records. Umbilical artery was abnormal if systolic or diastolic ratio was elevated or there was absent or reversed end diastolic flow. Composite neonatal outcome was defined as 5-minute Apgar less than 7, arterial cord pH less than 7.0, or intubation. &khgr;2 test was used for categorical variables and t test for continuous. Multiple logistic regression was used to control for statistically significant variables. RESULTS: Five hundred twenty-nine fetuses met inclusion and exclusion criteria. Ninety-one fetuses had abnormal umbilical artery and 438 normal. Neonates with estimated fetal weight 10th–20th percentile and abnormal umbilical artery had a threefold to sixfold increase in preterm birth, preeclampsia, low birth weight, and neonatal intensive care unit admission, whereas poor composite neonatal outcome was almost nine times greater than in fetuses with normal umbilical artery (Table 1). These findings remained statistically significant when controlling for gestational age at ultrasonography, delivery, and maternal age. Table 1 Perinatal Outcomes for Umbilical Artery Doppler (Leftwich, p. 193–4S) CONCLUSIONS: Doppler ultrasonography in fetuses with growth in the 10th–20th percentile can help identify those at increased risk for low birth weight, preterm birth, preeclampsia, neonatal intensive care unit admission, and poor neonatal composite.