Ibrahim Hammad

Peripartum complications with cesarean delivery: a review of Maternal-Fetal Medicine Units Network publications

Abstract Objective: Since 1997, the Maternal-Fetal Medicine Units (MFMU) have published 39 articles involving over 70 000 cesarean deliveries (CD), including primary, elective repeat (ERCD) or trial of labor after cesarean (TOLAC). The purpose of this review article is to summarize the peripartum morbidity or mortality (M/M) with CD (primary or ERCD) or TOLAC. Methods: For 12 clinical scenarios and 17 M/M, we summarized 135 rates and, whenever feasible, calculated odds ratio (OR) with 95% confidence intervals (CI). Results: Of the 58 comparable scenarios, the M/M differed significantly in 48% (28). At term, the rate of blood transfusion was significantly greater in TOLAC (2%) versus ERC (1%; OR, 1.71; 95% CI, 1.41–2.08) but not in the likelihood of a hysterectomy or operative injury. The rate of neonatal seizure and perinatal mortality was similar between TOLAC and ERCD. Conclusions: Our analysis provides an overview of peripartum M/M with CD; it allows clinicians to counsel women who had or are having CD. It also permits study design, with an appropriate sample size, with the aim to minimize the morbidities.

Indications for caesarean sections at ≥34 weeks among nulliparous women and differential composite maternal and neonatal morbidity

To compare composite maternal and neonatal morbidities (CMM, CNM) among nulliparous women with primary indications for caesarean section (CS) as acute clinical emergency (group I; ACE), non‐reassuring fetal heart rate (group II) and arrest disorder (group III).

Neonatal brachial plexus palsy with vaginal birth after cesarean delivery: a case-control study

OBJECTIVE The objective was to determine the rate of neonatal brachial plexus palsy (NBPP) among women with vaginal birth after cesarean delivery (VBAC) and to compare the peripartum characteristics with control subjects. STUDY DESIGN The Maternal-Fetal Medicine Unit cesarean registry data were used to identify nonanomalous singleton pregnancies with VBAC and NBPP at gestational age of ≥37 weeks (term) and 4 control subjects (matched for gestational age and diabetes mellitus status but without brachial injury). Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. RESULTS Among 11,313 VBACs at term, there were 23 women with NBPP (rate of 2.0/1000 women). Newborn infants with NBPP, compared with control infants, were significantly more likely to weigh ≥4000 g (48% vs 10%, respectively; OR, 8.45; 95% CI, 2.58-28.44) and to require admission to the neonatal intensive care unit (30% vs 13%; OR, 12.98; 95% CI, 2.61-72.18). CONCLUSION Women who desire VBAC should be informed about the low rate of NBPP and, if eligible, encouraged to have a trial of labor after cesarean delivery.

Uncomplicated Pregnancies and Ultrasounds for Fetal Growth Restriction: A Pilot Randomized Clinical Trial.

Objective The purpose of this multicenter pilot study was to determine the feasibility of randomizing uncomplicated pregnancies (UPs) to have third trimester ultrasonographic exams (USE) versus routine prenatal care (RPNC) to improve the detection of small for gestational age (SGA; birth weight < 10% for GA). Material and Methods At three referral centers, 50 UPs were randomized after gestational diabetes was ruled out. Women needed to screen, consenting, and loss to follow-up was ascertained, as was the detection rate of SGA in the two groups. Results During the study period at the three centers, there were 7,680 births, of which 64% were uncomplicated. Of the 234 women approached for randomization, 36% declined. We recruited 149 women and had follow-up delivery data on 97%. The antenatal detection rate of SGA in the intervention group was 67% (95% confidence intervals 31–91%) and 9% (0.5–43%) in control. Conclusion The pilot study provides feasibility data for a multicenter randomized clinical trial to determine if third trimester USE, compared with RPNC, improves the detection of SGA and composite neonatal morbidity.

Differential Morbidity in Preterm Small versus Appropriate for Gestational Age: Perhaps Unverifiable

OBJECTIVE The objective of this study was to determine the morbidity of preterm small for gestational age (SGA) infants compared with appropriate for GA (AGA). STUDY DESIGN This is a secondary analysis of the randomized trial evaluating magnesium sulfate for the prevention of cerebral palsy (CP). We compared outcomes of preterm (< 37 weeks) nonanomalous infants who were SGA (birth weight < 10% for GA) versus AGA (birth weight 10-89% for GA). We compared (1) the parent trial primary outcome, a composite of stillbirth, infant death by 1 year of age, or moderate to severe CP at 2 years of age and (2) composite neonatal morbidity (CNM). RESULTS Of the 1,948 infants who met inclusion criteria, 95% were AGA and 5% were SGA. The primary outcome was similar (10 and 15%, p = 0.08), as was the CNM (24 and 25%, p = 0.89). Sample size calculations indicate that detection of a one-third higher rate of CNM among SGA compared with AGA infants requires more than 93,900 preterm births; for a one-third difference in moderate to severe CP, more than 1.4 million infants. CONCLUSION Owing to the prohibitive sample size required, ascertaining a difference in sequela between preterm SGA and AGA infants is possibly unverifiable.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: A Comparison

OBJECTIVE To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD). STUDY DESIGN We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters. RESULTS We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65). CONCLUSION Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.