Israel Hendler

The impact of maternal obesity on midtrimester sonographic visualization of fetal cardiac and craniospinal structures

OBJECTIVE: To examine the impact of maternal obesity on the rate of suboptimal ultrasound visualization (SUV) of fetal anatomy and determine the optimal timing of prenatal ultrasound examination for the obese gravida.METHODS: A computerized ultrasound database was used to identify ultrasound examinations for singleton gestations performed between 140/7 and 236/7 weeks at a tertiary care, university-based hospital. Patients were divided into four groups and categorized based on body mass index (BMI): nonobese (BMI <30 kg/m2), class I obesity (30≤BMI<35 kg/m2), class II obesity (35≤BMI<40 kg/m2), and extreme obesity (BMI ≥40 kg/m2). The rates of SUV for fetal cardiac and craniospinal structures were calculated for each group and compared.RESULTS: A total of 11 019 pregnancies were studied, of which 38.6% of the patients were obese. Overall, the rate of SUV of the fetal structures was higher for obese compared to nonobese women for both cardiac (37.3 [1723/4200] vs 18.7% [1275/6819]; P<0.0001) and craniospinal structures (42.8 [1798/4200] vs 29.5% [2012/6819]; P<0.0001). Increased severity of maternal obesity was associated with SUV rate for both the cardiac (nonobese 18.7% [1275/6819], class I 29.6% [599/2022], class II 39.0% [472/1123], and extreme obesity 49.3% [580/1055]; P<0.0001) and for the craniospinal structures: (nonobese 29.5% [2012/6819], class I 36.8% [744/2022], class II 43.3% [486/1123], and extreme obesity 53.4% [563/1055]; P<0.0001). With increasing gestational age at examination, the rate of SUV decreased for both obese and nonobese women. However, for obese women there was minimal improvement in visualization after 18–20 weeks. Even after adjustment for gestational age and the type of ultrasound machine, obese women (class I, class II, and extreme obesity) were still associated with increased odds for SUV of the fetal cardiac and craniospinal structures compared to nonobese women.CONCLUSION: Maternal obesity increases the rate of SUV for the fetal cardiac structures by 49.8% and for the craniospinal structures by 31%. The optimal gestational age for visualization of fetal cardiac and craniospinal anatomy in obese patients may be after 18–20 weeks.

A SONOGRAPHIC SHORT CERVIX AS THE ONLY CLINICAL MANIFESTATION OF INTRA-AMNIOTIC INFECTION

Abstract Objective: A sonographically short cervix is a powerful predictor of spontaneous preterm delivery. However, the etiology and optimal management of a patient with a short cervix in the mid-trimester of pregnancy remain uncertain. Microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation are frequently present in patients with spontaneous preterm labor or acute cervical insufficiency. This study was conducted to determine the rate of MIAC and intra-amniotic inflammation in patients with a cervical length <25 mm in the mid-trimester. Study design: A retrospective cohort study was conducted of patients referred to our high risk clinic because of a sonographic short cervix or a history of a previous preterm birth. Amniocenteses were performed for the evaluation of MIAC and for karyotype analysis in patients with a short cervix. Fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients with MIAC were treated with antibiotics selected by their physician. Results: Of 152 patients with a short cervix at 14–24 weeks, 57 had amniotic fluid analysis. The prevalence of MIAC was 9% (5/57). Among these patients, the rate of preterm delivery (<32 weeks) was 40% (2/5). Microorganisms isolated from amniotic fluid included Ureaplasma urealyticum (n=4) and Fusobacterium nucleatum (n=1). Patients with a positive culture for Ureaplasma urealyticum received intravenous Azithromycin. Three patients with Ureaplasma urealyticum had a sterile amniotic fluid culture after treatment, and subsequently delivered at term. The patient with Fusobacterium nucleatum developed clinical chorioamnionitis and was induced. Conclusion: (1) Sub-clinical MIAC was detected in 9% of patients with a sonographically short cervix (<25 mm); and (2) maternal parenteral treatment with antibiotics can eradicate MIAC caused by Ureaplasma urealyticum. This was associated with delivery at term in the three patients whose successful treatment was documented by microbiologic studies.

Suboptimal second-trimester ultrasonographic visualization of the fetal heart in obese women: should we repeat the examination?

The purpose of this study was to determine whether a repeated antenatal ultrasound examination improves fetal cardiac visualization for the obese and nonobese population.

Clinical significance of the presence of amniotic fluid 'sludge' in asymptomatic patients at high risk for spontaneous preterm delivery.

To determine the clinical significance of the presence of amniotic fluid (AF) ‘sludge’ among asymptomatic patients at high risk for spontaneous preterm delivery.

Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor

OBJECTIVE: We sought to study the effects of prior vaginal delivery or prior vaginal birth after cesarean delivery (VBAC) on the success of a trial of labor after a cesarean delivery. METHODS: An observational study of patients who underwent a trial of labor after a single low-transverse cesarean delivery. Patients with a previous cesarean delivery and no vaginal birth were compared with patients with a single vaginal delivery before or after the previous cesarean delivery. The rates of successful VBAC, uterine rupture, and scar dehiscence were analyzed. Multivariable regression was performed to adjust for confounding variables. RESULTS: Of 2,204 patients, 1,685 (76.4%) had a previous cesarean delivery and no vaginal delivery, 198 (9.0%) had a vaginal delivery before the cesarean delivery, and 321 (14.6%) had a prior VBAC. The rate of successful trial of labor was 70.1%, 81.8%, and 93.1%, respectively (P < .001). A prior VBAC was associated with fewer third- and fourth-degree lacerations (8.5% versus 2.5% versus 3.7%, P < .001) and fewer operative vaginal deliveries (14.7% versus 5.6% versus 1.9%, P < .001) but not with uterine rupture (1.5% versus 0.5% versus 0.3%, P = .12). Patients with a prior VBAC had, in addition, a higher rate of uterine scar dehiscence (21.8%) compared with patients with a previous cesarean delivery and no vaginal delivery (5.3%; P = .001). CONCLUSION: A prior vaginal delivery and, particularly, a prior VBAC are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery. In addition, prior VBAC is associated with an increased rate of uterine scar dehiscence. LEVEL OF EVIDENCE: II-2

Association of obesity with pulmonary and nonpulmonary complications of pregnancy in asthmatic women

OBJECTIVE: To evaluate whether maternal obesity is associated with pulmonary and nonpulmonary pregnancy complications in asthmatic women. METHODS: This is a secondary analysis of the prospective cohort Asthma During Pregnancy Study. Asthma patients were classified as having either mild or moderate to severe disease at the beginning of the study. Rates of pulmonary complications of asthma in asthmatic women and rates of nonpulmonary complications of pregnancy among asthma patients and controls, were compared between obese (body mass index ≥ 30 kg/m2) and nonobese women. RESULTS: Maternal body mass index and pregnancy outcome data were available for 1,699 of 1,812 asthmatic women and for 867 of 881 controls. Of the asthma subjects, 30.7% (521) were obese compared with 25.5% of the controls, P = .006. Obese women, regardless of whether they had asthma, were more likely to undergo cesarean delivery (OR 1.6, 95% confidence interval [CI]1.3–2.0) to develop preeclampsia or gestational hypertension (OR 1.7 95% CI 1.3–2.3) and gestational diabetes (OR 4.2, 95% CI 2.8–6.3). There were no differences in the rates of overall asthma improvement (20.6% compared with 23.6%, P = .36) or deterioration (33.3% compared with 28.8%, P = .20) between obese and nonobese asthma patients. After adjustment for confounding variables, obesity, not asthma, was associated with nonpulmonary complications of pregnancy, and obesity was associated with an increase in asthma exacerbations as well (OR 1.3, 95% CI 1.1–1.7). CONCLUSION: Obesity is associated with an increased risk of asthma exacerbations during pregnancy. The increased rate of nonpulmonary complications of pregnancy in asthma patients is associated with obesity in this population and not with asthma status. LEVEL OF EVIDENCE: II-1

End tidal carbon monoxide levels are lower in women with gestational hypertension and pre-eclampsia.

BACKGROUND: The possible role of heme oxygenase and its byproduct carbon monoxide (CO) in the regulation of blood pressure is under investigation. The aim of this study was to compare end tidal breath CO (ETCO) levels in women with gestational hypertension (GH) or pre-eclampsia to the levels in healthy pregnant and nonpregnant women.MATERIALS AND METHODS: We prospectively performed ETCO measurements corrected for ambient CO (ETCOc) in two medical centers (Stanford, CA and Cleveland, OH). A Natus® CO-Stat® End Tidal Breath Analyzer (Natus Medical Inc., San Carlos, CA) was used. The study group included a convenience sample of 31 women with GH/pre-eclampsia (PE). Control groups included 46 nonpregnant healthy women, 44 first-trimester and 48 third-trimester pregnant healthy women.RESULTS: Mean±SD ETCOc measurements were significantly lower in the GH/PE group compared to first-trimester (p=0.004) and third-trimester (p=0.001) normotensive pregnant and nonpregnant women (p=0.002) (1.36±0.30 vs 1.76±0.47, 1.72±0.42 and 1.78±0.54 ppm, respectively). The ETCOc values were ≤1.6 ppm in 89% of GH/PE women compared with, respectively, only 45, 54, and 46% of nonpregnant, first- and third-trimester normotensive pregnant women (p<0.05). ETCO measurements were not influenced by maternal age, parity, ethnicity, body mass index, gestational age or presence of household smokers. In the two centers, the controls had a similar mean ETCOc and the differences found remained significant when results for each center were analyzed separately.CONCLUSIONS: ETCOc levels were found to be significantly lower in women with GH/PE. Further investigation is required to determine if the lower CO levels reflect a deficient compensatory response to the increase in blood pressure or whether these are primary changes of significance to our understanding of the pathogenesis of GH/PE.

The effect of gestational age on trial of labor after Cesarean section

Objectives: To evaluate the effect of gestational age on the rate of successful vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior Cesarean delivery.Study design: This was a cohort study including patients with a live singleton fetus undergoing a TOL after a previous low transverse Cesarean delivery between 1988 and 2002. Patients were divided into three groups according to gestational age: 24–36 weeks 6 days, 37–40 weeks 6 days and ≥41 weeks. Obstetric outcomes, including the rates of successful vaginal delivery and symptomatic uterine rupture, were compared between the groups. Multivariate logistic regression analysis was performed to adjust for potential confounding factors.Results: There were 253, 1911 and 329 patients in each group, respectively. In patients with advanced gestational age (≥41 weeks) the rate of uterine rupture was significantly higher (0% vs. 1.0% vs. 2.7%, p=0.006) and the rate of successful vaginal deliveries was significantly lower (83% vs. 76.9% vs. 62.6%, p<0.001). After adjusting for confounding variables, advanced gestational age was associated with a lower rate of successful vaginal delivery (odds ratio 0.68, 95% CI 0.51–0.89), and a higher rate of uterine rupture (odds ratio 2.85, 95% CI 1.27–6.42) when compared to 37–40 weeks 6 days.Conclusion: Advanced gestational age is associated with higher rates of failed TOL and uterine rupture.

Chemerin is present in human cord blood and is positively correlated with birthweight

OBJECTIVE Chemerin, a novel adipokine, has been implicated in adipogenesis, inflammation, and metabolism. The aims of this study were to determine the presence of chemerin in cord blood and its association with birthweight. STUDY DESIGN This cross-sectional study included the following: (1) twins with (n = 24) or without (n = 28) birthweight discordancy; and (2) singletons subclassified into small-for-gestational-age (SGA; n = 18); appropriate for gestational age (AGA; n = 33); and large-for-gestational-age (LGA; n = 8). Cord blood chemerin was determined. Parametric and nonparametric statistics were used for analysis. RESULTS The results of the study included the following: (1) within the discordant twins group, the median chemerin concentration was significantly lower in the SGA group than in their cotwins; (2) within singletons, the median chemerin concentration was significantly higher in the LGA than the AGA newborns; and (3) the regression model revealed that chemerin was independently associated with birthweight. CONCLUSION Cord blood chemerin is present in cord blood and its concentrations are positively correlated with birthweight. These novel findings support a role of adipokines in fetal growth.

Safety of labor induction with prostaglandin E2 in grandmultiparous women

Objective: The aim of this study was to assess the safety of labor induction with vaginal prostaglandin E2 (PGE2) in grandmultiparous women. Methods: We conducted a retrospective cohort study of 1376 grandmultiparous women who underwent induction of labor with low dose PGE2. The primary outcome was uterine rupture and secondary outcomes included mode of delivery, postpartum hemorrhage and five minutes Apgar score. Results: One case was diagnosed with uterine rupture (0.07%). Vaginal delivery was achieved in 1329 (96.6%) patients, whereas 47 (3.4%) patients had emergent cesarean delivery. Five minutes Apgar score ≤7 was recorded in three cases (0.2%). There was no correlation between parity and cesarean delivery rate or low Apgar score. There were no significant differences between the grandmultiparous and great-grandmultiparous patients regarding cesarean delivery rate (3.1 vs. 5%, P = 0.12), operative vaginal delivery rate (2 vs. 2.3%, P = 0.74) or postpartum hemorrhage rate (0.8 vs. 1.1%, P = 0.6). Conclusions: Low dose PGE2 is a safe and efficient method for induction of labor in grandmultiparous and great-grandmultiparous women.