Jaimey M. Pauli

Preeclampsia: Short-term and Long-term Implications

Preeclampsia is a hypertensive disorder that affects 4% of pregnancies and has a high risk of maternal, fetal, and neonatal morbidity and mortality, as well as long-term cardiovascular risk. Recent updates in the definition, diagnosis, and management guidelines for preeclampsia warrant review by general obstetrician-gynecologists. Screening and prevention algorithms for preeclampsia are available, but ultimately the cure remains delivery of the fetus and placenta. Close monitoring for the development and worsening of preeclampsia during pregnancy is essential to optimize both maternal and fetal/neonatal outcomes.

Current perspectives of insulin resistance and polycystic ovary syndrome

Diabet. Med. 28, 1445–1454 (2011)

Reduction in the Cesarean Delivery Rate After Obstetric Care Consensus Guideline Implementation.

OBJECTIVE: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines. METHODS: This is a before–after retrospective cohort study at a single academic center. This center adopted guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery. Nulliparous women attempting vaginal delivery with viable, singleton, vertex fetuses were included. For the primary outcome of cesarean delivery rate among induced or augmented patients, 200 consecutive women managed before guideline adoption were compared with 200 similar patients afterward. Secondary outcomes of overall cesarean delivery rate, maternal morbidity, neonatal outcomes, and labor management practices were analyzed with inclusion of intervening spontaneously laboring women. RESULTS: Between September 13, 2013, and September 28, 2014, 275 women preguideline and 292 postguideline were identified to include 200 deliveries after induction or augmentation each. Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38–0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38–0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46–0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications. CONCLUSION: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm.

Identification of small for gestational age by population-based and customized growth charts in newborns of obese and normal-weight primiparous women

Abstract Objective: Our hypothesis was that newborns of obese mothers would be more likely to be classified as small for gestational age (SGA) by their customized growth curves than by the standard growth curves when compared to newborns of normal-weight mothers. Methods: This is a retrospective cohort of primiparous patients delivering between 1 July 2008 and 30 June 2012. Normal-weight was defined as BMI ≤25 kg/m2 and obese as BMI ≥ 30 kg/m2. Infant birth-weight was characterized as SGA or non-SGA from the Lubchenco curve, the Fenton Preterm Growth Chart, and the customized growth curve. Results: Infants were more likely to be classified as SGA on the customized curve compared with Lubchenco curve. Odds ratio was 2.8 (CI: 1.7–4.4; p = 0.001) for obese women and was 2.9 (CI: 1.7–5.1; p < 0.001) for normal-weight women. Infants were also more likely to be classified as SGA based on the customized curve compared with the Fenton Preterm Growth Curve. The odds ratio was 2.3 (CI: 1.4–3.8; p = 0.001) for obese women and was 1.5 (CI: 1.01–2.33; p = 0.04) for normal-weight women. Conclusions: Population-based curves may mask SGA in obese women. Our study demonstrates that customized growth curves identify more SGA than population-based growth curves in obese and normal-weight women.

Fetal Growth Restriction May Be Underestimated in Obese Patients

INTRODUCTION: Fetal growth restriction is associated with poor perinatal outcomes. Unfortunately, only approximately 25% of children who are born growth restricted are identified prenatally. This underidentification of fetal growth restriction by standard measures is thought to be even higher in obese patients. The low sensitivity of outdated standardized fetal growth curves has been addressed by the development of customized fetal growth curves. Customized curves define fetal growth potential based on specific maternal factors. The objective of our study is to compare the identification of fetal growth restriction using customized compared with standardized curves (Hadlock) in normal-weight and obese patients. METHODS: In this retrospective study, 150 normal-weight (body mass index [BMI] less than 25 kg/m2) and 150 obese (BMI greater than 30 kg/m2) women aged 18–50 years who gave birth between July 1, 2008, and December 31, 2012, were included. Inclusion criteria were primiparity and an estimated fetal weight from a third-trimester ultrasound scan. For each fetus, a customized fetal growth curve was created using a program from www.gestation.net. Each fetus was then classified as growth-restricted or nongrowth-restricted using the third-trimester ultrasound-estimated weight and plotting it on the Hadlock and customized curves at the same gestational age. RESULTS: Obese women were more likely to have a fetus classified as growth-restricted by a customized curve compared with standard Hadlocks curve (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4–3.2, P=.001). Normal-weight women had no difference in classification of growth restriction (OR 0.9, 95% CI 0.7–1.2, P=.41). There was a statistically significant difference between the ORs comparing BMI categories (P=.001). CONCLUSION: In obese women, customized fetal growth curves better predict fetal growth restriction compared with standard growth curves.

Management of gestational hypertension – the impact of HYPITATa

Abstract Aims: The objective of this study was to examine the impact of one trial (the HYPITAT trial) on management of gestational hypertension. Study design: This is a retrospective cohort study of 5077 patients delivered at our institution from 7/1/2008 to 6/15/2011. “Pre-HYPITAT” was defined as 7/1/2008–9/30/2009 and “Post-HYPITAT” as 10/1/2009–6/15/2011. The primary outcome is the rate of delivery intervention for gestational hypertension. Secondary maternal and neonatal outcomes were analyzed in patients with gestational hypertension only. Statistical analyses included the χ2-test, Fisher’s exact test, and the two-sample t-test. Results: The rate of delivery intervention Pre-HYPITAT was 1.9%, compared to 4% Post-HYPITAT (P<0.001). There was no significant change in secondary outcomes. Conclusion: There was a statistically significant increase in delivery intervention for gestational hypertension at our institution after the publication of the HYPITAT trial. There was no significant change in immediate maternal or neonatal outcomes for patients with gestational hypertension.

Comparison of healthcare utilization and outcomes by gestational diabetes diagnostic criteria

Abstract Objective: To compare healthcare utilization and outcomes using the Carpenter-Coustan (CC) criteria vs. the National Diabetes Data Group (NDDG) criteria for gestational diabetes mellitus (GDM). Methods: This is a retrospective cohort study. Prior to 8/21/2013, patients were classified as “GDM by CC” if they met criteria. After 8/21/2013, patients were classified as “GDM by NDDG” if they met criteria and “Meeting CC non-GDM” if they met CC, but failed to reach NDDG criteria. “Non-GDM” women did not meet any criteria for GDM. Records were reviewed after delivery. Results: There was a 41% reduction in GDM diagnosed using NDDG compared to CC (P=0.01). There was no significant difference in triage visits, ultrasounds for growth or hospital admissions. Women classified as “Meeting CC non-GDM” were more likely to have preeclampsia than “GDM by CC” women [OR 11.11 (2.7, 50.0), P=0.0006]. Newborns of mothers “Meeting CC non-GDM” were more likely to be admitted to neonatal intensive care units than “GDM by CC” [OR 6.25 (1.7, 33.3), P=0.006], “GDM by NDDG” [OR 5.56 (1.3, 33.3), P=0.018] and “Non-GDM” newborns [OR 6.47 (2.6, 14.8), P=0.0003]. Conclusion: Using the NDDG criteria may increase healthcare costs because while it decreases the number of patients being diagnosed with GDM, it may also increase maternal and neonatal complications without changing maternal healthcare utilization.

Pitfalls With the New American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy.

The American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy was created to evaluate the existing literature, develop practice guidelines, and identify areas for future research focus. Several issues were identified that may not have been initially obvious during the process of developing this document, including limited practical use, a lack of high quality literature, conflicting recommendations, a potential for high resource utilization, need for continually updated information, and little headway in research that is clinically useful. The purpose of this review was to make suggestions to improving these guidelines’ overall usefulness and consistency for the busy clinician.