Jodi Regan

The Influence of Mode of Delivery on Breastfeeding Initiation in Women with a Prior Cesarean Delivery: A Population-Based Study

OBJECTIVE This study compared breastfeeding initiation following repeat cesarean delivery, successful vaginal birth after cesarean (VBAC), and unsuccessful trial of labor. SUBJECTS AND METHODS We performed a population-based retrospective cohort study of Ohio births (2006-2007) with a previous cesarean delivery. The primary outcomes were breastfeeding initiation rates among women with a previous cesarean delivery. Breastfeeding initiation rates were compared among three different delivery types: repeat cesarean delivery, successful VBAC, and unsuccessful trial of labor. Sociodemographic factors, medical risk factors, and pregnancy-related risk factors were also compared to assess influence on breastfeeding initiation rates. RESULTS Women delivered by successful VBAC were 47% more likely to initiate breastfeeding than women delivered by scheduled repeat cesarean (adjusted relative risk 1.47; 95% confidence interval 1.35, 1.60). Women who ultimately delivered by cesarean section with unsuccessful trial of labor were also more likely to breastfeed than women with a scheduled repeat cesarean section (61% vs. 58.7%, respectively) (adjusted relative risk 1.17; 95% confidence interval 1.04, 1.33). CONCLUSIONS Patients who undergo a scheduled repeat cesarean delivery are less likely to initiate breastfeeding. Women who attempt and succeed in achieving vaginal birth after a previous cesarean section are more likely to breastfeed than are women who deliver by repeat cesarean section. Also, those women who ultimately deliver by cesarean section after an unsuccessful trial of labor were also more likely to breastfeed than those women with a scheduled repeat cesarean section. This suggests there are influences on patient choice for delivery that also may influence the patients decision to breastfeed.

Adjunctive Therapies to Cerclage for the Prevention of Preterm Birth: A Systematic Review

The aim of this paper is to provide a thorough summary of published studies that have assessed the efficacy of adjunctive therapies used in addition to cervical cerclage as a preventive measure for preterm birth. We limited our paper to patients treated with cerclage plus an additional prophylactic therapy compared to a reference group of women with cerclage alone. The specific adjunctive therapies included in this systematic review are progesterone, reinforcing or second cerclage placement, tocolytics, antibiotics, bedrest, and pessary. We searched PubMed and Cochrane databases without date criteria with restriction to English language and human studies and performed additional bibliographic review of selected articles and identified 305 total studies for review. Of those, only 12 studies compared the use of an adjunctive therapy with cerclage to a reference group of cerclage alone. None of the 12 were prospective randomized clinical trials. No comparative studies were identified addressing the issues of antibiotics, bedrest, or pessary as adjunctive treatments to cerclage. None of the 12 studies included in this paper demonstrated a clear benefit of any adjunctive therapy used in addition to cerclage over and above cerclage used alone; however, few studies with small numbers limited the strength of the conclusions.

Vaginal birth after cesarean success in high-risk women: a population-based study

Objective:The study aim was to identify factors associated with vaginal birth after cesarean (VBAC) in high-risk women.Study Design:This is a population-based retrospective cohort study of all births in Ohio during 2006 and 2007. High-risk patients were defined as singleton gestations in women with one previous cesarean who had ⩾1 of the following risk factors: body mass index (BMI)⩾30, hypertension, or diabetes. Multivariate logistic regression was utilized to estimate the relative influence of each factor on successful VBAC.Result:A total of 280 882 births were analyzed: of them, 79 084 (27.1%) were high-risk pregnancies and 8658 (10.9%) women had undergone one previous cesarean; 1433 (16.6%) underwent a trial of labor after cesarean (TOLAC). Of them, 974 (68.0%) had a successful VBAC, whereas 459 (32.0%) did not. Factors significantly associated with VBAC success were as follows: a prior vaginal delivery; pregnancy weight gain ⩽30 lbs; Caucasian race; and labor augmentation.Conclusion:High-risk women with one prior cesarean are unlikely to undergo a TOLAC, but have a high rate of VBAC.

Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia.

Objective:To study the association between the cerebroplacental ratio (CPR) and the development of pre-eclampsia.Study Design:Three study groups were determined: Group 1—normal umbilical artery (UA; referent), Group 2—abnormal UA and normal CPR and Group 3—abnormal UA and an abnormal CPR. The primary outcome was the development of severe pre-eclampsia.Results:We included 270 women. Women in Group 3 had significantly elevated rates of severe pre-eclampsia versus those in Group 1 and Group 2, 52.5% versus 5.1% and 15.4%, respectively, (P<0.01), adjusted odds ratio 4.14 (95% confidence interval, 2.59 to 6.61). Kaplan–Meier analysis revealed earlier delivery in women with pre-eclampsia in Group 3 versus Group 1, Cox–Mantel hazard ratio 2.39 (1.17 to 4.88), log rank P=0.01.Conclusion:An abnormal CPR is associated with a higher rate severe pre-eclampsia with delivery at earlier gestational ages than with a normal UA or an abnormal UA, but normal CPR.

Doppler for growth restriction: the association between the cerebroplacental ratio and a reduced interval to delivery

Objective:Evaluation of the cerebroplacental ratio (CPR) as an adjunct to umbilical artery Doppler (UA) to assess risk of delivery before 32 weeks and/or delivery within 2 weeks from diagnosis of fetal growth restriction (FGR).Study Design:In a cohort of fetuses with suspected FGR, UA Doppler was performed, and when abnormal the CPR was calculated (middle cerebral pulsatility index/umbilical artery pulsatility index). Doppler characteristics were used to determine three study groups: (1) normal UA, (2) abnormal UA with normal CPR and (3) abnormal UA with abnormal CPR. The primary outcomes were delivery before 32 weeks and delivery within 2 weeks. Adjusted odds ratio (aOR) with 95% confidence intervals (CIs) were calculated controlling for maternal age, chronic hypertension and tobacco use. We performed a linear regression analysis comparing the value of the CPR with the gestational age at delivery. Kaplan–Meier survival curve analysis with log-rank tests for probability was performed.Results:We included 154 patients: 91, 31 and 32 in Group 1, 2 and 3, respectively. Subjects in Group 3 had higher rates of the two primary outcomes: there was a fivefold increased risk (aOR=5.2 (95% CI=2.85–9.48)) for delivery before 32 weeks and over a fourfold increased risk for delivery within 2 weeks (aOR=4.76 (95% CI=2.32–9.76)) compared with those with a normal CPR (Group 1). In contrast, subjects in Group 2 (abnormal UA Doppler but normal CPR) had a similar rate of delivery before 32 weeks (aOR=1.16 (95% CI=0.55–2.48)) and within 2 weeks (aOR=1.07 (95% CI=0.43–2.69)). The median gestational age at delivery was 36, 36 and 29 weeks in Groups 1, 2 and 3, respectively (P<0.001). Linear regression analysis revealed a strong correlation between the value of the CPR and gestational age at delivery: R2=0.56, correlation coefficient=0.75. Kaplan–Meier analysis revealed a significantly decreased latency to delivery in Group 3, as opposed to Groups 1 and 2 (Cox–Mantel hazard ratio (HR) of Group 2 versus Group 1 HR=1.20 (95% CI=0.78–1.83) and Group 3 versus Group 1 HR=5.00 (95% CI=2.4–10.21)).Conclusion:The CPR differentiates those fetuses with suspected growth restriction most at risk for delivery before 32 weeks and delivery within 2 weeks from those likely to have a more prolonged latency until delivery is required. In patients with suspected FGR and an abnormal UA, the CPR can be used to guide management decisions, such as maternal hospitalization and/or transport, aggressive fetal monitoring and antenatal corticosteroid administration.

Estimation of the Growth Rate in Fetuses With an Abnormal Cerebroplacental Ratio Compared to Those With Suspected Growth Restriction Without Evidence of Centralization of Blood Flow

To evaluate the growth rate in fetuses with suspected growth restriction according to their Doppler characteristics.

Damage-Associated Molecular Pattern and Fetal Membrane Vascular Injury and Collagen Disorganization in Lipopolysaccharide-Induced Intra-amniotic Inflammation in Fetal Sheep

To understand the changes in the structural integrity of fetal membranes during intrauterine inflammation, we evaluated the time course of expression and localization of damage-associated molecular patterns (DAMPs) and injury/remodeling in collagen and vascular smooth muscle. Time-mated ewes received intra-amniotic (IA) saline or IA lipopolysaccharide (LPS) for 5 hours to 15 days prior to a preterm delivery at 125 ± 2 days (n = 5-7 animals/group). The DAMP high mobility group box 1 (HMGB1) protein assessed by Western blot was induced within 24 hours after IA LPS in the fetal membranes, and HMGB1 expression was localized to amnion epithelium, chorion vascular endothelium, and infiltrating inflammatory cells by immunohistology. Markers of vascular injury, intercellular adhesion molecule 1, and tissue plasminogen activator messenger RNA (mRNA) expression increased 5 to 12 hours after IA LPS in the chorioamnion indicating vascular injury. Chorion vascular remodeling with increased chorion arteriolar smooth muscle actin expression by morphometric analyses of immunohistology was noted 15 days after IA LPS. Collagen expression was nonhomogeneous by histochemical staining, and there was a trend toward decreased mRNA expression of collagen subunit COL5A1 after IA LPS. Conclusions: Intrauterine inflammation induced early increases in HMGB1 in the chorioamnion with a concomitant vascular injury followed by chorion arteriolar hypertrophy. There was nonhomogeneous collagen expression in the chorioamnion. These results have implications for understanding the pathogenesis of IA inflammation-induced preterm rupture of membranes.

Comparison of prostaglandin and mechanical cervical ripening in the setting of small for gestational age neonates

Abstract Objective: The objective of this study is to determine whether cervical ripening with misoprostol (MP) is associated with higher rates of cesarean delivery (CD) compared with dinoprostone (DP) or Pitocin/Foley balloon (PFB) in infants found to be small for gestational age (SGA). Study design: Single center institution based cohort study of all inductions between 2008 and 2012 where birth weight was found to be as SGA (< 10th percentile). Maternal demographic, obstetric, and labor characteristics were compared between SGA births where cervical ripening with MP, DP, or PFB was used as the primary agent. The primary outcome was CD after attempted induction between the three study groups which included MP, DP, and PFB. Secondary outcomes included inability to achieve active labor (defined as cervical dilation of 6 cm or greater), cervical dilation at the time of CD, the incidence of CD for the indication of non-reassuring fetal status, and neonatal outcomes including Apgar scores and admission to neonatal intensive care unit. Multivariable logistic regression was performed to evaluate the association of these outcomes with MP as the induction agent versus the referent groups, PFB. Results: Of 260 inductions where the infant was found to be SGA by birth weight during the 5-year period, 172 (66.2%) patients were induced using MP, 38 (14.6%) with DP, and 50 (19.2%) with PFB. There were no differences in baseline characteristics between groups (age, race, BMI, parity, induction indication, birth weights, or maternal comorbidities). MP did not increase rate of CD which was 25.6%, 26.3%, and 22.0% in the MP, DP, and PFB groups, respectively (p = .86). There were also no differences in incidence of CD for non-reassuring fetal well-being (NRFWB), failure to attain active labor, or cervical dilation at time of CD between induction groups. NICU admission was 18%, 18%, and 16% (p = .94) between MP, DP, and PFB groups, respectively. MP was not associated with an increased rate of CD when compared with the other two agents combined, aOR 0.93 (0.67–1.30, 95% CI). Conclusion: MP appears to have similar efficacy and safety when compared with other cervical ripening agents in pregnancies complicated by SGA.