Johanna Quist-Nelson

Universal cervical length screening for preterm birth prevention in the United States (.)

Abstract Objective: To evaluate the incidence of implementation of universal cervical length (CL) screening for preterm birth (PTB) prevention among institutions with Maternal–Fetal Medicine (MFM) fellowship training in the United states. Methods: In January 2015, we conducted a national survey of institutions with MFM Fellowship Programs regarding implementation of universal CL screening, defined as CL screening of women with singleton gestations without a prior spontaneous PTB. We identified whether a transabdominal ultrasound (TAU) or transvaginal ultrasound (TVU) was used for screening. Results were compared by geographical regions. Results: We identified 78 MFM fellowship programs nationwide, of which 100% responded to the survey, provided by MFM fellows (86%) and MFM division directors (14%). In January 2015, 53 programs (68%) had implemented a CL screening program, with 25 programs (32%) using TVU while the rest (36%) used TAU for CL screening. The 16 programs in the Midwest had the highest percent of CL screening (15 programs, 94%), with the highest use of TVU (8 programs 50%). The 24 programs in the South had the lowest percent of CL screening (14 programs, 58%) (odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.19–1.46) and the lowest use of TVU (3 programs,12.5%) (OR: 0.22, 95% CI: 0.05–0.78) compared to rest of US). Conclusion: Universal CL screening has been implemented by over two-thirds of institutions with MFM Fellowship Programs, as of January 2015. Of these programs, about half screen by TAU and half by TVU.

Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE To assess the efficacy of vaginal cleansing before cesarean delivery in reducing postoperative endometritis. DATA SOURCES MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library were searched from their inception to January 2017. METHODS OF STUDY SELECTION Selection criteria included all randomized controlled trials comparing vaginal cleansing (ie, intervention group) with a control group (ie, either placebo or no intervention) in women undergoing cesarean delivery. Any method of vaginal cleansing with any type of antiseptic solution was included. The primary outcome was the incidence of endometritis. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% CI. TABULATION, INTEGRATION, AND RESULTS Sixteen trials (4,837 women) on vaginal cleansing immediately before cesarean delivery were identified as relevant and included in the review. In most of the included studies, 10% povidone-iodine was used as an intervention. The most common way to perform the vaginal cleansing was the use of a sponge stick for approximately 30 seconds. Women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% compared with 8.8%; RR 0.52, 95% CI 0.37-0.72; 15 studies, 4,726 participants) and of postoperative fever (9.4% compared with 14.9%; RR 0.65, 95% CI 0.50-0.86; 11 studies, 4,098 participants) compared with the control group. In the planned subgroup analyses, the reduction in the incidence of endometritis with vaginal cleansing was limited to women in labor before cesarean delivery (8.1% compared with 13.8%; RR 0.52, 95% CI 0.28-0.97; four studies, 440 participants) or those with ruptured membranes (4.3% compared with 20.1%; RR 0.23, 95% CI 0.10-0.52; three studies, 272 participants). CONCLUSION Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. Because it is generally inexpensive and a simple intervention, we recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds. More data are needed to assess whether this intervention may be also useful for cesarean deliveries performed in women not in labor and for those without ruptured membranes. SYSTEMATIC REVIEW REGISTRATION PROSPERO International prospective register of systematic reviews, https://www.crd.york.ac.uk/PROSPERO/, CRD42017054843.

Are Asian American women at higher risk of severe perineal lacerations

Abstract Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations. Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio. Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p < 0.0001). Analysis of literature indicated that Asian American women are 74% more likely to experience severe perineal lacerations (aOR 1.74, 99% CI 1.72–1.76, p < 0.0001) than non-Asians. Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.

Current Implementation of Universal Cervical Length Screening for Preterm Birth Prevention in the United States [19].

INTRODUCTION: To evaluate the incidence of implementation of universal cervical length (CL) screening for preterm birth (PTB) prevention among institutions with Maternal-Fetal Medicine (MFM) fellowship training in the United States. METHODS: In January 2015, we conducted a national survey of institutions with MFM Fellowship Programs regarding implementation of universal CL screening, defined as CL screening of women with singleton gestations without a prior spontaneous PTB. We also identified whether a transabdominal ultrasound (TAU) or transvaginal ultrasound (TVU) was used for screening. Results were compared by geographical regions. We also assessed if a low obstetrical volume (annual deliveries<3000) affected implementation of TVU CL screening program. RESULTS: We identified 78 MFM fellowship programs, of which 100% responded to the survey. Fifty-three programs (68%) had implemented a CL screening program, with 25 programs (32%) using TVU while the rest (36%) used TAU for CL screening. The Midwest had the highest percent of CL screening (94%), with the highest use of TVU (50%). The South had the lowest percent of CL screening (58%) (OR 0.52 [0.19–1.46]) and the lowest use of TVU (12.5%) (OR 0.22 [0.05–0.78]) compared to rest of the United States. Lower annual obstetrical volume did not affect the likelihood of implementing a program using TVU (7.6%) compared to programs having higher obstetrical volume (24.3%) (OR 0.73 [0.24–2.17]). CONCLUSION/IMPLICATIONS: Universal CL screening has been implemented by over two thirds of institutions with MFM Fellowship Programs. Of these programs, approximately half screen by TAU and half by TVU.

Progestogens in singleton gestations with preterm prelabor rupture of membranes: a systematic review and metaanalysis of randomized controlled trials

OBJECTIVE DATA: Preterm prelabor rupture of membranes occurs in 3% of all pregnancies. Neonatal benefit is seen in uninfected women who do not deliver immediately after preterm prelabor rupture of membranes. The purpose of this study was to evaluate whether the administration of progestogens in singleton pregnancies prolongs pregnancy after preterm prelabor rupture of membranes. STUDY: Searches were performed in MEDLINE, OVID, Scopus, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to “progesterone,” “progestogen,” “prematurity,” and “preterm premature rupture of membranes” from the inception of the databases until January 2018. We included all randomized controlled trials of singleton gestations after preterm prelabor rupture of membranes that were randomized to either progestogens or control (either placebo or no treatment). Exclusion criteria were trials that included women who had contraindications to expectant management after preterm prelabor rupture of membranes (ie, chorioamnionitis, severe preeclampsia, and nonreassuring fetal status) and trials on multiple gestations. We planned to include all progestogens, including but not limited to 17‐&agr; hydroxyprogesterone caproate, and natural progesterone. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was latency from randomization to delivery. Metaanalysis was performed with the use of the random effects model of DerSimonian and Laird to produce relative risk with 95% confidence interval. Analysis was performed for each mode of progestogen administration separately. RESULTS: Six randomized controlled trials (n=545 participants) were included. Four of the included trials assessed the efficacy of 17‐&agr; hydroxyprogesterone caproate; 1 trial assessed rectal progestogen, and 1 trial had 3 arms that compared 17‐&agr; hydroxyprogesterone caproate, rectal progestogen, and placebo. The mean gestational age at time randomization was 26.9 weeks in the 17‐&agr; hydroxyprogesterone caproate group and 27.3 weeks in the control group. 17‐&agr; Hydroxyprogesterone caproate administration was not found to prolong the latency period between randomization and delivery (mean difference, 0.11 days; 95% confidence interval, –3.30 to 3.53). There were no differences in mean gestational age at delivery, mode of delivery, or maternal or neonatal outcomes between the 2 groups. Similarly, there was no difference in latency for those women who received rectal progesterone (mean difference, 4.00 days; 95% confidence interval, –0.72 to 8.72). CONCLUSION: Progestogen administration does not prolong pregnancy in singleton gestations with preterm prelabor rupture of membranes.

Implementation of vaginal cleansing prior to cesarean delivery to decrease endometritis rates

Abstract Background: Endometritis is a postpartum complication that is more common after cesarean delivery. It frequently requires intravenous antibiotic administration, prolonged hospital stays, and carries a risk of sepsis or abscess formation. Precesarean vaginal preparation has been shown to decrease the risk of endometritis in patients who have labored or have ruptured membranes. Objective: The objective of this study was to assess the practical implementation of a protocol for vaginal cleansing prior to cesarean delivery and the subsequent effect on endometritis rates in a clinical setting. Study design: This is a before–after retrospective cohort study evaluating the first 6 months of implementation of a vaginal cleansing protocol at a single institution. The primary outcome was the rate of implementation. Secondary outcomes included endometritis and other postoperative complications. Results: The rate of implementation after 6 months was 68.3% (p < .001) and postoperative endometritis rates decreased from 14.0% before implementation to 11.7% after implementation (p .49, OR 0.77, CI 0.36–1.62). Postoperative fever decreased from 22.3% to 18.3% (p .256, OR 0.70, CI 0.37–1.30) and infectious wound complications were 4.5% and 5.8%, respectively (p .76, OR 1.07, CI 0.69–3.64). Conclusions: Implementation of a protocol for vaginal cleansing prior to cesarean delivery in women with ruptured membranes or in labor has high uptake, but in almost a third of eligible women it was not performed. The implementation, has led to a clinical, although not statistical, decrease in postoperative endometritis. Continued research is needed to explore how to improve uptake of this quality improvement measure.

Dextrose intravenous fluid therapy in labor reduces the length of the first stage of labor

The aim of this systematic review with meta-analysis was to evaluate the effect on length of labor when patients receive IVF with or without dextrose. Searches were performed in electronic databases from inception of each database to May 2018. Trials comparing intrapartum IVF containing dextrose (i.e. intervention group) with no dextrose or placebo (i.e. control group) were included. Only trials examining low-risk pregnancies in labor at ≥36 weeks were included. Studies were included regardless of oral intake restriction. The primary outcome was the length of total labor from randomization to delivery. The meta-analysis was performed using the random effects model. Sixteen trials (n = 2503 participants) were included in the meta-analysis. Women randomized in the IVF dextrose group did not have a statistically significant different length of total labor from randomization to delivery compared to IVF without dextrose (MD -38.33 min, 95% CI -88.23 to 11.57). IVF with dextrose decreased the length of the first stage (MD -75.81 min, 95% CI -120.67 to -30.95), but there was no change in the second stage. In summary, use of IVF with dextrose during labor in low-risk women at term does not affect total length of labor, but it does shorten the first stage of labor.

External cephalic version in premature rupture of membranes: a systematic review

Abstract Background: External cephalic version (ECV) increases the likelihood of a vaginal delivery in patients with breech presentation. Our objective was to determine the rate of cephalic vaginal delivery in women undergoing ECV after PROM. Methods: We performed a systematic review of all case reports, case series and clinical trials of patients undergoing an ECV after PROM ≥ 24 weeks. Maternal demographics and outcome data were obtained. The primary outcome was rate of cephalic vaginal delivery. Statistical analysis was performed for continuous outcomes by calculating mean and standard deviations for appropriate variables. Results: The systematic review yielded six papers with 13 case reports and no clinical trials of ECV after PROM. The rate of success to cephalic presentation was 46.1% (six of 13 cases), with a subsequent vaginal delivery rate of 23.1% (three of 13 cases). The rate of umbilical cord prolapse was 33.3% (two of six cases). Conclusions: ECV after PROM has been reported in 13 cases in the literature. For the cases reported, 46.1% of ECV were successful in turning to cephalic position, but only 23.1% resulted in a vaginal delivery. There was a 33.3% incidence of umbilical cord prolapse. Given the high rate of umbilical cord prolapse, it would be imperative to offer an ECV in the setting of PROM only at an institution that has the ability to perform the indicated emergent cesarean delivery and only after appropriate counseling.