Jordan H. Perlow

Massive maternal obesity and perioperative cesarean morbidity.

OBJECTIVE Our purpose was to determine the impact of massive maternal obesity (weight > 300 pounds) on perioperative morbidity among patients undergoing cesarean section. STUDY DESIGN A case-control study was conducted on 43 massively obese pregnant women, identified by perinatal database search, who were delivered by cesarean section between Jan. 1, 1987, and Dec. 31, 1991, at Long Beach Memorial Womens Hospital. Forty-three randomly selected patients who underwent cesarean delivery served as the control group. Medical records were abstracted for perioperative variables and compared between groups. Student t test, chi 2, and Fishers exact statistical analysis were used where appropriate. RESULTS No significant differences were observed between groups for maternal age, parity, use of prophylactic antibiotics, length of recovery room stay, or wound dehiscence. The massively obese group was observed to be at significantly increased risk for emergency cesarean section (32.6% vs 9.3%, p = 0.02), prolonged delivery interval (25.6% vs 4.6%, p = 0.01), and total operative time (48.8% vs 9.3%, p < 0.0001), blood loss > 1000 ml (34.9% vs 9.3%, p = 0.009), multiple epidural placement failures (14.0% vs 0%, p = 0.02), postoperative endometritis (32.6% vs 4.9%, p = 0.002), and prolonged hospitalization (34.9% vs 2.3%, p = 0.0003). CONCLUSION Massively obese pregnant women undergoing cesarean section are at significantly increased risk for perioperative morbidity.

Severity of asthma and perinatal outcome

Abstract OBJECTIVE : Our objective was to determine the impact of asthma and its severity, as determined by medication requirements, on perinatal outcome. STUDY DESIGN : A case-controlled study was conducted. Among 30,940 live births at Long Beach Memorial Medical Center Womens Hospital, 183 deliveries occurred between Jan. 1, 1985, and Dec. 31, 1990, that were coded for the diagnosis of asthma. Eighty-one that required the chronic use of medications to control their disease were identified. Thirty-one patients were steroid dependent and 50 were non-steroid-medication dependent. A control group was randomly selected (excluding maternal transports), and selected perinatal variables were compared between groups. RESULTS : When compared with controls, steroid-dependent asthmatics were at significantly increased risk for gestational (1.5% vs 12.9%) and insulin-requiring diabetes (0% vs 9.7%). Preterm delivery and preterm premature ruptured membranes occurred significantly more often in both asthmatic groups. Overall cesarean section rate was significantly increased in the non-steroid-medication-dependent asthmatic group when compared with controls (56.0% vs 30.0%). Delivery by primary cesarean section was significantly more common in the steroid-dependent group (38.7% vs 19.2%), and a strong trend was noted among the non-steroid-medication-dependent patients (34.0% vs 19.2%). Cesarean delivery for fetal distress was also more common in these two asthmatic groups. Neonates born to both groups of asthmatic pregnant women were significantly more likely to be of birth weight CONCLUSIONS : Perinatal outcome is compromised in the pregnancy complicated by chronic medication-dependent asthma. The extent is variable and is associated with disease severity, as measured by medication requirements. (Am J Obstet Gynecol 1992;167:963–7.)

Perinatal outcome in pregnancy complicated by massive obesity

OBJECTIVE: Our objective was to determine the impact of massive obesity during pregnancy, defined as maternal weight >300 pounds, on perinatal outcome. STUDY DESIGN: A case-controlled study was conducted. Between Jan. 1, 1986, and Dec. 31, 1990, 111 pregnant women weighing >300 pounds who were delivered at Long Beach Memorial Womens Hospital were identified with a perinatal data base search. A control group matched for maternal age and parity was selected, and perinatal variables were compared between groups. To control for potential confounding medical complications, massively obese patients with diabetes and/or chronic hypertension antedating the index pregnancy were excluded from the obese group, and the data were reanalyzed. The Student t test x2, and Fishers exact statistical analysis were used where appropriate. RESULTS: Massively obese pregnant women are significantly more likely to have a multitude of adverse perinatal outcomes, including primary cesarean section (32.4% vs 14.3%, p = 0.002), macrosomia (30.2% vs 11.6%, pp = 0.0001), intrauterine growth retardation (8.1% vs 0.9%, p = 0.03), and neonatal admission to the intensive care unit (15.6% vs 4.5%, p = 0.01). They also are significantly more likely to have chronic hypertension (27.0% vs 0.9%, p < 0.0001) and insulin-dependent diabetes mellitus (19.8% vs 2.7%, p = 0.0001). However, when those massively obese pregnant women with diabetes and/or hypertension antedating pregnancy are excluded from analysis, no statistically significant differences in perinatal outcome persisted. CONCLUSION: Massively obese pregnant women are at high risk for adverse perinatal outcome; however, this risk appears to be related to medical complications of obesity. (Am J Obstet Gynecol 1992;167:958–62.)

Obesity and pregnancy: clinical management of the obese gravida.

In recent years, the prevalence of obesity in the United States has risen dramatically, especially among women of reproductive age. Research that has specifically evaluated pregnancy outcomes among obese parturients has allowed for a better understanding of the myriad adverse perinatal complications that are observed with significantly greater frequency in the obese pregnant population. The antepartum, intrapartum, intraoperative, postoperative, and postpartum periods are all times in which the obese pregnant woman is at greater risk for adverse maternal-fetal outcomes, compared with her ideal bodyweight counterpart. Comorbid medical conditions that commonly are associated with obesity further accentuate perinatal risks. All obese pregnant women should be counseled regarding these risks, and strategies should be used to improve perinatal outcome whenever possible. Obese women of reproductive age ideally should be counseled before conception and advised to achieve ideal bodyweight before pregnancy.

The effect of colonization with group B streptococci on the latency phase of patients with preterm premature rupture of membranes

OBJECTIVE Our purpose was to determine whether colonization of pregnant women with group B streptococci shortens the latency time from rupture of membranes to delivery in patients with preterm premature rupture of membranes. STUDY DESIGN All patients transferred to Long Beach Memorial Womens Hospital with the diagnosis of preterm premature rupture of the membranes were prospectively recorded. The patients included in the study were transferred between Jan. 1, 1986, and June 30, 1991. Data were collected in regard to various obstetric characteristics, the presence or absence of a digital vaginal examination, tocolytic usage, antibiotic usage, and results of the culture for group B streptococci. The latency period was defined as days from membrane rupture to delivery. Patients with multiple gestations, cerclage in place, advanced labor on admission, or an indicated delivery on admission were excluded from data analysis. Patients with a positive culture for group B streptococci were then compared with those having a negative culture in regard to latency time after membrane rupture. RESULTS The study population was made up of 332 patients. Forty-three (13%) were positive for group B streptococci; they were compared with 289 that were culture negative. There was no difference in the latency period from membrane rupture to delivery when we controlled for digital vaginal examinations and antibiotic usage. In addition, all other comparisons between the two groups were not significant. CONCLUSION When the presence of a digital vaginal examination, antibiotic usage, and tocolytic usage are controlled for, colonization with group B streptococci by itself does not appear to affect the latency time from premature rupture of membranes to delivery.

Umbilical artery aneurysm.

BACKGROUND: Umbilical artery aneurysm is a rare condition associated with increased risk for aneuploidy and fetal demise. CASE: We report a case of umbilical artery aneurysm discovered at 27 weeks of gestation in one fetus of a dichorionic, diamniotic twin pregnancy. The patient was hospitalized to monitor for expansion of the aneurysm. Corticosteroids were administered, and, after genetic amniocentesis revealed a normal karyotype, cesarean delivery was performed at 28 2/7 weeks of gestation. Pathologic examination confirmed an umbilical artery aneurysm in the cord of the affected fetus. CONCLUSION: Given the high incidence of aneuploidy associated with umbilical artery aneurysm, it is important to consider karyotype analysis of the affected fetus. If a normal karyotype is identified, early delivery may be warranted to decrease the risk of fetal demise.

Body mass index and operative times at cesarean delivery.

To the Editor: We read with interest the article by Girsen and colleagues regarding prolonged cesarean operative times among obese women. The findings raise important clinical questions for the care of pregnancies complicated by extreme obesity. We are interested in the authors’ thoughts regarding the clinical implications of the significantly prolonged operative delivery times. Should we be presenting such information to patients with extreme obesity and creating awareness of the potential compromised status of the newborn imposed by the effects of obesity on our surgical abilities should emergent cesarean delivery become necessary? In a case–control study, an incision-to-delivery interval of greater than 15 minutes was required in more than 25% of women weighing 300 pounds or more. For patients with more extreme degrees of obesity at high risk for emergent cesarean delivery, complete counseling might include a discussion of how prolonged surgical delivery timemay affect fetal well-being. With cesarean delivery rates reported at nearly 50% for superobese pregnant women, is there a point at which a planned primary cesarean delivery is preferable to the risks imposed by the potential need for urgent cesarean delivery and its greater risk of adverse maternal–fetal–neonatal outcomes? One may anticipate that the increased time from incision to delivery will negatively affect optimal outcomes should emergent cesarean delivery be required. Although we believe that improving overall obstetric outcomes includes safe attempts at reducing cesarean delivery rates overall, we suggest that information concerning prolonged delivery interval times be shared with obese patients to allow for the most informed decision regarding delivery mode.

Maternal mortality: time for national action.

To the Editor: As obstetric practitioners committed to the call for “national action” against the rising U.S. maternal mortality rate, as recently outlined by Main and Menard, we read with interest their editorial pointing out the common causes of maternal mortality and severe maternal morbidities, the preventable nature of many such unfortunate outcomes, the critical need for standardized approaches to acute hypertension and obstetric hemorrhage management, and the importance of systematic maternal mortality reviews. In discussing the causes of maternal mortality, the authors state: “cardiovascular conditions. including cardiomyopathy have emerged as the number one cause of death....” We wish to point out, however, recent compelling data indicating that, sadly, maternal deaths due to homicide and suicide may occur with greater frequency than the common obstetric causes noted in the editorial. Given these data and our own patient-care experiences in these tragic situations, we have advocated universal prenatal and postpartum depression screening, despite a lack of consensus in this regard from the American College of Obstetricians and Gynecologists. As the important nationwide initiatives outlined byMain andMenard begin tackling the rising maternal mortality rate through the establishment of case review committees, we strongly encourage that issues of intimate partner violence, maternal depression, and suicide be addressed seriously as potentially preventable causes of maternal death. Whereas the timely use of uterotonics, anticoagulants, and antibiotics likely can contribute to the prevention of maternal death in specific clinical scenarios, it also is conceivable that a simple screening tool designed to detect maternal depression and perception of physical threat may have similar benefits.