Joseph R. Wax

Fetal laceration injury at cesarean delivery

Objective To investigate the incidence of fetal laceration injury in cesarean delivery. Methods A retrospective review was conducted using a computer-based data coding system. All neonatal records were reviewed for infants delivered by cesarean during a 2-year period. Maternal records were reviewed in those cases of documented fetal laceration injury. The Fisher exact test was used when indicated. Results There were 904 cesarean deliveries performed during the study period; of these, 896 neonatal records (98.4%) were available for review. Seventeen laceration injuries were recorded (1.9%). The incidence of laceration appeared higher when the indication for cesarean was nonvertex (6.0% versus 1.4%, P = .02). One of 17 (5.9%) maternal records indicated the presence of the laceration of the fetus. Conclusion Fetal laceration injury at cesarean delivery is not rare, especially when it is performed for nonvertex presentation. The minority of obstetric records show documentation of such lacerations, suggesting that this complication often may not be recognized by obstetricians.

Obesity-related complications of pregnancy vary by race.

OBJECTIVE To evaluate racial effects on obstetric complications in obese gravidas. METHODS The obstetric database was reviewed for the period 6/1/94 to 3/31/97. All clinic patients delivering singletons were included. Obesity was defined as a body mass index (BMI) of 29 kg/m2 or more, or a pre-pregnancy weight of 200 pounds or more. Complications studied included hypertension, diabetes, cesarean delivery, and fetal macrosomia. RESULTS Of 2,424 eligible subjects, 168 were obese (6.9%). Obese patients had higher rates of chronic hypertension and pregestational diabetes, as well as increased rates of preeclampsia, gestational diabetes, fetal macrosomia, cesarean delivery, and operative vaginal delivery compared to nonobese patients. Of the obese patients, 105 (63%) were Hispanic, 39 (23%) were African American, and 24 (14%) were White; no Asian or Mixed/Other patients were obese. Mean BMIs of the obese subgroups did not differ (P = 0.14), but prepregnancy weights were greater in Whites than Hispanics (P < 0.002). Obese Hispanics had an increased rate of gestational diabetes (P = 0.04) and of infant weight > or =4,500 g (P =.03). Obese Hispanic and African American women were more likely than obese Whites to deliver by cesarean (P = 0.03). CONCLUSION Racial differences affect the complication rates in obese gravidas, and may influence prenatal counseling and pregnancy management.

Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births

OBJECTIVE We sought to evaluate perinatal morbidity by delivery location (hospital, freestanding birth center, and home). STUDY DESIGN Selected 2006 US birth certificate data were accessed online from the Centers for Disease Control and Prevention. Low-risk maternal and newborn outcomes were tabulated and compared by birth facility. RESULTS A total of 745,690 deliveries were included, of which 733,143 (97.0%) occurred in hospital, 4661 (0.6%) at birth centers, and 7427 (0.9%) at home. Compared with hospital deliveries, home and birthing center deliveries were associated with more frequent prolonged and precipitous labors. Home births experienced more frequent 5-minute Apgar scores <7. In contrast, home and birthing center deliveries were associated with less frequent chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, neonatal intensive care unit admission, and birthweight <2500 g. CONCLUSION Home births are associated with a number of less frequent adverse perinatal outcomes at the expense of more frequent abnormal labors and low 5-minute Apgar scores.

Risks and management of obesity in pregnancy: current controversies

Purpose of review To explore recent developments in obesity-related topics of interest and importance to obstetricians. Specifically addressed are the impact of gestational weight gain on perinatal risk, the increased risk of congenital anomalies in offspring, developmental origins of health and disease in offspring, and reproductive issues following bariatric surgery. Recent findings Limiting maternal weight gain in obese women to less than 15 lb may favorably attenuate perinatal risk (macrosomia, cesarean delivery, preeclampsia) but increase risk for small-for-gestational-age newborns. Obese women are at significantly increased risk for offspring to develop open neural tube defects and congenital heart disease as well as other anomalies. Impaired sonographic visualization in this population may impede prenatal diagnosis of these serious birth defects. Intrauterine nutritional overabundance may cue adaptive fetal responses predisposing to childhood and adult obesity as well as the metabolic syndrome. Bariatric surgery, the only effective treatment for morbid obesity, causes lifelong physiologic and anatomic changes associated with significant reproductive implications. Procedures can predispose to caloric and micronutrient deficiencies, improved fertility and fecundity, and late surgical complications. Pregnancy outcomes are typically similar to those of women without previous bariatric surgery and better than those of untreated morbidly obese women. Summary Obesity and its surgical treatment are associated with lifelong health implications for the mother as well as her offspring. An appreciation of these obesity-related reproductive issues is critical for optimal care of this growing segment of the female population.

Female reproductive issues following bariatric surgery

One in 3 adult American women is obese. Almost half of the approximately 100,000 bariatric surgeries performed in 2004 were on reproductive-aged women. Anatomic and physiologic changes resulting from such surgery may have significant clinical implications for preconception, pregnancy, and postpartum care. This review summarizes these issues and the available related literature, and offers guidelines for care of these patients. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that bariatric surgery has many anatomic and physiologic changes that potentially will affect future pregnancies, and state that attention to these physiologic changes and attention to potential nutritional deficiencies significantly improves the chances of a good pregnancy outcome.

Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital.

Objective: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar. Study design: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother–neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother–neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery. Results: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p < 0.05). Mother–neonatal dyads with a failed trial of labor sustained the greatest risk of complications. Conclusion: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.

The apgar score

The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting form that accounts for concurrent resuscitative interventions.

Congenital jejunal and ileal atresia: natural prenatal sonographic history and association with neonatal outcome.

Objective. The purpose of this study was to describe the prenatal sonographic features and natural course of congenital jejunal and ileal atresia and correlate the findings with neonatal outcomes. Methods. We identified all neonates with surgically confirmed jejunal or ileal atresia that had prenatal sonography and neonatal surgery in our center from January 1, 1995, to April 1, 2005. Sonography reports and images were reviewed, without knowledge of neonatal outcomes, for features of intestinal obstruction. Obstetric and neonatal outcomes were evaluated. Results. Fifteen (60%) of 25 offspring with atresias (10 jejunal, 4 ileal, and 1 jejunoileal) had sonography, of which 13 (86.6%) had features of atresia. Findings, number of affected fetuses, and gestational age at recognition included fetal echogenic bowel (n = 8), mean ± SD, 21.3 ± 3.8 weeks (range, 17.7–28.4 weeks); enlarged stomach (n = 5), 27.5 ± 5.0 weeks (range, 22.0–34.3 weeks); dilated bowel (n = 13), 27.8 ± 5.8 weeks (range, 18.3–35.9 weeks); and polyhydramnios (n = 6), 33.3 ± 1.7 weeks (range, 31.0–35.6 weeks). No fetus with ileal atresia had an enlarged stomach or polyhydramnios. Delivery occurred at a mean of 34.7 ± 3.6 weeks, with 9 (60%) cesarean deliveries. Neonatal outcomes of age at surgery, neonatal intensive care unit days, hospital days, total parenteral nutrition days, and death were similar whether or not fetal echogenic bowel, enlarged stomach, dilated bowel, or polyhydramnios was present. Likewise, these outcomes did not vary by type of atresia or time of diagnosis (prenatal or neonatal). Conclusions. Jejunal and ileal atresia have specific sonographic patterns allowing specific prenatal diagnoses in most affected fetuses. Prenatal sonographic findings and time of diagnosis did not affect neonatal outcome.

Mild fetal cerebral ventriculomegaly: Diagnosis, clinical associations, and outcomes

The normal fetal lateral ventricular diameter remains stable at 10 mm over gestation. Mild ventriculomegaly, defined as a lateral ventricular diameter of ≥10 mm but ≤15 mm or a choroid-lateral ventricular separation ≥3 mm but ≤8 mm occurs bilaterally in 0.15–0.7% of fetuses and unilaterally in 0.07% of pregnancies. This finding is associated with an increased risk of fetal chromosomal abnormalities, congenital anomalies and infections, syndromes, perinatal death, and childhood developmental delays. Prenatal evaluation includes targeted sonographic examination for central nervous system and extra-central nervous system abnormalities, and diagnostic amniocentesis for chromosomal analysis and infectious disease studies. Individualized patient counseling is based on these test results. Optimal postnatal care involves appropriate pediatric neurologic and developmental specialists. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to define the normal appearance and size of the fetal cerebral ventricles, to list the conditions associated with mild ventriculomegaly, and to explain the natural course of mild bilateral isolated ventriculomegaly.

Fetal intracardiac echogenic foci: does it matter which ventricle?

We sought to determine whether an association exists between the location of intracardiac echogenic foci and fetal aneuploidy or structural cardiac lesions. A search of the English language literature since 1980 revealed nine studies reporting location of intracardiac echogenic foci, fetal chromosomal abnormalities, and cardiac anomalies. Aneuploidy was noted in 10 of 217 fetuses with left ventricular and in one of 18 with right ventricular intracardiac echogenic foci. Three of 11 fetuses with biventricular intracardiac echogenic foci were aneuploid, which is significantly more frequently than when intracardiac echogenic foci were present in either ventricle alone (P = 0.02). There were nine cases of trisomy 21, four of trisomy 13, and one of trisomy 18. Structural cardiac lesions were recognized in eight of 217 fetuses with left ventricular foci, two of 18 with right ventricular foci, and one of 11 with biventricular intracardiac echogenic foci (P = 0.16). Biventricular intracardiac echogenic foci are more frequently associated with fetal aneuploidy but not structural lesions, as compared to isolated left or right ventricular intracardiac echogenic foci.