Lina Salman

Antiphospholipid syndrome characteristics and adverse pregnancy outcomes after 20 weeks of pregnancy

To assess outcomes after 20 weeks of pregnancy according to autoantibody profile and clinical presentation of maternal antiphospholipid syndrome (APS).

Adverse neonatal and maternal outcome following vacuum-assisted vaginal delivery: does indication matter?

PurposeTo estimate the impact of indication for vacuum-assisted vaginal delivery on neonatal and maternal adverse outcome.MethodsRetrospective analysis of women carrying singleton-term pregnancies undergoing vacuum-assisted vaginal delivery in a tertiary hospital (2007–2014). Cohort was stratified by indication: non-reassuring fetal heart rate or prolonged second stage. Primary outcome was adverse neonatal outcome and secondary outcome was maternal morbidity. Logistic regression analysis was utilized to adjust for potential confounders.ResultOverall, 4931 women met inclusion criteria. Delivery indication was prolonged second stage in 3143 (64%) cases and non-reassuring fetal heart rate in 1788 (36%). In the non-reassuring fetal heart rate group, there were higher rates of cephalohematoma, low 5-min Apgar-score, and asphyxia. In the prolonged second-stage group, there were higher rates of sepsis and post-partum hemorrhage. Composite neonatal birth trauma and maternal morbidity were higher for vacuum-assisted vaginal delivery following prolonged second stage. Following adjustment for confounders cephalohematoma (aOR 1.21, 95% CI 1.04–1.41), low 5-min Apgar-score (aOR 2.91, 95% CI 1.26–4.67) and asphyxia (aOR 1.81 95% CI 1.35–2.44) remained significant in the non-reassuring fetal heart rate group and neonatal sepsis remained significant for the prolonged second-stage group (aOR 1.77, 95% CI 1.38–2.27), pu2009<u20090.05 for all. However, there was no longer difference in the composite birth trauma, other neonatal or maternal morbidity.ConclusionThe indication for vacuum-assisted vaginal delivery has an impact on neonatal outcome. While cephalohematoma, low 5′ Apgar score, and asphyxia were more common in the non-reassuring fetal heart rate group, neonatal sepsis was more common in cases of prolonged second stage of labor.

The association between neonatal head circumference and second stage duration

Abstract Purpose: To determine if head circumference (HC) is an independent factor influencing second stage duration stratified by parity and epidural use. Materials and methods: A retrospective cohort analysis of all live, singleton, term (37–42 weeks) vaginal deliveries in one university affiliated medical center (2012–2014). Exclusion criteria included operative deliveries due to fetal distress, major fetal anomalies/chromosomal abnormalities or cases with missing anthropometric data. Maternal demographics, labor characteristics and neonatal anthropometrics including birth weight and HC were retrieved. Multivariate linear regression was utilized to evaluate the association between HC and second stage duration. Analysis was stratified into four groups by parity and epidural use. Results: Of the 16 240 singleton vaginal deliveries during study period, 12 428 deliveries met inclusion criteria. Stratification by parity and epidural analgesia yielded four groups: 3337 (26.9%), 735 (5.9%), 5099 (41.0%) and 3257 (26.2%) deliveries – nullipara with/without epidural and multipara with/without epidural, respectively. In all groups, a large neonatal HC was significantly and independently associated with longer second stage duration: nullipara with epidural (beta 10.06, 95% CI 7.75–12.37), nullipara without epidural (beta 7.58, 95% CI 4.73–10.43), multipara with epidural (beta 4.64, 95%CI 3.47–5.8) and multipara without epidural (beta 1.35, 95% CI 0.76–1.94), pu2009<u2009.001 for all. Birth weight was not associated with second stage duration in any of the groups (pu2009>u2009.05). Conclusion: Large neonatal HC is significantly associated with longer second stage duration.

Intrapartum fever and the risk for perinatal complications – the effect of fever duration and positive cultures

Abstract Objective: To estimate the association between intrapartum fever and adverse perinatal outcome. Methods: A retrospective cohort study of women attempting vaginal delivery at term in a tertiary hospital (2012–2015). Perinatal outcome of deliveries complicated by intrapartum fever (≥38.0u2009°C) were compared to women with no intrapartum fever matched by parity and gestational age at delivery in a 1:2 ratio. Maternal outcome included cesarean section (CS), operative vaginal delivery (OVD), retained placenta or post-partum hemorrhage. Neonatal outcome included 5-minute Apgar score <7, umbilical artery pH <7.1, meconium aspiration syndrome, need for mechanical ventilation or hypoxic ischemic encephalopathy. Results: Overall, 309 women had intrapartum fever and 618 served as controls. Women with intrapartum fever had higher rates of OVD (34.3 versus 19.6%, pu2009<u2009.001) and CS (20.7 versus 8.7%, pu2009<u2009.001). In multivariate analysis, intrapartum fever was independently associated with adverse maternal (3.75, 95%CI 2.65–5.30, pu2009<u2009.001) and neonatal outcome (3.39, 95%CI 1.78–6.45, pu2009<u2009.001). In febrile women, fever duration was related to maternal complications, specifically to CS. In addition, maternal bacteremia and positive placental cultures were risk factors for neonatal complications compared to those with negative cultures (23.3 versus 9.8%, pu2009=u2009.01). Conclusions: Intrapartum fever was associated with adverse perinatal complications. The duration of intrapartum fever, maternal bacteremia, and positive cultures further increase this risk.

The influence of body mass index on pregnancy outcome following single-embryo transfer

PurposeThe association between obesity and reproductive outcome is controversial. The aim of this study is to evaluate the effects of obesity on clinical pregnancy rates following transfer of a single fresh embryo.MethodsA retrospective cohort study was conducted at a single tertiary medical center, including all first, fresh, single-embryo transfers using non-donor oocytes, during 2008–2013. We compared clinical pregnancy rate and pregnancy outcomes of singleton live births resulting from the transfer of a single fresh embryo in normal weight, overweight, and obese women, defined as body mass index (BMI)u2009<u200925xa0kg/m2, ≥u200925xa0BMIu2009<30xa0kg/m2, and BMIu2009≥u200930xa0kg/m2, respectively.ResultsOverall, 1345 cases met the inclusion criteria with 864 single-embryo transfers (SETs) in normal weight women, 292 in overweight women, and 189 SETs in obese women, resulting in 538 clinical pregnancies and 354 singleton births. The clinical pregnancy rate per transfer was similar among the three groups (41.3, 37.6, 37.5%, respectively, pxa0=u20090.416). Similarly, there were no significant differences in live births or ongoing pregnancies. On multivariate logistic regression analysis, BMI did not impact the likelihood for clinical pregnancy (OR 0.98, 95% CI 0.96–1.008, pxa0=u20090.216).ConclusionsOur study demonstrated that obesity has no detrimental effect on the clinical pregnancy rate resulting from the transfer of a single fresh embryo.

Gestational weight gain and weight loss among women with gestational diabetes mellitus

AIMSnTo assess the association of gestational weight gain or loss with adverse pregnancy outcome among women with gestational diabetes mellitus (GDM).nnnMETHODSnRetrospective study of all women diagnosed with GDM, from July 2012 to December 2016, stratified by gestational weight change according to the institute of medicine recommendations. Primary maternal outcome was glycemic control and primary neonatal outcome was large or small for gestational age (LGA or SGA).nnnRESULTSn451 women were enrolled. Total weight change was associated with poor glycemic control, cesarean delivery, polyhydramnios, higher birthweight (when above recommendations), oligohydramnios and SGA (when below recommendations). GDM-related weight change was associated with polyhydramnios, cesarean delivery, higher birthweight (when above recommendations) and lower incidence of hypertensive disorders (when below recommendations). Adjusted odds ratio for poor glucose control among those with total weight gain above recommendations was 2.194 (95% CI 1.214-3.961) vs. those within-; and 1.048 (95% CI 0.611-1.799) vs. those who gained below- recommendations. The rate of SGA or LGA was not different for those gaining below or above vs. within recommendations.nnnCONCLUSIONnGestational weight gain is an important predictor of glycemic control and adverse pregnancy outcome among women with GDM - both overall and GDM-related.

The impact of epidural analgesia on the duration of the second stage of labor

BACKGROUNDnWe aimed to describe the length of second stage of labor in a contemporary cohort. We calculated the 5th, 50th, and 95th percentiles for second-stage length stratified by parity and epidural analgesia use and evaluated the effect of labor induction and oxytocin augmentation in our cohort.nnnMETHODSnWe did a retrospective analysis of all live, singleton, term vaginal deliveries in one tertiary hospital. Multivariate linear regression was used to evaluate second-stage duration confounders. First, we calculated the second-stage length and presented it as 5th, 50th, and 95th percentiles stratified by epidural analgesia and parity. Second, we evaluated the effect of labor induction and oxytocin augmentation on second-stage length, and third, we determined the demographic and obstetrical confounders that affected second-stage length.nnnRESULTSnOverall, 15xa0500 deliveries were included. Nulliparity, oxytocin augmentation, epidural use, birthweight, labor induction, lower body mass index, and higher maternal age were found to be significantly associated with prolongation of the second stage. Epidural use was associated with an additional 82xa0minutes for the 95th percentile for both nulliparas and multiparas and tripled the rate of prolonged second stage for the entire cohort. Labor induction was associated with clinically significant prolongation of the second stage in nulliparas with epidural analgesia only. Oxytocin was associated with longer duration of the second stage for nulliparas, regardless of epidural use.nnnDISCUSSIONnOur findings suggest a significant prolongation of the second stage in women receiving epidural analgesia. Recommendations for management of second stage should be reconsidered by contemporary data.

Complicated primary cesarean delivery increases the risk for uterine rupture at subsequent trial of labor after cesarean

PurposeTo evaluate whether cesarean delivery (CD) indication, labor status, and other primary CD characteristics affect the risk for uterine rupture in subsequent deliveries.MethodsA case–control study of women attempting trial of labor after cesarean (TOLAC) in a single, tertiary, university-affiliated medical center (2007–2016). Deliveries complicated by uterine rupture were matched to successful vaginal birth after cesarean (VBAC) deliveries in a 1:3 ratio. Indication, labor status and post-partum complications (postpartum hemorrhage and postpartum infection) at primary CD were compared between study and control group.ResultsDuring study period, there were 75,682 deliveries, of them, 3937 (5.2%) were TOLAC. Study group included 53 cases of uterine rupture at TOLAC and 159 women with successful VBAC. Women in study group had significantly lower rates of previous VBAC (15.1 vs. 28.9%, pu2009=u20090.047). Rate of postpartum complications at primary CD was significantly higher in women with TOLAC complicated by uterine rupture (7.5 vs. 1.9%, respectively, pu2009=u20090.042). Utilizing the multivariate logistic regression analysis, postpartum complications remained an independent risk factor for uterine rupture in the following TOLAC (aOR 4.07, 95% CI 1.14–14.58, pu2009=u20090.031).ConclusionPostpartum hemorrhage and infection, in primary CD, seem to be associated with increased risk for uterine rupture during subsequent TOLAC.

Cup detachment during vacuum-assisted vaginal delivery and birth outcome

ObjectiveTo determine the perinatal outcome associated with cup detachment during vacuum-assisted vaginal delivery (VAVD).MethodsA retrospective cohort study of all women attempting VAVD in a tertiary hospital (2012–2014). Singleton-term pregnancies were included. Antepartum fetal death and major fetal structural or chromosomal abnormalities were excluded. Primary outcome was neonatal birth trauma (subgaleal hematoma, subarachnoid hematoma, subdural hematoma, skull fracture, and/or erb’s palsy). Secondary outcomes were maternal complications or other neonatal morbidities. Outcomes were compared between women after ≥1 cup detachment (study group) and the rest (control group). Logistic regression analysis was utilized to adjust results to potential confounders.ResultsOverall, 1779 women attempted VAVD during study period. Of them, in 146 (8.2%), the cup detached prior to delivery; 130/146 (89%) had a single detachment. After detachment, 4 (2.7%) delivered by cesarean section, 77 (52.7%) delivered after cup reapplication, and 65 (44.6%) delivered spontaneously. Women in the study group were more likely to undergo VAVD due to prolonged second stage, and were characterized by lower rates of metal cup use. Neonates in the detachment group had higher rates of subarachnoid hematoma and composite neonatal birth trauma (2.7 vs. 0.1% and 4.8 vs. 1.8%, respectively, pxa0<xa00.05). This remained significant after adjustment to potential confounders (subarachnoid hematoma aORxa0=xa045.44, 95% CI 6.42–321.62 and neonatal birth trauma aORxa0=xa02.62, 95% CI 1.1–6.22, pxa0<xa00.05 for all). Other neonatal and maternal morbidities were similar between groups.ConclusionCup detachment is associated with a higher rate of adverse neonatal outcome. Cup reapplication should be considered carefully.