Lorene A. Temming

Universal cervical length screening: implementation and outcomes

BACKGROUND Transvaginal measurement of cervical length (CL) has been advocated as a screening tool to prevent preterm birth, but controversy remains regarding the overall utility of universal screening. OBJECTIVE We aimed to evaluate the acceptability of a universal CL screening program. Additionally we evaluated risk factors associated with declining screening and subsequent delivery outcomes of women who accepted or declined screening. STUDY DESIGN This was a retrospective cohort study of transvaginal CL screening at a single institution from July 1, 2011, through December 31, 2014. Institutional protocol recommended transvaginal CL measurement at the time of anatomic survey between 17-23 weeks in all women with singleton, viable pregnancies, without current or planned cerclage, with patients able to opt out. Patients with CL ≤20 mm were considered to have clinically significant cervical shortening and were offered treatment. We assessed acceptance rate, risk factors for declining CL screening, and the trend of acceptance of CL screening over time. We also calculated the prevalence of CL ≤25, ≤20, and ≤15 mm, and estimated the association between CL screening and spontaneous preterm birth. RESULTS Of 12,740 women undergoing anatomic survey during the study period, 10,871 (85.3%; 95% confidence interval [CI], 84.7-85.9%) underwent CL screening. Of those, 215 (2.0%) had a CL ≤25 mm and 131 (1.2%) had a CL ≤20 mm. After the first 6 months of implementation, there was no change in rates of acceptance of CL screening over time (P for trend = .15). Women were more likely to decline CL screening if they were African American (adjusted odds ratio [aOR], 2.17; 95% CI, 1.93-2.44), obese (aOR, 1.18; 95% CI, 1.06-1.31), multiparous (aOR, 1.45; 95% CI, 1.29-1.64), age <35 years (aOR, 1.24; 95% CI, 1.08-1.43), or smokers (aOR, 1.42; 95% CI, 1.20-1.68). Rates of spontaneous preterm birth <28 weeks were higher in those who declined CL screening (aOR, 2.01; 95% CI, 1.33-3.02). CONCLUSION Universal CL screening was implemented successfully with 85% of women screened. Overall incidence of short cervix was low and women with significant risk factors for preterm birth were more likely to decline screening. Patients who declined CL screening were more likely to be African American, obese, multiparous, age <35 years, and smokers. Rates of early, but not late, spontaneous preterm birth were significantly higher among women who did not undergo CL screening.

Group Prenatal Care Compared With Traditional Prenatal Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of group prenatal care on perinatal outcomes compared with traditional prenatal care. DATA SOURCES: We searched MEDLINE through PubMed, EMBASE, Scopus, Cumulative Index of Nursing and Allied Health literature, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We searched electronic databases for randomized controlled trials and observational studies comparing group care with traditional prenatal care. The primary outcome was preterm birth. Secondary outcomes were low birth weight, neonatal intensive care unit admission, and breastfeeding initiation. Heterogeneity was assessed using the Q test and I2 statistic. Pooled relative risks (RRs) and weighted mean differences were calculated using random-effects models. TABULATIONS, INTEGRATION, AND RESULTS: Four randomized controlled trials and 10 observational studies met inclusion criteria. The rate of preterm birth was not significantly different with group care compared with traditional care (11 studies: pooled rates 7.9% compared with 9.3%, pooled RR 0.87, 95% confidence interval [CI] 0.70–1.09). Group care was associated with a decreased rate of low birth weight overall (nine studies: pooled rate 7.5% group care compared with 9.5% traditional care; pooled RR 0.81, 95% CI 0.69–0.96), but not among randomized controlled trials (four studies: 7.9% group care compared with 8.7% traditional care, pooled RR 0.92, 95% CI 0.73–1.16). There were no significant differences in neonatal intensive care unit admission or breastfeeding initiation. CONCLUSION: Available data suggest that women who participate in group care have similar rates of preterm birth, neonatal intensive care unit admission, and breastfeeding.

Early Second-Trimester Fetal Growth Restriction and Adverse Perinatal Outcomes.

OBJECTIVE To estimate the risk of adverse perinatal outcomes among women with isolated fetal growth restriction from 17 to 22 weeks of gestation. METHODS This was a retrospective cohort study of all singleton, nonanomalous pregnancies undergoing ultrasonography to assess fetal anatomy between 17 and 22 weeks of gestation at a single center from 2010 to 2014. After excluding patients with fetal structural malformations, chromosomal abnormalities, or identified infectious etiologies, we compared perinatal outcomes between pregnancies with and without fetal growth restriction, defined as estimated fetal weight less than the 10th percentile for gestational age. Our primary outcome was small for gestational age (SGA) at birth, defined as birth weight less than the 10th percentile. Secondary outcomes included preterm delivery at less than 37 and less than 28 weeks of gestation, preeclampsia, abruption, stillbirth, neonatal death, neonatal intensive care unit admission, intraventricular hemorrhage, need for respiratory support, and necrotizing enterocolitis. RESULTS Of 12,783 eligible patients, 355 (2.8%) had early second-trimester fetal growth restriction. Risk factors for growth restriction were African American race and tobacco use. Early second-trimester growth restriction was associated with a more than fivefold increase in risk of SGA at birth (36.9% compared with 9.1%, adjusted odds ratio [OR] 5.5, 95% CI 4.3-7.0), stillbirth (2.5% compared with 0.4%, OR 6.2, 95% CI 2.7-12.8), and neonatal death (1.4% compared with 0.3%, OR 5.2, 95% CI 1.6-13.5). Rates of indicated preterm birth at less than 37 weeks of gestation (7.3% compared with 3.3%, OR 2.3, 95% CI 1.5-3.5) and less than 28 weeks of gestation (2.5% compared with 0.2%, OR 10.8, 95% CI 4.5-23.4), neonatal need for respiratory support (16.9% compared with 7.8%, adjusted OR 1.6, 95% CI 1.1-2.2), and necrotizing enterocolitis (1.4% compared with 0.2%, OR 7.7, 95% CI 2.3-20.9) were also significantly higher for those with growth restriction. Rates of preeclampsia, abruption, and other neonatal outcomes were not significantly different. CONCLUSION Although fetal growth restriction in the early second trimester occurred in less than 3% of our cohort and most of those with isolated growth restriction did not have adverse outcomes, it is a strong risk factor for SGA, stillbirth, neonatal death, and indicated preterm birth.

Clinical management of medications in pregnancy and lactation

Prescription and over-the-counter medication use during pregnancy and lactation is exceedingly common. There are many available resources to gather information and guide patient counseling. These include primary literature, online resources, professional society recommendations, and drug labels. One must consider both disease and drug characteristics when making decisions on medication use during pregnancy and lactation. Providers can then use this information to balance the risks of fetal or neonatal exposure against the potential benefits of maternal treatment and the risks of untreated disease.

Microwave Ablation for Twin-Reversed Arterial Perfusion Sequence: A Novel Application of Technology

Introduction: Twin-reversed arterial perfusion sequence is a rare complication of monochorionic pregnancies that is characterized by the presence of an acardiac mass perfused by an apparently normal pump twin. The risk of death to the pump twin has led to a range of therapeutic interventions aimed at separating their vascular connection. We report a novel application of microwave ablation for vessel coagulation in the treatment of twin-reversed arterial perfusion sequence. Material and Methods: Microwave ablation has been adopted by surgical subspecialties as a superior energy source for vessel and tissue ablation as it creates heat without a circuit and has less thermal spread. We describe the use of a 2.45-GHz microwave system using a 1.8-mm antenna to coagulate the intra-abdominal portion of umbilical vessels of the acardiac mass. Results: We report 6 cases of twin-reversed arterial perfusion sequence treated by microwave ablation. All patients were treated with microwave ablation with successful coagulation of intra-abdominal umbilical cord vessels of the acardiac mass with cessation of flow. Discussion: Microwave ablation is an excellent energy source for vessel coagulation due to its thermal properties and can be used effectively in the treatment of twin-reversed arterial perfusion sequence.

SMFM Special Report: Putting the “M” back in MFM: Reducing racial and ethnic disparities in maternal morbidity and mortality: A call to action

Racial and ethnic disparities in maternal morbidity and mortality rates are an important public health problem in the United States. Because racial and ethnic minorities are expected to comprise more than one-half of the US population by 2050, this issue needs to be addressed urgently. Research suggests that the drivers of health disparities occur at 3 levels: patient, provider, and system. Although we have recognized this issue and identified elements that contribute to it, knowledge must be converted into action to address it. In addition, despite available funding and databases, research directed towards understanding and reducing these disparities is lacking. This document summarizes findings of a workshop convened at the 2016 Society for Maternal-Fetal Medicines 36th Annual Pregnancy meeting in Atlanta, GA, to review and make recommendations about immediate actions in clinical care and research that will serve to reduce racial and ethnic disparities in maternal morbidity and mortality rates in the United States.

Impact of evidence-based interventions on wound complications after cesarean delivery

BACKGROUND: A number of evidence‐based interventions have been proposed to reduce post–cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE: We sought to estimate the impact of a group of evidence‐based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine‐alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN: We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine‐alcohol vs iodine‐alcohol for skin antisepsis at cesarean delivery from 2011–2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence‐based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine‐alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence‐based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS: Of 1082 patients with follow‐up data, 349 (32.3%) received all the evidence‐based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence‐based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58–0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence‐based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12–2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18–11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence‐based measures. CONCLUSION: Implementation of evidence‐based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence‐based measures.

Diagnostic ability of elevated 1-h glucose challenge test.

Objective:To determine whether a threshold of a 1-h glucose challenge test (GCT) eliminates the need for a 3-h glucose tolerance test (GTT).Study Design:A retrospective cohort of patients undergoing GTT after GCT was ⩾140 mg dl−1. Gestational diabetes mellitus (GDM) was diagnosed using National Diabetes Data Group (NDDG) and Carpenter–Coustan (CC) criteria. Sensitivity, specificity and predictive values were calculated for 1-h GCT values of 160 to 220 mg dl−1.Result:Of 6218 patients, 988 (15.9%) had an elevated GCT and 753 (12.1%) underwent a GTT. In all, 165 (2.7%) were diagnosed with GDM using NDDG criteria, and 250 (4.0%) by CC criteria. The positive predictive value of a 1-h of GCT ⩾200 mg dl−1 for GDM was 68.6% by NDDG and 80.0% for GDM by CC criteria.Conclusion:Although the predictive value of an elevated 1-h ⩽200 mg dl−1 for GDM was high, 1 in 3 to 1 in 5 women would be overdiagnosed with GDM if the 3-h GTT was omitted.

Medical termination of pregnancy after endometrial ablation resulting in uterine rupture

Although pregnancy after endometrial ablation is rare, with an estimated rate of approximately 0.65% (Hare and Olah 2005), it is associated with a significant risk of complications including premat...

Obesity and the Risk of Preterm Birth in Patients With Cerclage

INTRODUCTION: The objective of this study was to compare the incidence of preterm birth before 34 weeks of gestation among obese patients compared with nonobese patients with cerclage. METHODS: This retrospective cohort examined women with cerclage placed between 2007 and 2012. Rates of preterm birth before 34 weeks of gestation were compared for women with cerclage who were nonobese with women with cerclage who were obese. RESULTS: Of 617 charts reviewed, 196 were eligible with 103 patients who were nonobese with body mass index (BMI) less than 30 kg/m2 and 93 patients who were obese with BMI greater than 30 kg/m2. The rate of preterm birth before 34 weeks of gestation was not different between obese and nonobese patients (37.9% compared with 31.2%, P=.327). CONCLUSIONS: Two studies have investigated the effect of obesity on cerclage efficacy with conflicting results with one showing that increasing obesity decreases cerclage efficacy. In our cohort, there was no relationship between BMI and rates of preterm birth at any gestational age in women with cerclage.