Lorinne Levitt

Re-laparotomy following cesarean delivery - risk factors and outcomes.

Abstract Introduction: Re-laparotomy following caesarean delivery (CD) is a rare yet serious complication. The aim of this study was to identify risk factors, diagnostic features and outcomes following re-laparotomy. Materials and methods: This retrospective cohort study reviewed cases of re-laparotomy following CD performed at Hadassah-Hebrew University Medical Center. Occurrences were identified via the electronic medical record database. Results: During the study period, 17u2009213 women underwent CD, of which 55 (0.3%) underwent re-laparotomy during the same hospitalization. Main indications for re-laparotomy were intra-peritoneal bleeding (62%) and wound infection/dehiscence (22%). During re-laparotomy, the bleeding source was found and ligated in 85% of the cases. Age, parity, previous CD, induction of labor, anesthesia type and operative duration were significant risk factors for re-laparotomy. In a selected group of patients, trial of conservative treatment was made. However, in 76% of these women a re-laparotomy was required. Discussion: Risk factors for re-laparotomy following CD should be identified, thus enabling more intensified monitoring of patients considered at risk for this complication. When intra-peritoneal bleeding following CD is suspected, conservative management has a high failure rate and should be reserved for a selected group of stable patients.

The association between ABO blood group and obstetric hemorrhage

AbstractnWhether intra- and early post-partum hemorrhage is influenced by ABO blood groups remains unknown. Therefore, we compared women with O to non-O blood groups with regard to maternal post-partum hemorrhage and transfusion need. This retrospective study was conducted in a single tertiary center between 2005 and 2014. For the purpose of the study, parturients were categorized as O and non-O blood groups. Data included all deliveries but excluded patients with missing blood grouping or hemoglobin values, and/or stillbirth. Drop in hemoglobin was defined as hemoglobin concentration at admission for delivery minus lowest hemoglobin concentration post-delivery. Study outcomes were postpartum hemorrhage, hemoglobin drop >2–7xa0g/dL inclusive, and packed red blood cells transfusion. Statistics: descriptive, χ2 (pxa0<xa00.05 significant) and multivariable regression models [odds ratio (OR), 95xa0% confidence interval (CI), p value]. 125,768 deliveries were included. After multivariable analysis, women with O blood type relative to women with non-O blood type had significantly higher odds of postpartum hemorrhage (OR 1.14; 95xa0% CI 1.05–1.23, pxa0<xa00.001), higher odds of statistically significant hemoglobin decreases of >2, 3, or 4xa0g/dL (OR 1.07; 95xa0% CI 1.04–1.11, pxa0<xa00.001, OR 1.08; 95xa0% CI 1.03–1.14, pxa0=xa00.002, OR 1.14; 95xa0% CI 1.05–1.23, pxa0=xa00.001; respectively), and higher odds, albeit not statistically significant of 5, 6, or 7xa0g/dL decreases in hemoglobin (OR 1.13; 95xa0% CI 1.00–1.29, pxa0=xa00.055, OR 1.05; 95xa0% CI 0.84–1.32, pxa0=xa00.66, OR 1.15; 95xa0% CI 0.79–1.68, pxa0=xa00.46; respectively), but no difference in blood products transfusion (OR 1.03; 95xa0% CI 0.92–1.16, pxa0=xa00.58). In conclusion, women with blood type O may be at greater risk of obstetrical hemorrhage.

OC16.07: Variations between fetal and neonatal head circumference and fetal and neonatal weight are size-dependent

regression performed, to identify relation of AOP predicting CD to cervical dilatation. Results: 119 women were included in the study. 90(76%) delivered vaginally while 29 had CD (24%). Women undergoing CD had significantly narrower AOP at rest (93 versus 104, P=0.001) and under maternal pushing (102 versus 118, P<0.0001). ROC curve analysis for AOP as a predictor of CD showed AUC of 68% (95 CI 59-77%) for static and 73% (95CI 64-81%) for dynamic assessment. On univariate logistic regression analysis both static AoP (OR 1.04 (95CI 1.01-1.07, P =0.008)) dynamic AoP (1.05 (95CI 1.02-1.08), P =0.0003) were independent predictors of CD from cervical dilatation (OR 1 (95% CI 0.97-1.03), P= 0.8). Conclusions: AoP at rest and on maternal pushing can predict Caesarean delivery in the first stage independently from cervical dilatation.

OC16.06: Macrosomia: a self-fulfilling prophecy

regression performed, to identify relation of AOP predicting CD to cervical dilatation. Results: 119 women were included in the study. 90(76%) delivered vaginally while 29 had CD (24%). Women undergoing CD had significantly narrower AOP at rest (93 versus 104, P=0.001) and under maternal pushing (102 versus 118, P<0.0001). ROC curve analysis for AOP as a predictor of CD showed AUC of 68% (95 CI 59-77%) for static and 73% (95CI 64-81%) for dynamic assessment. On univariate logistic regression analysis both static AoP (OR 1.04 (95CI 1.01-1.07, P =0.008)) dynamic AoP (1.05 (95CI 1.02-1.08), P =0.0003) were independent predictors of CD from cervical dilatation (OR 1 (95% CI 0.97-1.03), P= 0.8). Conclusions: AoP at rest and on maternal pushing can predict Caesarean delivery in the first stage independently from cervical dilatation.

Vacuum extraction failure is associated with a large head circumference

Abstract Objective: To determine whether large head circumference increases the risk of vacuum extraction failure. Study design: This EMR-based study included all attempted vacuum extractions performed in a tertiary center between January 2010 and June 2015. All term singleton live births were eligible. Cases were divided into four groups: head circumference ≥90th percentile both with birth weight ≥90th percentile and <90th percentile and fetal head circumference <90th percentile with birth weight ≥90th and <90th percentile. Risk of failed vacuum extraction was compared among these groups. Other neonatal and maternal parameters were also evaluated as potential risk factors. Multinomial multivariable regression provided adjusted odds ratio for vacuum extraction failure while controlling for potential confounders. Results: During the study period, 48,007 deliveries met inclusion criteria, of which 3835 had an attempt at vacuum extraction. We identified 215 (5.6%) cases of vacuum extraction failure. The adjusted odds ratios (aOR) for vacuum extraction failure in cases of large fetal head circumference was 2.31 (95%CI, 1.7–3.15, pu2009<u2009.001). Primiparity, prolonged second stage and occipito-posterior presentation were also found to be significant risk factors for failed vacuum extraction. Comments: In this study, we found that large head circumference was associated with vacuum extraction failure rather than high birth weight.

Fetal macrosomia as a risk factor for shoulder dystocia during vacuum extraction.

Abstract Objective: Vacuum extraction of a macrosomic fetus is considered a risk factor for shoulder dystocia (SD). We evaluated maternal and fetal outcomes following vacuum extraction of macrosomic infants. Methods: A retrospective cohort study conducted in two large teaching hospitals. All deliveries of macrosomic infants by vacuum extraction and vaginal delivery were compared. The primary outcome measure was SD. Secondary outcome measures were severe perineal lacerations and postpartum hemorrhage. For statistical analysis, we used McNemar’s test and χ2 or Fisher’s exact tests. Odds ratios were analyzed via a logistic regression model. Results: From 2003 to 2013, there were 6019 (5.45%) deliveries of macrosomic fetuses, and 230 (0.21%) were delivered by vacuum extraction. There were 23 (10%) and seven (3.04%) cases of SD in the study and control groups, respectively. The risk of SD was significantly higher in the study group (pu2009>u20090.05). We found a significant association between SD and vacuum delivery [pu2009=u20090.003; ORu2009=u20093.54 (95% CI: 1.49–8.42)]. The composite adverse neonatal outcome rate was 6.5% (15/230) and 1.7% (4/230) in the study and control groups, respectively (pu2009=u20090.009). Conclusion: Vacuum extraction of a macrosomic infant is a risk factor for shoulder dystocia but not for postpartum hemorrhage or severe vaginal tears.

Reversible Fetal Renal Impairment following Angiotensin Receptor Blocking Treatment during Third Trimester of Pregnancy: Case Report and Review of the Literature

Background. Late pregnancy usage of angiotensin converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) may cause severe oligohydramnios due to fetal renal impairment. Affected neonates will often suffer from fatal, renal, and respiratory failure. Case. A 39-year-old multigravida admitted due to anhydramnios secondary to valsartan (ARB) exposure at 30 weeks gestation. Following secession of treatment amniotic fluid volume returned to normal. Delivery was induced at 34 weeks gestation following premature rupture of membranes and maternal fever. During the two-year follow-up, no signs of renal insufficiency were noted. Conclusions. This description of reversible fetal renal damage due to ARB intake during pregnancy is the first to show no adverse renal function in a two-year follow-up period. This case may help clinicians counsel patients with pregnancies complicated by exposure to these drugs.