Marcela C. Smid

Hysteroscopic sterilization in a large group practice: experience and effectiveness.

OBJECTIVE: To estimate device placement and tubal occlusion rates for hysteroscopic sterilization and evaluate risk factors for failure. METHODS: Women undergoing hysteroscopic sterilization at Kaiser Permanente Northern California from January 2004 to December 2006 were identified. Risk factors assessed included age, parity, body mass index (BMI), operative location, and provider experience with the technique. Occlusion was determined by hysterosalpingogram. Univariable analyses were performed to identify factors predictive of successful placement and occlusion. The Cochrane-Armitage test was performed for trend analysis. RESULTS: Hysteroscopic sterilization was attempted in 884 women by 118 physicians at 30 Kaiser Permanente Northern California facilities. The initial placement attempt was successful in 850 patients (96.2%). Patient age, nulliparity, and BMI were not predictive of successful placement. Bilateral occlusion was demonstrated by hysterosalpingogram in 687 of 739 patients (93.0%). There were no significant differences in age, nulliparity, and BMI between those with and without occlusion. Loss to follow-up before a hysterosalpingogram was obtained was 13%. There was no significant increase in occlusion rate with experience (P for trend=.6). CONCLUSION: High placement and occlusion rates were noted from the first insertions, and success was not related to age, parity, BMI, or operator experience. LEVEL OF EVIDENCE: III

A Worldwide Epidemic: The Problem and Challenges of Preterm Birth in Low- and Middle-Income Countries.

Preterm birth (PTB) is the most common cause of neonatal death worldwide and the second leading cause of under-5 mortality. Low- and middle-income countries (LMICs) bear a disproportionate burden of this disease. An estimated 1 million preterm infants die in the neonatal period each year and many of those who survive face lifelong disability. In this review, we explore the global burden of PTB through an examination of risk factors and predisposing clinical conditions found in LMICs. We then discuss current interventions available to prevent PTB and/or mitigate its clinical sequelae. A major finding of this review is that although the majority of the global PTB disease burden is shouldered by LMICs, very little of the research evidence for its prevention and treatment derives from these settings. Primary research and implementation studies that involve LMIC populations are urgently needed.

Extreme Obesity and Postcesarean Wound Complications in the Maternal-Fetal Medicine Unit Cesarean Registry

OBJECTIVE The objective of this study was to estimate the association between obesity and wound complications after cesarean delivery. METHODS A secondary cohort analysis of the Maternal-Fetal Medicine Unit Cesarean Registry. We stratified the exposure, maternal body mass index (BMI) at delivery, as not obese (BMI < 30), obese (BMI 30-45), and extremely obese (BMI > 45). Our primary outcome was wound complication composite of wound infection, endometritis, wound opening, seroma/hematoma, and hospital readmission. Our secondary outcomes included infection composite (wound infection and endometritis) and each individual outcome included in the primary composite. We performed unadjusted and multivariable logistic regression analyses. RESULTS We included 38,229 women who underwent cesarean; 39% were not obese, 55% were obese, and 6% were extremely obese. In our cohort, 40% of women underwent repeat cesarean and 57% underwent cesarean after labor. Extremely obese women had increased risk for any wound complication (14%, adjusted odds ratio [AOR], 1.65; 95% confidence interval [CI], 1.44-1.89), endometritis (8.3%, AOR, 1.26; 95% CI, 1.07-1.49), wound infection (2.0%, AOR, 3.77; 95% CI, 2.60-5.46), wound opening (0.8%, AOR, 5.47; 95% CI, 2.79-10.71), and wound infection-related hospital readmission (3.6%, AOR, 2.97; 95% CI, 2.26-3.91) compared with nonobese women. Obese women had increased risk for any wound complication (9.6%, AOR, 1.14; 95% CI, 1.06-1.23) and postcesarean infection (7.7%, AOR, 1.12; 95% CI, 1.03-1.22) but not other outcomes. CONCLUSION In a large multicenter cohort study, we found that extreme obesity was associated with substantial increase in maternal postcesarean complications, and the association between obesity and postcesarean complications appears dose related. These findings validate associations found in single-center studies.

Predictors and outcomes of low birth weight in Lusaka, Zambia.

To determine factors associated with low birth weight (LBW) in an urban Zambian cohort and investigate risk of adverse outcomes for LBW neonates.

Maternal race and intergenerational preterm birth recurrence

BACKGROUND: Preterm birth is a complex disorder with a heritable genetic component. Studies of primarily White women born preterm show that they have an increased risk of subsequently delivering preterm. This risk of intergenerational preterm birth is poorly defined among Black women. OBJECTIVE: Our objective was to evaluate and compare intergenerational preterm birth risk among non‐Hispanic Black and non‐Hispanic White mothers. STUDY DESIGN: This was a population‐based retrospective cohort study, using the Virginia Intergenerational Linked Birth File. All non‐Hispanic Black and non‐Hispanic White mothers born in Virginia 1960 through 1996 who delivered their first live‐born, nonanomalous, singleton infant ≥20 weeks from 2005 through 2009 were included. We assessed the overall gestational age distribution between non‐Hispanic Black and White mothers born term and preterm (<37 weeks) and their infants born term and preterm (<37 weeks) using Cox regression and Kaplan‐Meier survivor functions. Mothers were grouped by maternal gestational age at delivery (term, ≥37 completed weeks; late preterm birth, 34‐36 weeks; and early preterm birth, <34 weeks). The primary outcomes were: (1) preterm birth among all eligible births; and (2) suspected spontaneous preterm birth among births to women with medical complications (eg, diabetes, hypertension, preeclampsia and thus higher risk for a medically indicated preterm birth). Multivariable logistic regression was used to estimate odds of preterm birth and spontaneous preterm birth by maternal race and maternal gestational age after adjusting for confounders including maternal education, maternal age, smoking, drug/alcohol use, and infant gender. RESULTS: Of 173,822 deliveries captured in the intergenerational birth cohort, 71,676 (41.2%) women met inclusion criteria for this study. Of the entire cohort, 30.0% (n = 21,467) were non‐Hispanic Black and 70.0% were non‐Hispanic White mothers. Compared to non‐Hispanic White mothers, non‐Hispanic Black mothers were more likely to have been born late preterm (6.8% vs 3.7%) or early preterm (2.8 vs 1.0%), P < .001. Non‐Hispanic White mothers who were born (early or late) preterm were not at an increased risk of early or late preterm delivery compared to non‐Hispanic White mothers born term. The risk of early preterm birth was most pronounced for Black mothers who were born early preterm (adjusted odds ratio, 3.26; 95% confidence interval, 1.77–6.02) compared to non‐Hispanic White mothers. CONCLUSION: We found an intergenerational effect of preterm birth among non‐Hispanic Black mothers but not non‐Hispanic White mothers. Black mothers born <34 weeks carry the highest risk of delivering their first child very preterm. Future studies should elucidate the underlying pathways leading to this racial disparity.

Maternal super obesity and neonatal morbidity after term cesarean delivery

Objective To estimate the association between maternal super obesity (body mass index [BMI] ≥ 50 kg/m(2)) and neonatal morbidity among neonates born via cesarean delivery (CD). Methods Retrospective cohort of singleton neonates delivered via CD ≥ 37 weeks in the Maternal-Fetal Medicine Unit Cesarean Registry. Maternal BMI at delivery was stratified as 18.5 to 29.9 kg/m(2), 30 to 39.9 kg/m(2), 40 to 49.9 kg/m(2), and ≥ 50 kg/m(2). Primary outcomes included acute (5-minute Apgar score < 5, cardiopulmonary resuscitation and ventilator support < 24 hours, neonatal injury, and/or transient tachypnea of the newborn) and severe (grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, seizure, respiratory distress syndrome, hypoxic ischemic encephalopathy, meconium aspiration, ventilator support ≥ 2 days, sepsis and/or neonatal death) neonatal morbidity. Odds of neonatal morbidity were estimated for each BMI category adjusting for clinical and operative characteristics. Results Of 41,262 maternal-neonatal dyads, 36% of women were nonobese, 49% had BMI of 30 to 39.9 kg/m(2), 12% had BMI of 40 to 49.9 kg/m(2), and 3% were super obese. Compared with nonobese women, super obese women had twofold odds of acute (5 vs. 10%; adjusted odds ratio [aOR]: 1.81, 95% confidence interval [CI]: 1.59-2.73) and severe (3 vs. 6%; aOR: 2.08; 95% CI: 1.59-2.73) neonatal morbidity. Conclusion Among term infants delivered via CD, maternal super obesity is associated with increased risk of neonatal morbidity.

The Problem of the Pannus: Physician Preference Survey and a Review of the Literature on Cesarean Skin Incision in Morbidly Obese Women.

OBJECTIVE This study aims to determine preferences of a nationally representative sample of obstetrician/gynecologists (OB/GYNs) regarding cesarean delivery (CD) incision practices for women with morbid obesity (body mass index ≥ 40 kg/m(2)). STUDY DESIGN We conducted an online survey using the American College of Obstetricians and Gynecologists database. We compared physician demographics, practice characteristics, and CD incision type preference. RESULTS After exclusion of ineligible participants, 247 OB/GYNs completed the survey (42% response rate). In nonemergency CD of morbidly obese women, 84% of physicians preferred a Pfannenstiel skin incision (67% preferring taping the pannus; 17% without taping the pannus). In emergency CD, 66% preferred a Pfannenstiel incision (46% without taping the pannus; 20% with taping the pannus) and 20% a vertical incision. For both emergency and nonemergency CD, there was no difference in incision type preferences by provider years in practice, practice scope, or number of CD performed each year. CONCLUSION Given the preference of a Pfannenstiel incision with taping the pannus during CD of morbidly obese women, further investigation is needed to assess the risks and benefits of this incision and the practice of elevating the pannus.

Maternal Gut Microbiome Biodiversity in Pregnancy

Objective To measure maternal gut microbiome biodiversity in pregnancy. Materials and Methods In phase 1, maternal fecal samples were collected by rectal swab in 20 healthy pregnant women (14‐28 weeks gestation) to measure bacterial abundance. In phase 2, fecal samples were collected from 31 women at enrollment (<20 weeks gestation, baseline) and at 36 to 39 weeks of gestation (follow‐up). We assessed cluster analysis to assess bacterial community profiles at the phylum level longitudinally through pregnancy. DNA was extracted from swabs, followed by PCR of the bacterial 16s rRNA gene and multiplex high‐throughput sequencing (Ion Torrent). Results In phase 1, 16 of 20 samples yielded usable data. White women (n = 10) had greater abundance of Firmicutes (23 ± 0.15 vs. 16% ± 0.75, p = 0.007) and Bacteroidetes (24 ± 0.14 vs. 19% ± 0.68, p = 0.015) compared with non‐White women (n = 6). In the 11 paired specimens, Bacteroidetes increased in abundance from baseline to follow‐up. Compared with women who gained weight below the median gestational weight gain (GWG, <15.4 kg), those who gained above the median GWG had increased abundance of Bacteroidetes (p = 0.02) and other phyla (p = 0.04). Conclusion Maternal microbiome biodiversity changes as pregnancy progresses and correlates with GWG.

Prophylactic negative pressure wound therapy for obese women after cesarean delivery: A systematic review and meta-analysis

OBJECTIVE To summarize available studies on wound complication outcomes after prophylactic negative pressure wound therapy for obese women (body mass index 30 or greater). DATA SOURCES We conducted a systematic review and meta-analysis using electronic database search (PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Google scholar, and Web of Science), Cochrane, and trial registries including ClinicalTrials.gov. METHODS OF STUDY SELECTION We conducted an electronic search of research articles from 1966 to January 2017 for randomized controlled trials (RCTs), prospective cohort, and retrospective cohort studies of negative pressure wound therapy compared with standard dressing after cesarean delivery among obese women. Our primary outcome was defined as a composite of wound complication, including wound or surgical site infection, cellulitis, seroma, hematoma, wound disruption, or dehiscence. For cohort studies and RCTs, we performed a descriptive systematic review. For available RCTs, we performed a meta-analysis and pooled risk ratios using a random-effects model. We assessed for heterogeneity using χ test for heterogeneity and I test. We assessed for publication bias using a funnel plot. TABULATION, INTEGRATION, AND RESULTS Of 10 studies meeting eligibility criteria, five were RCTs and five were cohort studies. Results of cohort studies were varied; however, all had a high potential for selection bias. In the meta-analysis, there was no difference in primary composite outcome among those women with negative pressure wound therapy (16.8%) compared with those who had standard dressing (17.8%) (risk ratio 0.97, 95% CI 0.63-1.49). There was no statistically significant heterogeneity (χ test 4.80, P=.31, I=17%). CONCLUSION Currently available evidence does not support negative pressure wound therapy use among obese women for cesarean wound complication prevention. SYSTEMATIC REVIEW REGISTRATION PROSPERO: International prospective register of systematic reviews, 42016033948.

Lost in translation? English- and Spanish-speaking women’s perceptions of gestational weight gain safety, health risks and counseling

Objective:To determine English- and Spanish-speaking women’s perceptions on gestational weight gain (GWG) counseling.Study design:We administered a written survey to 279 pregnant women regarding GWG counseling and knowledge. We compared English- and Spanish-speaking women’s responses using X2-tests and logistic regression analyses.Result:Seventy-four (27%) women completed the survey in Spanish and 205 (73%) in English. More Spanish compared with English speakers did not know if their provider recommended weight gain goals (26% vs 10%, odds ratio (OR) 3.2, confidence interval (CI) 1.5 to 6.5); if there are risks to excessive GWG for mother (27% vs 11%, OR 3.1, CI 1.5 to 6.4) or infant (38% vs 16%, OR 3.3, CI 1.7 to 6.3); or if exercise (15% vs 1%, OR 12.1, CI 3.0 to 69.1) or weight loss (35% v 12%, OR 4.0, CI 2.0 to 8.0) were safe during pregnancy.Conclusion:Significant differences exist between Spanish- and English-speaking women’s perception of GWG counseling, which may be due to language or cultural barriers.