Mari-Paule Thiet

Effect of stage of initial labor dystocia on vaginal birth after cesarean success

OBJECTIVE The objective of the study was to examine whether the stage of labor dystocia causing a primary cesarean delivery (CD) affects a trial of labor after cesarean (TOLAC) success. STUDY DESIGN This was a retrospective cohort study of women who had primary CD of singleton pregnancies for first- or second-stage labor dystocia and attempted TOLAC at a single hospital between 2002 and 2014. We compared TOLAC success rates between women whose primary CD was for first- vs second-stage labor dystocia and investigated whether the effect of prior dystocia stage on TOLAC success was modified by previous vaginal delivery (VD). RESULTS A total of 238 women were included; nearly half (49%) achieved vaginal birth after cesarean (VBAC). Women with a history of second-stage labor dystocia were more likely to have VBAC compared with those with first-stage dystocia, although this trend was not statistically significant among the general population (55% vs 45%, adjusted odds ratio, 1.4, 95% confidence interval, 0.8-2.5]). However, among women without a prior VD, those with a history of second-stage dystocia did have statistically higher odds of achieving VBAC than those with prior first-stage dystocia (54% vs 38%, adjusted odds ratio, 1.8 [95% confidence interval, 1.0-3.3], P for interaction = .043). CONCLUSION Nearly half of women with a history of primary CD for labor dystocia will achieve VBAC. Women with a history of second-stage labor dystocia have a slightly higher VBAC rate, seen to a statistically significant degree in those without a history of prior VD. TOLAC should be offered to all eligible women and should not be discouraged in women with a prior second-stage arrest.

Perinatal neuroprotection update.

Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.

Retained Placenta Accreta Mimicking Choriocarcinoma

This case demonstrates a rare event of retained invasive placenta masquerading as choriocarcinoma. The patient presented with heavy vaginal bleeding following vaginal delivery complicated by retained products of conception. Ultrasound and computed tomography demonstrated a vascular endometrial mass, invading the uterine wall and raising suspicion for choriocarcinoma. Hysterectomy revealed retained invasive placenta.

The association between nitroglycerin use and adverse outcomes in women undergoing cesarean delivery in the second stage of labor

Abstract Objective: To identify predictors of hysterotomy extension in women undergoing cesarean delivery (CD) in the second stage of labor, and whether use of nitroglycerin (NTG) during CD has a protective effect. Methods: We conducted a retrospective cohort study of women undergoing CD in the second stage of labor from 2012 to 2015. Some women received NTG at the obstetrician’s request. Logistic regression was used to examine the relationship between second stage duration and NTG administration on maternal and neonatal outcomes. Results: Of the 391 women in the sample, 27% had an extension and 12% received NTG. Second stage ≥4 h was associated with a 2.14-fold higher risk of extension (95% CI 1.22–3.75), a 2.00-fold higher risk of hemorrhage (95% CI: 1.20–3.33) and 2.42-fold higher risk of blood transfusion during delivery hospitalization (95% CI: 0.99–5.91). Intravenous (IV) and sublingual-spray (SL-spray) NTG administration were not associated with an increased risk of hemorrhage or extension. SL-NTG was associated with 4.68-fold increased odds of 5-min Apgar <7 (95% CI 1.42–15.41) and 3.36-fold greater odds of NICU admission (95% CI 1.20–9.41). Conclusion: We found no evidence that NTG protects against extension, and SL-NTG use was associated with adverse neonatal outcomes. Clinical trials should be conducted to evaluate risk and benefits of NTG use.

Maternal Arrhythmia and Perinatal Outcomes: A Pregnancy and Cardiac Disease Treatment Program

INTRODUCTION: Maternal cardiac diseases can be severely compromised in the setting of arrhythmias. We compared perinatal outcomes among women with a cardiac arrhythmia with women with other types of cardiac disease. METHODS: This is a retrospective cohort study of pregnant women with cardiac disease who delivered from 2008 to 2013. Perinatal outcomes among women with an arrhythmia were compared with those with other types of maternal cardiac disease (congenital, structural, or cardiomyopathy). RESULTS: A cohort of 143 women was identified; 37 (26%) had a diagnosis of an arrhythmia. Compared with women without arrhythmias, those with an arrhythmia were more likely to have a spontaneous vaginal delivery (62% compared with 43%, P<.05) and required fewer operative vaginal births (11% compared with 26%, P=.05). Pregnancies were more likely to be complicated by intrauterine growth restriction (IUGR) (16% compared with 5%, P<.05) and placental abruption (5% compared with 0%, P<.05). The risk of IUGR remained increased in multivariable model controlling for confounding (adjusted odds ratio 6.9, 95% confidence interval 1.6–30.4, P=.01). There were no differences in rates of other maternal complications including gestational diabetes, postpartum hemorrhage, chorioamnionitis, or intensive care unit admission. Neonatal outcomes including gestational age at delivery, birth weight, 5-minute Apgar, umbilical artery pH less than 7, and neonatal intensive care unit admission were not different. CONCLUSIONS: Patients with arrhythmias were more likely to have a successful vaginal delivery compared with those other maternal cardiac diseases. However, the pregnancy had an increased risk for IUGR and placental abruption. The rates of adverse neonatal outcomes were similar between the groups.