Massimo Agosti

A randomized trial of preinduction cervical ripening: dinoprostone vaginal insert versus double-balloon catheter

OBJECTIVE We sought to compare the efficacy of a double-balloon transcervical catheter to that of a prostaglandin (PG) vaginal insert among women undergoing labor induction. STUDY DESIGN In all, 210 women with a Bishop score ≤6 were assigned randomly to cervical ripening with either a double-balloon device or a PGE2 sustained-release vaginal insert. Primary outcome was vaginal delivery within 24 hours. RESULTS The proportion of women who achieved vaginal delivery in 24 hours was higher in the double-balloon group than in the PGE2 group (68.6% vs 49.5%; odds ratio, 2.22; 95% confidence interval, 1.26-3.91). There was no difference in cesarean delivery rates (23.8% vs 26.2%; odds ratio, 0.88; 95% confidence interval, 0.47-1.65). Oxytocin and epidural analgesia were administered more frequently when a double-balloon device was used. Uterine tachysystole or hypertonus occurred more frequently in the PGE2 arm (9.7% vs 0%, P = .0007). CONCLUSION The use of a double-balloon catheter for cervical ripening is associated with a higher rate of vaginal birth within 24 hours compared with a PGE2 vaginal insert.

Is transcervical Foley catheter actually slower than prostaglandins in ripening the cervix? A randomized study

OBJECTIVE The purpose of this study was to determine whether the maximum time for cervical ripening (from 24-12 hours) would influence the efficacy of a transcervical Foley catheter and to compare efficacy to that of a prostaglandin E(2) vaginal insert. STUDY DESIGN Three hundred ninety-seven women were assigned randomly to (1) Foley catheter left in place for a maximum of 24 hours, (2) Foley catheter left in place for a maximum of 12 hours, or (3) prostaglandin E(2) controlled-release vaginal insert. Primary outcome was vaginal delivery within 24 hours. RESULTS There were no differences in vaginal delivery rates. The proportion of women who achieved vaginal delivery in 24 hours was lower in the 24-hour Foley catheter group than in the other 2 groups (24-hour Foley catheter, 21.0%; 12-hour Foley catheter, 59.8%; vaginal prostaglandin E(2), 48.5%; P < .0001). CONCLUSION Cutting the ripening time with a Foley catheter by one-half increases the proportion of women who deliver vaginally within 24 hours and yields efficacy similar to that of prostaglandin E(2) vaginal insert.

Joel‐Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference?

Objective.  To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome.

Fertility rates, course of pregnancy and perinatal outcomes after laparoscopic ureterolysis for deep endometriosis: A long-term follow-up study.

We evaluated fertility rates, pregnancy course and maternal/neonatal outcomes following laparoscopic ureterolysis for deep endometriosis. Data about women who underwent laparoscopic excision of ureteral endometriosis were analysed. After exclusion of women who underwent hysterectomy/bilateral adnexectomy at initial surgery, and those lost-to-follow-up or with follow-up <1 year, a total of 61 patients were included. Of them, 36 (59%) wished to conceive after surgery. Twenty women became pregnant: nine (45%) of them after assisted reproductive technologies. Twenty-six pregnancies were observed with four (15.6%) miscarriages. Median gestational week at delivery was 38 weeks + 2 days (range, 33 + 1–41 + 6), with three (13.6%) and two (9%) deliveries before 37 and 34 weeks, respectively. Nine caesarean sections were performed (40.9%). Fertility rates after laparoscopic ureterolysis are comparable to those of other women operated for other forms of deep endometriosis. Apart from a higher risk of caesarean and preterm birth, the course of pregnancy and peripartum outcomes appear encouraging.

Assisted reproductive technology and breastfeeding outcomes: a case-control study

OBJECTIVE To determine if breastfeeding outcomes differ between mothers who conceived spontaneously compared with those who conceived with assisted reproductive technology (ART). DESIGN Matched case-control study. SETTING Teaching hospital. PATIENT(S) Ninety-four women having a singleton baby conceived with ART, matched by maternal age, parity, mode of delivery, and gestational age to controls who conceived spontaneously. INTERVENTION(S) Cases and controls were interviewed using a standardized, structured questionnaire, to obtain information on lactation. Exposure to maternity care practices contributing to breastfeeding success was investigated. MAIN OUTCOME MEASURE(S) Initiation, exclusivity, and continuation of breastfeeding. RESULT(S) Cases were as likely as controls to initiate breastfeeding (89.4% vs. 90.4%), but by 6 weeks postpartum, a greater proportion of mothers who conceived through ART has ceased breastfeeding (20.2% vs. 5.3%). The percentage of mothers who exclusively breastfed their child for 6 months was similar among the 2 groups. On univariate conditional logistic regression, a history of using ART was the only predictor of early breastfeeding cessation (odds ratio = 65.3 [95% confidence interval: 1.5-2889.3]). CONCLUSION(S) Women who have conceived with ART should be regarded as being at higher risk for early breastfeeding cessation. This study serves as a first step in the investigation of potential modifiable factors that contribute to breastfeeding failure among women who give birth after using ART, and may help in efforts to customize breastfeeding support strategies.

Risk of peripartum hysterectomy in births after assisted reproductive technology

OBJECTIVE To investigate whether women who conceive after assisted reproductive technology (ART) are at higher risk for emergency peripartum hysterectomy. DESIGN A case-control study using a prospectively maintained institutional database. SETTING A tertiary referral university teaching maternity hospital. PATIENT(S) Thirty-one women who underwent peripartum hysterectomy for management of hemorrhage, and 19,902 control women. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Association between potential predictors and peripartum hysterectomy. RESULT(S) The incidence of peripartum hysterectomy was 1.7 cases per 1,000 births (95% confidence interval [CI] 1.2-2.4). After adjustment for maternal age and twin pregnancy, placenta previa (odds ratio [OR] 50.78, 95% CI 23.30-110.68), prior cesarean delivery (OR 6.72, 95% CI 2.99-15.09 for one cesarean; OR 6.80, 95% CI 1.45-31.90 for two or more cesareans), previous myomectomy (OR 24.59, 95% CI 6.70-90.19), and ART conception (OR 5.98, 95% CI 2.18-16.40) were all antenatal predictors for peripartum hysterectomy. In women having a peripartum hysterectomy, 13.4% of the risk is attributable to mode of conception. CONCLUSION(S) A history of ART increases the likelihood of needing a peripartum hysterectomy to control hemorrhage. Further investigation is needed to determine whether ART conception should be included in algorithms of risk stratification for emergency cesarean hysterectomy and plan of care be modified accordingly.

Interobserver reliability to interpret intrapartum electronic fetal heart rate monitoring: Does a standardized algorithm improve agreement among clinicians?

Abstract Our aim was to investigate the accuracy in predicting intrapartum fetal acidaemia and the interobserver reproducibility of a mathematical algorithm for the interpretation of electronic fetal heart rate (FHR) monitoring throughout labour. Eight physicians (blinded to the clinical outcomes of the deliveries) evaluated four randomly selected intrapartum FHR tracings by common visual interpretation, trying to predict umbilical artery base excess at birth. They subsequently were asked to re-evaluate the tracings using a mathematical algorithm for FHR tracing interpretation. Common visual interpretation allowed a correct estimation of the umbilical artery base excess in 34.4% of cases, with a poor interobserver reproducibility (Kappa correlation coefficient = 0.24). After implementation of the algorithm, the proportion of correct estimates significantly increased to 90.6% (p < 0.001), with excellent inter-clinician agreement (κ: 0.85). To conclude, incorporation of a standardised algorithm reduces the interobserver variability and allows a better estimation of fetal acidaemia at birth.

Prediction of fetal base excess values at birth using an algorithm to interpret fetal heart rate tracings: a retrospective validation

Objective  To evaluate whether a standardised algorithm to interpret fetal heart rate (FHR) tracings during the entire length of labour can predict umbilical artery base excess at birth, and to investigate its inter‐ and intra‐observer reproducibility.

Use of an antispasmodic (rociverine) to shorten the length of labor: a randomized, placebo-controlled trial.

Objective. To determine the effectiveness of rociverine, an antispasmodic drug, for reducing the duration of labor among nulliparous women managed according to a standard intrapartum protocol. Design. Randomized controlled trial. Setting. An academic tertiary care hospital. Population. Nulliparae in spontaneous active labor, with cervical dilatation between 3 and 5cm. Methods. Participants were randomly assigned to receive either an intramuscular injection of 20mg rociverine (n=55) or the same volume of saline (n=56). Main Outcome Measure. Cervical dilatation rate (from administration of study drug to full dilatation). Results. Laboring women who received rociverine had faster cervical dilatation than those assigned to placebo (2.43±1.84 vs. 1.85±1.38cm/hour, p=0.03). The time interval from treatment administration to full cervical dilatation was shorter in the rociverine group than in the placebo group (220±125 vs. 278±129min, p=0.04). No difference was found in any other obstetric outcome. No adverse effects have been recorded from rociverine administration. Conclusions. Intrapartum administration of rociverine to nulliparous women may help to reduce the duration of the first stage of labor in a context of uniform labor management.