Megan L. Stephenson

Fetal heart rate and cardiotocographic abnormalities with varying dose misoprostol vaginal inserts

Objective: Characterize the incidence and timing of fetal heart rate (FHR) and cardiotocographic abnormalities (CTG) associated with the misoprostol vaginal insert (MVI) during labor induction. Methods: This secondary analysis of data from the MVI Trial, a multi-site, double-masked, randomized trial of 374 women assigned to MVI 100, 150 or 200 mcg requiring cervical ripening before labor induction evaluated the incidence and clinical outcomes associated with FHR and CTG abnormalities diagnosed using 1997 NICHD definitions. Results: MVI 200 was associated with an increased rate of tachysystole versus MVI 100 (p < 0.001, RR 2.11, 95% CI 1.39, 3.22) but not MVI 150 (p = 0.29, RR 1.31, 95% CI 0.82, 2.11). Tachysystole occurred with the drug in situ in 17 (14.4%) and 50 (38.2%) of MVI 100 and 200 subjects, respectively (p < 0.001). Category II or III FHR patterns after tachysystole occurred in 9 (7.6%) and 26 (19.8%) women in MVI 100 and 200 groups, (p = 0.006). Abnormal FHR patterns were the indication for cesarean in 18 (13.7%) MVI 200 women versus 11 (9.3%) MVI 100 women (p = 0.33). Neonatal outcomes were similar between groups. Conclusions: While FHR and CTG abnormalities were encountered frequently during all inductions, few were clinically significant.

Misoprostol for induction of labor

Labor-induction rates have increased considerably in the United States as well as around the world. With up to half of all induced labors requiring cervical ripening, prostaglandins have been utilized to increase induction success and achieve vaginal delivery. Misoprostol, a synthetic prostaglandin E1 analog has the ability to mimic the changes of spontaneous labor and has been used off label for over 30 years as a labor-induction agent. In the following article, cervical ripening and induction of labor with misoprostol will be discussed. The risks and benefits of misoprostol for ripening and induction and routes of administration will be reviewed, as well as future directions and new developments for its use.

A randomized controlled trial of differing doses of postcesarean enoxaparin thromboprophylaxis in obese women.

Objective:To compare two enoxaparin dosing strategies at achieving prophylactic anti-Xa levels in women with a body mass index (BMI) ⩾35 (kg m−2) postcesarean delivery.Study Design:Women with BMI ⩾35 were randomized to receive prophylactic enoxaparin at a fixed dose of 40 mg daily or weight-based dosing of 0.5 mg kg−1 twice daily. The primary outcome was the proportion of subjects with peak anti-Xa levels in the prophylactic range of 0.2 to 0.6 IU ml−1.Result:From August 2013 through February 2014, 84 demographically similar women completed the protocol. In the weight-based group, 88% (37/42) of the women reached prophylactic anti-Xa levels versus 14% (6/42) in the fixed dose group (odds ratio 44.4, 95% confidence interval 12.44, 158.48, P<0.001). No anti-Xa level exceeded 0.48 IU ml−1. There were no venous thromboembolic or bleeding events requiring reoperation or transfusion in either group.Conclusion:Compared with fixed dosing daily, weight-based dosing twice daily more effectively achieved prophylactic anti-Xa levels without reaching the therapeutic range.

Live unilateral twin ectopic pregnancy in a fallopian tube remnant after previous ipsilateral salpingectomy.

Ectopic pregnancy remains an important cause of morbidity and mortality in women of childbearing age. We report a case of a unilateral twin ectopic pregnancy in a fallopian tube remnant after previous ipsilateral salpingectomy. The pregnancy was conceived spontaneously and included two live gestations. Although the presentation of this ectopic pregnancy was unique, the patients risk factors were not. As an example of the type of patient who would benefit from ultrasound screening for ectopic pregnancy, our patient renews the debate around this controversial issue.

Diabetes mellitus: an independent predictor of duration of prostaglandin labor induction

Objective:The objective of this study is to analyze the association of diabetes mellitus with progress and outcomes of prostaglandin (PG) labor induction using a retrievable vaginal insert.Study Design:This is a secondary analysis of data collected during the Misoprostol Vaginal Insert Trial (Miso-Obs-004), a multicenter, double-blind, randomized controlled trial of women undergoing induction of labor with PGs. The duration, characteristics and outcomes of labor were compared in women with and without diabetes. Multivariable regression analysis was performed on all outcomes of interest, adjusting for differences in baseline characteristics.Results:There were 122 women with diabetes within the sample of 1275 women who delivered during their first admission. The time to reach active labor was significantly prolonged among women with diabetes compared with those without (22.0±13.0 vs 18.5±11.1, P=0.008) as was the time to delivery (30.2±15.0 vs 26.0±12.6, P=0.004). Fewer women with diabetes delivered within 36 h (adjusted odds ratio: 0.41, 95% confidence interval: 0.26 to 0.66, P=0.0003) and 48 h (adjusted odds ratio: 0.36, 95% confidence interval: 0.19 to 0.71, P=0.004). These relationships were significant after a multivariate regression analysis of baseline characteristics that adjusted for age, race, parity, body mass index, baseline modified Bishop Score, gestational age at induction and treatment group allocation.Conclusion:After PG labor induction, women with diabetes took longer to reach active labor and to deliver. We emphasize that this result comes from a secondary analysis and needs confirmation with additional studies.

Maternal and neonatal outcomes among scheduled versus unscheduled deliveries in women with prenatally diagnosed, pathologically proven placenta accreta

Abstract Objective: To evaluate maternal and neonatal outcomes among scheduled versus unscheduled deliveries in cases of prenatally diagnosed, pathologically proven placenta accreta. Study design: Retrospective cohort of placenta accreta cases delivered in five University of California hospitals. Results: Of 151 cases of histopathologically proven placenta accreta, 82% were prenatally diagnosed. Sixty-seven percent of women underwent scheduled deliveries and 33% were unscheduled. There were no differences in demographics between groups except a higher rate of antepartum bleeding in the unscheduled delivery group (81 versus 53%; p = .003). Scheduled deliveries were associated with a later gestational age at delivery (34.6 versus 32.6 weeks; p = .001), lower blood loss (2.0 versus 2.5 l; p = .04), higher birth weight (2488 versus 2010 g; p < .001), shorter postpartum length of stay (4 versus 5 d; p = .03) and neonatal length of stay (12 versus 20 d; p = .005). Conclusion: Despite a prenatal diagnosis of placenta accreta, 1/3 of these cases require unscheduled delivery, portending poorer maternal and neonatal outcomes.