Neil Seligman

Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates.

OBJECTIVE The objective of the study was to identify maternal variables predicting length of treatment for neonatal abstinence syndrome (NAS). STUDY DESIGN This was a retrospective cohort study of infants treated for NAS during 2000-2006 whose mothers were on methadone maintenance at delivery. Mixed-effects linear regression was used to examine the interaction of maternal and neonatal variables with length of treatment. RESULTS Of 204 neonates born to methadone exposed mothers, the average dose at delivery was 127 mg daily (25-340 mg) with median length of treatment 32 days (1-122 days). Trimester of initial exposure (P = .33), methadone dose at delivery (P = .198), body mass index (P = .31), antidepressant use (P = .40), cigarette use (P = .76), race (P = .78), and maternal age (P = .84) did not predict length of treatment. In the multivariate analysis, gestational age at delivery and benzodiazepine use were significant predictors of length of treatment. CONCLUSION Later gestational age and concomitant benzodiazepine use were associated with longer treatment.

Relationship between maternal methadone dose at delivery and neonatal abstinence syndrome.

OBJECTIVE To estimate the relationship between maternal methadone dose and the incidence of neonatal abstinence syndrome (NAS). STUDY DESIGN We performed a retrospective cohort study of pregnant women treated with methadone for opiate addiction who delivered live-born neonates between 1996 and 2006. Four dose groups, on the basis of total daily methadone dose, were compared (<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d). The primary outcome was treatment for NAS. Symptoms of NAS were objectively measured with the Finnegan scoring system, and treatment was initiated for a score>24 during the prior 24 hours. RESULTS A total of 330 women treated with methadone and their 388 offspring were included. Average methadone dose at delivery was 117+/-50 mg/d (range, 20-340 mg/d). Overall, 68% of infants were treated for NAS. Of infants exposed to methadone doses<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d, treatment for NAS was initiated for 68%, 63%, 70%, and 73% of neonates, respectively (P=.48). The rate of maternal illicit opiate abuse at delivery was 26%, 28%, 19%, and 11%, respectively (P=.04). CONCLUSION No correlation was found between maternal methadone dose and rate of NAS. However, higher doses of methadone were associated with decreased illicit opiate abuse at delivery.

Physical Examination–indicated Cerclage: A Systematic Review and Meta-analysis

OBJECTIVE: To estimate the effectiveness of physical examination–indicated cerclage in the setting of second-trimester cervical dilatation by systematic review and meta-analysis of published studies. DATA SOURCES: We searched MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and the Cochrane Library for studies published between 1966 and 2014 that evaluated cervical cerclage for the treatment of cervical insufficiency. METHODS OF STUDY SELECTION: The search yielded 6,314 citations. We included cohort studies and randomized controlled trials comparing cerclage placement with expectant management of women with cervical dilatation between 14 and 27 weeks of gestation. Two investigators independently reviewed each citation for inclusion or exclusion and discordant decisions were arbitrated by a third reviewer. Summary estimates were reported as the mean difference and 95% confidence interval (CI) for continuous variables or relative risk and with 95% CI for dichotomous outcomes. Fixed- and random-effects meta-analysis was used, depending on heterogeneity. TABULATION, INTEGRATION, AND RESULTS: Ten studies met inclusion criteria and were included in the final analysis. One was a randomized controlled trial, two were prospective cohort studies, and the remaining seven were retrospective cohort studies. Of the 757 women, 485 (64%) underwent physical examination–indicated cerclage placement and 272 (36%) were expectantly managed. Cerclage was associated with increased neonatal survival (71% compared with 43%; relative risk 1.65, 95% CI 1.19–2.28) and prolongation of pregnancy (mean difference 33.98 days, 95% CI 17.88–50.08). CONCLUSION: Physical examination–indicated cerclage is associated with a significant increase in neonatal survival and prolongation of pregnancy of approximately 1 month when compared with no such cerclage. The strength of this conclusion is limited by the potential for bias in the included studies.

Gestational weight gain and obesity: is 20 pounds too much?

OBJECTIVE To compare maternal and neonatal outcomes in obese women according to weight change and obesity class. STUDY DESIGN Cohort study from the Consortium on Safe Labor of 20,950 obese women with a singleton, term live birth from 2002-2008. Risk for adverse outcomes was calculated by multiple logistic regression analysis for weight change categories (weight loss [<0 kg], low [0-4.9 kg], normal [5.0-9.0 kg], high weight gain [>9.0 kg]) in each obesity class (I 30.0-34.9 kg/m(2), II 35.0-39.9 kg/m(2), and III ≥40 kg/m(2)) and by predicted probabilities with weight change as a continuous variable. RESULTS Weight loss was associated with decreased cesareans for class I women (nulliparas odds ratio [OR], 0.21; 95% confidence interval [CI], 0.11-0.42; multiparas OR, 0.61; 95% CI, 0.45-0.83) and increased small for gestational age infants (class I OR, 1.8; 95% CI, 1.3-2.5; class II OR, 2.2; 95% CI, 1.5-3.2; class III OR, 1.7; 95% CI, 1.1-2.6). High weight gain was associated with increased large for gestational age infants (class I OR, 2.4; 95% CI, 1.9-2.9; class II OR, 1.7; 95% CI, 1.3-2.1; class III OR, 1.6; 95% CI, 1.3-2.1). As weight change increased, the predicted probability for cesareans and large for gestational age infants increased. The predicted probability of low birthweight never exceeded 4% for all obesity classes, but small for gestational age infants increased with decreased weight change. The lowest average predicted probability of adverse outcomes (cesarean, postpartum hemorrhage, small for gestational age, large for gestational age, neonatal care unit admission) occurred when women (class I, II, III) lost weight. CONCLUSION Optimal maternal and neonatal outcomes appear to occur when weight gain is less than current Institute of Medicine recommendations for obese women. Further study of long-term outcomes is needed with respect to gestational weight changes.

Hypertensive Emergencies in Pregnancy.

The prevalence of hypertensive disorders in pregnancy is increasing. The etiology and pathophysiology of hypertensive disorders in pregnancy remain poorly understood. Hypertensive disorders are a major cause of maternal and perinatal morbidity and mortality. Treatment of hypertension decreases the incidence of severe hypertension, but it does not impact rates of preeclampsia or other pregnancy complications. Several antihypertensive medications are commonly used in pregnancy, although there is a lack of randomized controlled trials. Severe hypertension should be treated immediately to prevent maternal end-organ damage. Appropriate antepartum, intrapartum, and postpartum management is important in caring for patients with hypertensive disorders.

The Polish National Registry for Fetal Cardiac Pathology: organization, diagnoses, management, educational aspects and telemedicine endeavors†

We describe the National Registry for Fetal Cardiac Pathology, a program under the Polish Ministry of Health aimed at improving the prenatal diagnosis, care, and management of congenital heart disease (CHD).

Pouch function and gastrointestinal complications during pregnancy after ileal pouch-anal anastomosis

Objective. To estimate the risk of gastrointestinal and pouch complications and alterations in pouch function related to pregnancy in women treated with ileal pouch-anal anastomosis (IPAA). Methods. Pregnancies following IPAA were identified in our center, and in the literature through MEDLINE and PUBMED searches. The incidence of each complication was calculated. Pouch function was compared before and after pregnancy, by mode of delivery, and between women who became pregnant versus those that did not. Results. The incidence of complications in 283 pregnancies after IPAA was 12.7% including antepartum (2.8%) or postpartum (6.7%) small bowel obstruction, pouchitis (1.8%), and perianal abscess (0.4%). Stool frequency and incontinence were not significantly affected by pregnancy or mode of delivery. Conclusion. Pregnancy after IPAA is overall safe, associated with limited complications and no significant alteration in pouch function. Vaginal delivery appears as safe as cesarean section for most women.

Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta‐analysis

The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal‐Fetal Medicine have emphasized the need to promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate.

Trends in cerclage use

The indications of placement of cerclage have recently changed, and so it is important to evaluate how many women are undergoing this procedure. With the recent completion of clinical trials, it is plausible that obstetricians and perinatologists may have become more selective in terms of the best candidates for cerclage.

The three-vessel view in the fetal mediastinum in the diagnosis of interrupted aortic arch.

Interruption of the aortic arch (IAA) is difficult to detect and diagnose in utero. However, prenatal diagnosis may be beneficial because IAA is rapidly fatal (median age, 10 d) if left uncorrected. Our objective was to review the direct and indirect echocardiographic markers associated with IAA, focusing on the importance of the three-vessel view (3VV), which is obtained during routine ultrasound examination to rule out malformations. We analyzed the fetal echocardiograms of nine fetuses and compared them with 56 normal controls. In each fetus, there was a large discrepancy between the diameter of the larger, dilated pulmonary artery (PA) and smaller, narrow aortic arch (Ao). The calculated ratio of PA/Ao in fetuses with IAA was 2.6 ± 0.4 compared with 1.1 ± 0.09 in normal controls (p < 0.0001). The calculated ratio of PA/Ao in fetuses with IAA type A was 2.1 ± 0.09 and IAA type B 2.9 ± 0.2 (p = 0.0007). Discrepancy between PA/Ao diameters should raise the suspicion of aortic arch anomalies and a large discrepancy is a nearly pathognomonic sign of IAA type B.