Omar M. Young

Maternal Obesity in Pregnancy, Gestational Weight Gain, and Risk of Childhood Asthma

BACKGROUND AND OBJECTIVE: Environmental or lifestyle exposures in utero may influence the development of childhood asthma. In this meta-analysis, we aimed to assess whether maternal obesity in pregnancy (MOP) or increased maternal gestational weight gain (GWG) increased the risk of asthma in offspring. METHODS: We included all observational studies published until October 2013 in PubMed, Embase, CINAHL, Scopus, The Cochrane Database, and Ovid. Random effects models with inverse variance weights were used to calculate pooled risk estimates. RESULTS: Fourteen studies were included (N = 108 321 mother–child pairs). Twelve studies reported maternal obesity, and 5 reported GWG. Age of children was 14 months to 16 years. MOP was associated with higher odds of asthma or wheeze ever (OR = 1.31; 95% confidence interval [CI], 1.16–1.49) or current (OR = 1.21; 95% CI, 1.07–1.37); each 1-kg/m2 increase in maternal BMI was associated with a 2% to 3% increase in the odds of childhood asthma. High GWG was associated with higher odds of asthma or wheeze ever (OR = 1.16; 95% CI, 1.001–1.34). Maternal underweight and low GWG were not associated with childhood asthma or wheeze. Meta-regression showed a negative association of borderline significance for maternal asthma history (P = .07). The significant heterogeneity among existing studies indicates a need for standardized approaches to future studies on the topic. CONCLUSIONS: MOP and high GWG are associated with an elevated risk of childhood asthma; this finding may be particularly significant for mothers without asthma history. Prospective randomized trials of maternal weight management are needed.

Pharmacokinetics of cefazolin prophylaxis in obese gravidae at time of cesarean delivery

OBJECTIVE The objective of the study was to compare the pharmacokinetics of 2 g and 3 g doses of cefazolin when used for perioperative prophylaxis in obese gravidae undergoing cesarean delivery. STUDY DESIGN We performed a double-blinded, randomized controlled trial from August 2013 to April 2014. Twenty-six obese women were randomized to receive either 2 or 3 g intravenous cefazolin within 30 minutes of a skin incision. Serial maternal plasma samples were obtained at specific time points up to 8 hours after drug administration. Umbilical cord blood was obtained after placental delivery. Maternal adipose samples were obtained prior to fascial entry, after closure of the hysterotomy, and subsequent to fascial closure. Pharmacokinetic parameters were determined via noncompartmental analysis. RESULTS The median area under the plasma concentration vs time curve was significantly greater in the 3 g group than in the 2 g group (27204 μg/mL per minute vs 14058 μg/mL per minute; P = .001). Maternal plasma concentrations had an impact by body mass index. For every 1 kg/m(2) increase in body mass index at the time of the cesarean delivery, there was an associated 13.77 μg/mL lower plasma concentration of cefazolin across all time points (P = .01). By the completion of cesarean delivery, cefazolin concentrations in maternal adipose were consistently above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria with both the 2 g and 3 g doses. The median umbilical cord blood concentrations were significantly higher in the 3 g vs the 2 g group (34.5 μg/mL and 21.4 μg/mL; P = .003). CONCLUSION Cefazolin concentrations in maternal adipose both at time of hysterotomy closure and fascial closure were above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria when either 2 g or 3 g cefazolin was administered as perioperative surgical prophylaxis. Maternal cefazolin concentrations in plasma and maternal adipose tissue are related to both dose and body mass index.

Maternal prepregnancy obesity and cause-specific stillbirth

BACKGROUND In high-income countries, maternal obesity is one of the most important modifiable causes of stillbirth, yet the pathways underpinning this association remain unclear. OBJECTIVE We estimated the association between maternal prepregnancy body mass index (BMI) and the risk of stillbirth defined by pathophysiologic contributors or causes. DESIGN Using a case-cohort design, we randomly sampled 1829 singleton deliveries from a cohort of 68,437 eligible deliveries at Magee-Womens Hospital in Pittsburgh, Pennsylvania (2003-2010), and augmented it with all remaining cases of stillbirth for a total of 658 cases. Stillbirths were classified based on probable cause(s) of death (maternal medical conditions, obstetric complications, fetal abnormalities, placental diseases, and infection). A panel of clinical experts reviewed medical records, placental tissue slides and pathology reports, and fetal postmortem reports of all stillbirths. Causes of fetal death were assigned by using the Stillbirth Collaborative Research Network Initial Causes of Fetal Death protocol from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Proportional hazards models were used to estimate the BMI-stillbirth association after adjustment for confounders. RESULTS The rate of stillbirth among lean, overweight, obese, and severely obese women was 7.7, 10.6, 13.9, and 17.3 per 1000 live-born and stillborn infants, respectively. Adjusted stillbirth HRs (95% CIs) were 1.4 (1.1, 1.8) for overweight, 1.8 (1.3, 2.4) for obese, and 2.0 (1.5, 2.8) for severely obese women, respectively, compared with lean women; associations strengthened when limited to antepartum stillbirths. Obesity and severe obesity were associated with stillbirth resulting from placental diseases, hypertension, fetal anomalies, and umbilical cord abnormalities. BMI was not related to stillbirth caused by placental abruption, obstetric conditions, or infection. CONCLUSIONS Multiple mechanisms appear to link obesity to stillbirth. Interventions to reduce stillbirth among obese mothers should consider targeting stillbirth due to hypertension and placental diseases-the most common causes of fetal death in this at-risk group.

Pre‐pregnancy maternal obesity and the risk of preterm preeclampsia in the American primigravida

To estimate the risk of preterm preeclampsia in primiparous women by pre‐pregnancy obesity class.

Antenatal Spontaneous Renal Forniceal Rupture Presenting as an Acute Abdomen

Background Renal forniceal rupture is a lesser-known cause of acute abdomen in pregnancy. The ureteral compression by the gravid uterus places pregnant women at a higher risk. Sequelae in pregnancy could include intractable pain, acute kidney injury, and preterm birth. Case A 22-year-old primigravida with no prior medical history presented with an acute abdomen in her second trimester. The diagnosis of renal forniceal rupture was made by a radiologist using MRI. A percutaneous nephrostomy catheter was placed, and the patients pain was relieved. She subsequently delivered at term. Conclusion Upon presentation of an acute abdomen in pregnancy, providers may not include renal forniceal rupture in their differential as readily as obstetric or gynecologic causes, resulting in delayed diagnosis, unnecessary invasive interventions, and potentially adverse maternal and neonatal outcomes. Increasing provider awareness could result in improved outcomes.

A Prediction Model for Severe Maternal Morbidity in Laboring Patients at Term

Objective To determine the factors associated with severe maternal morbidity in a modern cohort of women laboring at term and to create a prediction model. Study Design This is a retrospective cohort study of all term, laboring patients with live births at a single tertiary care center from 2004 to 2014. The primary outcome was composite maternal morbidity including organ failure, amniotic fluid embolism, anesthesia complications, sepsis, shock, thrombotic events, transfusion, or hysterectomy. Multivariable logistic regression was used to identify independent risk factors. Antepartum, intrapartum, and combined risk scores were created and test characteristics were analyzed. Results Among 19,249 women delivering during the study period, 323 (1.68%) patients experienced severe morbidity, with blood transfusion the most common complication (286, 1.49%). Factors in the antepartum model included advanced maternal age, race, hypertension, nulliparity, history of cesarean delivery, smoking, and unfavorable Bishop score. Intrapartum factors included mode of delivery, use of cervical ripening agents or oxytocin, prolonged second stage, and macrosomia. The combined model had an area under the curve of 0.76 (95% confidence interval [CI], 0.73, 0.79). Conclusion This three‐part risk scoring system can help clinicians counsel patients and guide clinical decision making for anticipating severe maternal morbidity and necessary resources.

Utility of the Simplified Bishop Score in Spontaneous Labor

Objective The objective of this study was to evaluate the relationship between the simplified Bishop score (SBS) on admission for labor and subsequent labor outcomes to identify women at higher risk for cesareans. Study Design This was a secondary analysis of a prospective cohort study of 4,733 singleton pregnancies. Adjusted odds ratios (aOR) were calculated comparing outcomes in women with an unfavorable SBS ≤ 5 to women with a favorable SBS > 5. A favorable SBS was compared with the individual parameters of dilation, effacement, and station. The primary outcome was vaginal delivery. Secondary outcomes were prolonged first stage, completion of first stage, oxytocin augmentation, and prolonged second stage. Results 47.8% of the patients admitted in labor had an unfavorable SBS. Nulliparous and multiparous patients with a favorable SBS were more likely to have a vaginal delivery (aOR 1.96, 95% confidence intervals [CI] 1.49-2.57; aOR 1.91, 95% CI 1.44-2.53) and less likely to require oxytocin augmentation (aOR 0.34, 95% CI 0.28-0.42; aOR 0.26, 95% CI 0.22-0.30. Compared with dilation alone, the SBS in its entirety was associated with a higher likelihood of vaginal delivery in nulliparous. Conclusion An unfavorable SBS on admission for labor is associated with a decreased likelihood of having a vaginal delivery.