Roxane Rampersad

Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis.

OBJECTIVE: To estimate whether staples or subcuticular suture closure is associated with a higher risk of wound complications when used for transverse skin incisions after cesarean delivery. DATA SOURCES: A systematic review and meta-analysis were performed through electronic database searches (MEDLINE, Cochrane, and Trial Registries). METHODS OF STUDY SELECTION: We searched electronic databases from 1966 to September 2010 for randomized controlled trials (RCTs) and prospective cohort studies comparing staples to subcuticular sutures after cesarean delivery. The primary outcome was occurrence of a wound complication (infection or separation). Secondary outcomes were components of the composite outcome, operating time, postoperative pain, cosmesis, and patient satisfaction. Heterogeneity was assessed using the &khgr;2 test for heterogeneity, and I2 test. Pooled odds ratios (ORs) were calculated using a fixed-effects model. We assessed publication bias using funnel plots and Egger test. RESULTS: Six studies met inclusion criteria: five RCTs and one prospective cohort study. Staple closure (n=803) was associated with a twofold higher risk of wound infection or separation compared with subcuticular suture closure (n=684) (13.4% versus 6.6%, pooled OR 2.06, 95% confidence interval [CI] 1.43–2.98). The number needed to harm associated with staple closure was 16. The increased risk persisted when analysis was limited to the RCTs (OR 2.43, 95% CI 1.47–4.02). There was no evidence of significant statistical heterogeneity among studies (&khgr;2=0.74, P=.327, I2=13.7%) or publication bias (Egger test, t=−0.86, P=.439). Staple closure was associated with shorter duration of surgery, whereas the two techniques appeared equivalent overall with regard to pain, cosmesis, and patient satisfaction. CONCLUSION: Staple closure is faster to perform but associated with a higher risk of wound complications.

Prenatal Screening for Thrombophilias: Indications and Controversies

A thrombophilia is defined as a disorder of hemostasis that predisposes a person to a thrombotic event. Data suggest that at least 50% of cases of venous thromboembolism in pregnant women are associated with an inherited or acquired thrombophilia, which can lead to an increased risk of maternal thromboembolism and adverse pregnancy outcomes such as recurrent pregnancy loss, intrauterine fetal demise, preterm preeclampsia, and intrauterine growth restriction. Inherited and acquired thrombophilias have different indications for testing. This article examines screening procedures for thrombophilias in the setting of adverse pregnancy outcomes.

Prevalence and likelihood ratios for aneuploidy in fetuses diagnosed prenatally with isolated congenital cardiac defects

OBJECTIVE To determine the prevalence and likelihood ratios for aneuploidy in fetuses diagnosed prenatally with isolated congenital cardiac defects. STUDY DESIGN Retrospective cohort study over a 16-year period using our computerized perinatal database. Cardiac diagnosis was confirmed before establishing karyotype by prenatal diagnosis or postnatal chromosome testing. The screening efficiency and likelihood ratios for any aneuploidy and for trisomy 21, 18, 13, and 45, X were calculated with 95% confidence intervals. RESULTS A total of 233 (0.4%) isolated congenital cardiac defects were diagnosed among 62,111 patients who had obstetric ultrasounds during the study period. The likelihood ratio (LR+) for any aneuploidy was 24.9 (95% confidence interval [CI], 17.8-35.0). The corresponding likelihood ratio for trisomy 21, 18, and 13 were 29.8 (95% CI, 19.6-45.4), 26 (95% CI, 10.5-64.6), and 19.7 (95% CI, 4.7-82.2), respectively. CONCLUSION Prenatal diagnosis of congenital cardiac defects is highly associated with aneuploidy.

Assessing the Optimal Definition of Oligohydramnios Associated With Adverse Neonatal Outcomes

The purpose of this study was to compare the use of an amniotic fluid index (AFI) less than 5 cm to the use of an AFI less than the fifth percentile for gestational age in predicting adverse perinatal outcomes.

Early Second-Trimester Fetal Growth Restriction and Adverse Perinatal Outcomes.

OBJECTIVE To estimate the risk of adverse perinatal outcomes among women with isolated fetal growth restriction from 17 to 22 weeks of gestation. METHODS This was a retrospective cohort study of all singleton, nonanomalous pregnancies undergoing ultrasonography to assess fetal anatomy between 17 and 22 weeks of gestation at a single center from 2010 to 2014. After excluding patients with fetal structural malformations, chromosomal abnormalities, or identified infectious etiologies, we compared perinatal outcomes between pregnancies with and without fetal growth restriction, defined as estimated fetal weight less than the 10th percentile for gestational age. Our primary outcome was small for gestational age (SGA) at birth, defined as birth weight less than the 10th percentile. Secondary outcomes included preterm delivery at less than 37 and less than 28 weeks of gestation, preeclampsia, abruption, stillbirth, neonatal death, neonatal intensive care unit admission, intraventricular hemorrhage, need for respiratory support, and necrotizing enterocolitis. RESULTS Of 12,783 eligible patients, 355 (2.8%) had early second-trimester fetal growth restriction. Risk factors for growth restriction were African American race and tobacco use. Early second-trimester growth restriction was associated with a more than fivefold increase in risk of SGA at birth (36.9% compared with 9.1%, adjusted odds ratio [OR] 5.5, 95% CI 4.3-7.0), stillbirth (2.5% compared with 0.4%, OR 6.2, 95% CI 2.7-12.8), and neonatal death (1.4% compared with 0.3%, OR 5.2, 95% CI 1.6-13.5). Rates of indicated preterm birth at less than 37 weeks of gestation (7.3% compared with 3.3%, OR 2.3, 95% CI 1.5-3.5) and less than 28 weeks of gestation (2.5% compared with 0.2%, OR 10.8, 95% CI 4.5-23.4), neonatal need for respiratory support (16.9% compared with 7.8%, adjusted OR 1.6, 95% CI 1.1-2.2), and necrotizing enterocolitis (1.4% compared with 0.2%, OR 7.7, 95% CI 2.3-20.9) were also significantly higher for those with growth restriction. Rates of preeclampsia, abruption, and other neonatal outcomes were not significantly different. CONCLUSION Although fetal growth restriction in the early second trimester occurred in less than 3% of our cohort and most of those with isolated growth restriction did not have adverse outcomes, it is a strong risk factor for SGA, stillbirth, neonatal death, and indicated preterm birth.

Impact of evidence-based interventions on wound complications after cesarean delivery

BACKGROUND: A number of evidence‐based interventions have been proposed to reduce post–cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE: We sought to estimate the impact of a group of evidence‐based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine‐alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN: We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine‐alcohol vs iodine‐alcohol for skin antisepsis at cesarean delivery from 2011–2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence‐based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine‐alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence‐based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS: Of 1082 patients with follow‐up data, 349 (32.3%) received all the evidence‐based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence‐based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58–0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence‐based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12–2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18–11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence‐based measures. CONCLUSION: Implementation of evidence‐based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence‐based measures.

Impact of fetal growth on pregnancy outcomes in women with severe preeclampsia

OBJECTIVE To estimate whether pregnancy outcomes in women with severe preeclampsia (sPE) with small for gestational age (SGA) fetuses differ from those with sPE without SGA or isolated SGA. STUDY DESIGN We conducted a retrospective cohort study of consecutive non-anomalous, livebirths in a single tertiary care institution from 2004 to 2008. We compared pregnancy outcomes in women who had sPE with SGA (birthweight<10th percentile), and sPE without SGA to those with isolated SGA as reference. The primary outcome was a neonatal composite score including low 5-min APGAR, NICU admission and neonatal death. Secondary outcomes were components of the composite as well as placental abruption and cesarean delivery. Analysis was repeated with SGA defined as birthweight<5th percentile. Multivariable logistic regression was used to adjust for confounders. RESULTS 1905 women met inclusion criteria: 156 sPE with SGA, 746 sPE without SGA, 1003 isolated SGA. The risk of the neonatal composite score was higher for sPE with SGA (adjusted odds ratio [aOR] 2.29; 95% confidence interval [CI] 1.39-3.79) and sPE without SGA (aOR 3.66; 95% CI 2.71-4.93) compared to isolated SGA. The risk of abruption and cesarean were similarly increased in women with sPE with SGA and sPE without SGA compared to those with isolated SGA. CONCLUSION Similar to women with sPE without SGA fetus, women who have sPE with SGA are at a higher risk for several adverse maternal and neonatal outcomes compared to isolated SGA. These findings suggest that women with preeclampsia and SGA should be managed as sPE rather than as isolated SGA.

Delivery Outcomes after Term Induction of Labor in Small-for-Gestational Age Fetuses

Objective The objective of this study was to estimate the delivery outcomes after induction of labor (IOL) at term in patients with small‐for‐gestational age (SGA) fetuses. Study Design A secondary analysis of a prospective cohort study of all term, singleton deliveries from 2010 to 2014. Patients who underwent an IOL for any indication were included. Delivery outcomes were compared between patients with and without SGA fetuses (defined as birth weight < 10th percentile for gestational age). Analysis was stratified by parity. Indication for cesarean was compared between the two groups for those who did not achieve vaginal delivery. Logistic regression was used to adjust for confounders. Results Of 3,787 patients who underwent an IOL, 644 patients had SGA fetuses and 3,143 were included in the non‐SGA group. There was no significant difference in rate of successful vaginal delivery for patients with and without SGA fetuses (77.2 vs. 72.0% [adjusted odds ratio: 1.22, 95% confidence interval 1.00–1.50]). Of the patients who were delivered by cesarean, women with SGA fetuses were more likely to undergo cesarean for nonreassuring fetal status and less likely for arrest disorders than women without an SGA fetus. Conclusion Term patients undergoing IOL with SGA fetuses are as likely to achieve a vaginal delivery as patients with non‐SGA fetuses.