Sara N. Iqbal

Maternal and Neonatal Outcomes by Attempted Mode of Operative Delivery From a Low Station in the Second Stage of Labor.

OBJECTIVE: To evaluate maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor. METHODS: Retrospective study of 2,518 women carrying singleton fetuses at 37 weeks of gestation or greater who underwent attempted forceps-assisted delivery, attempted vacuum-assisted vaginal delivery, or cesarean delivery from a low station in the second stage of labor. Primary outcomes were stratified by parity and included a maternal adverse outcome composite (postpartum hemorrhage, transfusion, endometritis, peripartum hysterectomy, or intensive care unit admission) and a neonatal adverse outcome composite (5-minute Apgar score less than 4, respiratory morbidity, neonatal intensive care unit admission, shoulder dystocia, birth trauma, or sepsis). RESULTS: In nulliparous patients, the maternal adverse composite was not significantly different between women who underwent attempted forceps (12.1% compared with 10.8%, adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.40–1.34) or vacuum (8.3% compared with 10.8%, adjusted OR 0.68, 95% CI 0.40–1.16) delivery compared with cesarean delivery. Among parous women, the maternal adverse composite was not significantly different with attempted forceps (10.7% compared with 12.5%, adjusted OR 0.40, 95% CI 0.09–1.71) or vacuum (11.3% compared with 12.5%, adjusted OR 0.44, 95% CI 0.11–1.72) compared with cesarean delivery. Compared with neonates delivered by cesarean, the neonatal adverse composite was significantly lower among neonates born to nulliparous women who underwent attempted forceps (9.4% compared with 16.7%, adjusted OR 0.44, 95% CI 0.27–0.72) but not among those who underwent vacuum delivery (11.9% compared with 16.7%, adjusted OR 0.68, 95% CI 0.44–1.04). Among parous women, the neonatal adverse composite was not significantly different after attempted forceps (4.1% compared with 12.5%, adjusted OR 0.28, 95% CI 0.06–1.35) or vacuum (12.5% compared with 12.5%, adjusted OR 1.03, 95% CI 0.28–3.87) compared with cesarean delivery. CONCLUSION: A trial of forceps delivery from a low station compared with cesarean delivery was associated with decreased neonatal morbidity among neonates born to nulliparous women. LEVEL OF EVIDENCE: II

Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy

OBJECTIVE We sought to determine predictors of adverse neonatal outcomes in women with intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN This study was a multicenter retrospective cohort study of all women diagnosed with ICP across 5 hospital facilities from January 2009 through December 2014. Obstetric and neonatal complications were evaluated according to total bile acid (TBA) level. Multivariable logistic regression models were developed to evaluate predictors of composite neonatal outcome (neonatal intensive care unit admission, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, transient tachypnea of the newborn, mechanical ventilation use, oxygen by nasal cannula, pneumonia, and stillbirth). Predictors including TBA level, hepatic transaminase level, gestational age at diagnosis, underlying liver disease, and use of ursodeoxycholic acid were evaluated. RESULTS Of 233 women with ICP, 152 women had TBA levels 10-39.9 μmol/L, 55 had TBA 40-99.9 μmol/L, and 26 had TBA ≥100 μmol/L. There was no difference in maternal age, ethnicity, or prepregnancy body mass index according to TBA level. Increasing TBA level was associated with higher hepatic transaminase and total bilirubin level (P < .05). TBA levels ≥100 μmol/L were associated with increased risk of stillbirth (P < .01). Increasing TBA level was also associated with earlier gestational age at diagnosis (P < .01) and ursodeoxycholic acid use (P = .02). After adjusting for confounders, no predictors were associated with composite neonatal morbidity. TBA 40-99.9 μmol/L and TBA ≥100 μmol/L were associated with increased risk of meconium-stained amniotic fluid (adjusted odds ratio, 3.55; 95% confidence interval, 1.45-8.68 and adjusted odds ratio, 4.55; 95% confidence interval, 1.47-14.08, respectively). CONCLUSION In women with ICP, TBA level ≥100 μmol/L was associated with increased risk of stillbirth. TBA ≥40 μmol/L was associated with increased risk of meconium-stained amniotic fluid.

Glycemic control, compliance, and satisfaction for diabetic gravidas in centering group care

Abstract Purpose: To determine if diabetic gravidas enrolled in Centering® group care have improved glycemic control compared to those attending standard prenatal care. To compare compliance and patient satisfaction between the groups. Materials and methods: We conducted a prospective cohort study of diabetics enrolled in centering group care from October 2013 to December 2015. Glycemic control, compliance and patient satisfaction (five-point Likert scale) were evaluated. Student’s t-test, Chi-Square and mixed effects model were used to compare outcomes. Results: We compared 20 patients in centering to 28 standard prenatal care controls. Mean fasting blood sugar was lower with centering group care (91.0 versus 105.5 mg/dL, p =0.017). There was no difference in change in fasting blood sugar over time between the two groups (p = 0.458). The percentage of time patients brought their blood glucose logs did not differ between the centering group and standard prenatal care (70.7 versus 73.9%, p = 0.973). Women in centering group care had better patient satisfaction scores for “ability to be seen by a physician” (5 versus 4, p = 0.041) and “time in waiting room” (5 versus 4, p =0.001). Conclusion: Fasting blood sugar was lower for patients in centering group care. Change in blood sugar over time did not differ between groups. Diabetic gravidas enrolled in centering group care report improved patient satisfaction.

Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route

BACKGROUND: Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. OBJECTIVE: We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. STUDY DESIGN: Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. RESULTS: Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85–3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77–1.27) cardiac anomalies. CONCLUSION: Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.

Maternal outcomes associated with early preterm cesarean delivery.

Background: Data on complications associated with classic cesarean delivery are conflicting. In extremely preterm cesarean delivery (22 0/7–27 6/7 weeks’ gestation), the lower uterine segment is thicker. It is plausible that the rates of maternal complications may not differ between classic and low transverse cesarean. Objective: We sought to compare maternal outcomes associated with classic versus low transverse cesarean after stratifying by gestation (23 0/7–27 6/7 and 28 0/7–31 6/7 weeks’ gestation). Study Design: We conducted a multihospital retrospective cohort study of women undergoing cesarean delivery at 23 0/7 to 31 6/7 weeks’ gestation from 2005 through 2014. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between classic and low transverse cesarean. Outcomes were calculated using multivariable logistic regression models yielding adjusted odds ratios with 95% confidence intervals and adjusted P values controlling for maternal characteristics, emergency cesarean delivery, and comorbidities. Analyses were stratified by gestational age categories (23 0/7–27 6/7 and 28 0/7–31 6/7 weeks’ gestation). Results: Of 902 women, 221 (64%) and 91 (16%) underwent classic cesarean between 23 0/7 and 27 6/7 and between 28 0/7 and 31 6/7 weeks’ gestation, respectively. There was no increase in maternal complications for classic cesarean versus low transverse cesarean between 23 0/7 and 27 6/7 weeks’ gestation. However, between 28 0/7 and 31 6/7 weeks’ gestation, classic cesarean was associated with increased risks of the composite maternal outcome (adjusted odds ratio, 1.95; 95% confidence interval, 1.10–3.45), transfusion (adjusted odds ratio, 2.42; 95% confidence interval, 1.06–5.52), endometritis (adjusted odds ratio, 3.23; 95% confidence interval, 1.02–10.21), and intensive care unit admission (adjusted odds ratio, 5.05; 95% confidence interval, 1.37–18.52) compared to low transverse cesarean. Conclusion: Classic cesarean delivery compared with low transverse was associated with higher maternal complication rates between 28 0/7 and 31 6/7 weeks, but not between 23 0/7 and 27 6/7 weeks’ gestation.

Duration of Oxytocin and Rupture of the Membranes Before Diagnosing a Failed Induction of Labor

OBJECTIVE: To compare maternal and neonatal outcomes based on length of the latent phase during induction with rupture of membranes before 6 cm dilation. METHODS: This is a retrospective cohort study using data from the Consortium of Safe Labor study, including 9,763 nulliparous and 8,379 multiparous women with singleton, term pregnancies undergoing induction at 2 cm dilation or less with rupture of membranes before 6 cm dilation after which the latent phase ended. Outcomes were evaluated according to duration of oxytocin and rupture of membranes. RESULTS: At time points from 6 to 18 hours of oxytocin and rupture of membranes, the rates of nulliparous women remaining in the latent phase declined (35.9–1.4%) and the rates of vaginal delivery for those remaining in the latent phase at these time periods decreased (54.1–29.9%) Nulliparous women remaining in the latent phase for 12 hours compared with women who had exited the latent phase had significantly increased rates of chorioamnionitis (12.1% compared with 4.1%) and endometritis (3.6% compared with 1.3%) and increased rates of neonatal intensive care unit admission (8.7% compared with 6.3%). Similar patterns were present for multiparous women at 15 hours. CONCLUSION: Based on when neonatal morbidity increased, in an otherwise uncomplicated induction of labor with rupture of membranes, a latent phase after initiation of oxytocin of at least 12 hours for nulliparous women and 15 hours in multiparous women is a reasonable criterion for diagnosing a failed induction.

Catecholaminergic Ventricular Tachycardia, Pregnancy and Teenager: Are They Compatible?

Arrhythmias in pregnancy are becoming more common given more available and effective medical, ablation and device treatment options. Several changes associated with pregnancy, increased blood volume, cardiac output, and heart rate secondary to an increased sympathetic state, facilitate more frequent occurrences of arrhythmias throughout the pregnancy and during labor and delivery. We present a case of successful pregnancy in a teenage female with a previous diagnosis of CPVT, followed by a review of the literature.

Early Preterm Preeclampsia Outcomes by Intended Mode of Delivery

BACKGROUND: The optimal route of delivery in early‐onset preeclampsia before 34 weeks is debated because many clinicians are reluctant to proceed with induction for perceived high risk of failure. OBJECTIVE: Our objective was to investigate labor induction success rates and compare maternal and neonatal outcomes by intended mode of delivery in women with early preterm preeclampsia. STUDY DESIGN: We identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth, or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n = 460) and planned cesarean delivery (n = 454) and women with successful induction of labor (n = 214) and unsuccessful induction of labor (n = 246). We calculated relative risks and 95% confidence intervals to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birthweight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance, marital status, and steroid use. RESULTS: Among the 460 women with induction (50%), 47% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7, and 32 to 33 6/7, the induction of labor success rates were 38% (12 of 32), 39% (70 of 180), and 54% (132 of 248), respectively. Induction of labor compared with planned cesarean delivery was less likely to be associated with placental abruption (adjusted relative risk, 0.33; 95% confidence interval, 0.16–0.67), wound infection or separation (adjusted relative risk, 0.23; 95% confidence interval, 0.06–0.85), and neonatal asphyxia (0.12; 95% confidence interval, 0.02–0.78). Women with vaginal delivery compared with those with failed induction of labor had decreased maternal morbidity (adjusted relative risk, 0.27; 95% confidence interval, 0.09–0.82) and no difference in neonatal outcomes. CONCLUSION: About half of women with preterm preeclampsia who attempted an induction had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high‐risk population of women.

Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy

Abstract Purpose: To determine the performance of third trimester ultrasound in women with suspected fetal macrosomia. Materials and methods: We performed a retrospective cohort study of fetal ultrasounds from January 2004 to December 2014 with estimated fetal weight (EFW) between 4000 and 5000 g. We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, accounting for diabetic status and time between ultrasound and delivery. Results: There were 405 ultrasounds evaluated. One hundred and twelve (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) were performed in diabetics. Sonographic identification of EFW over 4000 g at less than 38 weeks was associated with higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 versus 259.4 g, p < .024). EFW to birth weight correlation was within 1.7% of birth weight for ultrasound performed less than 38 weeks and within 6.5% of birth weight for ultrasound performed at greater than 38 weeks. Conclusions: Identification of EFW with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed later in gestation. EFW to birth weight correlation was more accurate than previous reports.

Evaluation of Classical Cesarean Delivery Outcomes [20K]

INTRODUCTION: To compare maternal outcomes for classical cesarean delivery (CCD) with low transverse cesarean delivery (LTCD) early preterm. METHODS: We conducted a multi-hospital retrospective cohort study of women undergoing cesarean delivery (CD) at 23–31 weeks between 2005 and 2014. Intraoperative outcomes (incision-delivery time [ID-time], total operative time [TO-time], and estimated blood loss [EBL]) and composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, pulmonary edema, and intensive care unit [ICU] admission) were compared between CCD and LTCD. Outcomes were calculated using multivariable logistic regression models yielding adjusted odds ratios (aOR) with 95% CI and adjusted P values controlling for maternal characteristics, emergency CD, and comorbidities. Analyses were stratified by gestational age (GA) groups (23–27 and 28–31 weeks) as well as primary versus repeat CD. RESULTS: Of 902 women meeting inclusion criteria, 221 (64%) and 82 (16%) underwent CCD at 23–27 and 28–31 weeks, respectively. For primacy CDs, no difference was seen in ID-times regardless of GA. For repeat CDs, CCD was associated with longer ID-times regardless of GA (P<.05 for all). Primary and repeat CCD were associated with longer TO-times regardless of GA (P<.01 for all). At 28–31 weeks, CCD was associated with increased risk of transfusion (aOR=3.06; 95% CI=1.39–6.75), ICU admission (aOR=5.42; 95% CI=1.39–21.06), and composite maternal outcome (aOR=2.23; 95% CI=1.27–3.91); no increased risk was seen for CCD at 23–27 weeks. CONCLUSION: CCD at 28–31 weeks was associated with increased maternal complications. CCD did not enhance faster ID-time and therefore CCD solely for facilitating more rapid delivery is not indicated.