Sean Esplin

How do good candidates for trial of labor after cesarean (TOLAC) who undergo elective repeat cesarean differ from those who choose TOLAC

OBJECTIVEnOur aim was to compare good candidates for trial of labor after cesarean (TOLAC) who underwent repeat cesarean to those who chose TOLAC.nnnSTUDY DESIGNnData for all deliveries at 14 regional hospitals over an 8-year period were reviewed. Women with a primary cesarean and 1 subsequent delivery in the dataset were included. The choice of elective repeat cesarean vs TOLAC was assessed in the first delivery following the primary cesarean. Women with ≥70% chance of successful vaginal birth after cesarean as calculated by a published nomogram were considered good candidates for TOLAC. Good candidates who chose an elective repeat cesarean were compared to those who chose TOLAC. Women who were delivered at 2 preselected tertiary centers by a general obstetrician-gynecologist practice were subanalyzed to determine whether there was an effect of physician group.nnnRESULTSnIn all, 5445 women had a primary cesarean and a subsequent delivery. A total of 3120 women were calculated to be good TOLAC candidates. Of this group, 925 (29.7%) chose TOLAC. Women managed by a family practitioner or who were obese were less likely to choose TOLAC while women who were managed by a midwife or had a prior vaginal delivery were more likely to choose TOLAC. At the 2 tertiary centers, 1 general obstetrician-gynecologist group had significantly more patients who chose TOLAC compared to the other obstetrician-gynecologist physician groups (P < .001), with 63% of their patients choosing TOLAC.nnnCONCLUSIONnLess than one-third of the good candidates for TOLAC chose TOLAC. Managing provider influences this decision.

Detection and confirmation of serum lipid biomarkers for preeclampsia using direct infusion mass spectrometry

Despite substantial research, the early diagnosis of preeclampsia remains elusive. Lipids are now recognized to be involved in regulation and pathophysiology of some disease. Shotgun lipidomic studies were undertaken to determine whether serum lipid biomarkers exist that predict preeclampsia later in the same in pregnancy. A discovery study was performed using sera collected at 12–14 weeks pregnancy from 27 controls with uncomplicated pregnancies and 29 cases that later developed preeclampsia. Lipids were extracted and analyzed by direct infusion into a TOF mass spectrometer. MS signals, demonstrating apparent differences were selected, their abundances determined, and statistical differences tested. Statistically significant lipid markers were reevaluated in a second confirmatory study having 43 controls and 37 preeclampsia cases. Multi-marker combinations were developed using those lipid biomarkers confirmed in the second study. The initial study detected 45 potential preeclampsia markers. Of these, 23 markers continued to be statistically significant in the second confirmatory set. Most of these markers, representing several lipid classes, were chemically characterized, typically providing lipid class and potential molecular components using MS2. Several multi-marker panels with areas under the curve >0.85 and high predictive values were developed. Developed panels of serum lipidomic biomarkers appear to be able to identify most women at risk for preeclampsia in a given pregnancy at 12–14 weeks gestation.

Influence of Patient-Level Factors on Mode of Delivery among Operative Vaginal Delivery Candidates in Modern Practice

Objective We aimed to evaluate which patient‐level factors influence mode of delivery among candidates for operative vaginal delivery. Study Design Cross‐sectional study of candidates for operative vaginal delivery from 18 hospitals over 8 years. Probabilities of mode of delivery were estimated using hierarchical logistic modeling adjusting for clustering within physician and hospital. Results Total 3,771 (64%) women delivered with forceps, 1,474 (25%) vacuums, and 665 (11%) cesareans. Odds of forceps versus vacuum were higher with induction (OR = 2.16, 95% CI: 1.76‐2.65), nulliparity (OR = 2.06, 95% CI: 1.59‐2.66), epidural (OR = 2.05, 95% CI: 1.19‐3.56), maternal indication (OR = 1.53, 95% CI 1.16‐2.02), older maternal age (OR 1.18, 95% CI 1.06‐1.31 per 5 years), and longer second stage (OR = 1.10, 95% CI: 1.01‐1.20 per hour). Odds of cesarean versus operative vaginal delivery were higher with maternal indication (OR = 9.0, 95% CI: 7.23‐11.20), a perinatologist (OR = 2.51, 95% CI: 1.09‐5.78), longer second stage (OR = 1.79, 95% CI: 1.65‐1.93 per hour), older gestational age (OR = 1.10, 95% CI: 1.01‐1.20 per week), and longer labor (OR = 1.02, 95% CI: 1.01‐1.04 per hour). Conclusion Patient‐level factors influence the decision to proceed with an operative vaginal delivery and the choice of instrument, thereby emphasizing the importance of maintaining availability of both forceps and vacuums.