Shayna N. Conner

Loop Electrosurgical Excision Procedure and Risk of Preterm Birth: A Systematic Review and Meta-analysis

OBJECTIVE: To assess whether loop electrosurgical excision procedure (LEEP) increases the risk for preterm birth before 37 weeks of gestation and clarify whether the increased risk for preterm birth is attributable to the procedure itself or to risk factors associated with cervical dysplasia. DATA SOURCES: Two authors performed a search of the relevant data through February 2013 using PubMed, Embase, Scopus, CENTRAL, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We included observational studies that compared rates of preterm birth in women with prior LEEP with women with no history of cervical excision. Nineteen of 559 identified studies met selection criteria. TABULATION, INTEGRATION, AND RESULTS: We compared women with a history of LEEP with two unexposed groups without a history of cervical excision: 1) women with an unknown or no history of cervical dysplasia; and 2) women with a history of cervical dysplasia but no cervical excision. The primary outcome was preterm birth before 37 weeks of gestation. Secondary outcomes were preterm birth before 34 weeks of gestation, spontaneous preterm birth, preterm premature rupture of membranes, and perinatal mortality. DerSimonian-Laird random effects models were used. We assessed heterogeneity between studies using the Q and I2 tests. Stratified analyses and metaregression were performed to assess confounding. Nineteen studies were included with a total of 6,589 patients with a history of LEEP and 1,415,015 without. Overall, LEEP was associated with an increased risk of preterm birth before 37 weeks of gestation (pooled relative risk 1.61, 95% confidence interval [CI] 1.35–1.92). However, no increased risk was found when women with a history of LEEP were compared with women with a history cervical dysplasia but no cervical excision (pooled relative risk 1.08, 95% CI 0.88–1.33). CONCLUSION: Women with a history of LEEP have similar risk of preterm birth when compared with women with prior dysplasia but no cervical excision. Common risk factors for both preterm birth and dysplasia likely explain findings of association between LEEP and preterm birth, but LEEP itself may not be an independent risk factor for preterm birth.

Maternal Obesity and Risk of Postcesarean Wound Complications

OBJECTIVE To estimate the effect of increasing severity of obesity on postcesarean wound complications and surgical characteristics. STUDY DESIGN We performed a retrospective cohort study of consecutive cesarean deliveries at a tertiary care facility from 2004 to 2008. Four comparison groups were defined by body mass index (BMI; kg/cm2): < 30 (n = 728), 30 to 39.9 (n = 1,087), 40 to 49.9 (n = 428), or ≥ 50 (n = 201). The primary outcome was wound complication, defined as wound disruption or infection within 6 weeks postoperatively. Surgical characteristics were compared between groups including administration of preoperative antibiotics, type of skin incision, estimated blood loss (EBL), operative time, and type of skin closure. RESULTS Of the 2,444 women with complete follow-up data, 266 (10.9%) developed a wound complication. Compared with nonobese women (6.6%), increasing BMI was associated with an increased risk of wound complications: BMI 30.0 to 39.9, 9.2%, adjusted odds ratio (aOR) 1.4 (95% confidence interval [CI] 0.99 to 2.0); BMI 40.0 to 49.9, 16.8%, aOR 2.6 (95% CI 1.7 to 3.8); BMI ≥ 50, 22.9%, aOR 3.0 (95% CI 1.9 to 4.9). Increasing BMI was also associated with increased rates of midline vertical incision, longer operative time, higher EBL, and lower rates of subcuticular skin closure. CONCLUSION A dose-response relationship exists between increasing BMI and risk of postcesarean wound complications. Increasing obesity also significantly influences operative outcomes.

Maternal Marijuana Use and Adverse Neonatal Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate whether marijuana use in pregnancy increases risks for adverse neonatal outcomes and clarify if any increased risk is attributable to marijuana use itself or to confounding factors such as tobacco use. DATA SOURCES: Two authors performed a search of the data through August 2015 utilizing PubMed, Embase, Scopus, Cochrane reviews, ClinicalTrials.gov, and Cumulative Index to Nursing and Allied Health. METHODS OF STUDY SELECTION: We looked at observational studies that compared rates of prespecified adverse neonatal outcomes in women who used marijuana during pregnancy with women who did not. TABULATION, INTEGRATION, AND RESULTS: Two authors independently extracted data from the selected studies. Primary outcomes were low birth weight (less than 2,500 g) and preterm delivery at less than 37 weeks of gestation. Secondary outcomes were birth weight, gestational age at delivery, small for gestational age, level II or greater nursery admission, stillbirth, spontaneous abortion, low Apgar score, placental abruption, and perinatal death. DerSimonian-Laird random-effects models were used. We assessed heterogeneity using the Q test and I2 statistic. Stratified analyses were performed for the primary outcomes and pooled adjusted estimates were calculated. We included 31 studies that assessed the effects of maternal marijuana use on adverse neonatal outcomes. Based on pooled unadjusted data, marijuana use during pregnancy was associated with an increased risk of low birth weight (15.4% compared with 10.4%, pooled relative risk [RR] 1.43, 95% confidence interval [CI] 1.27–1.62) and preterm delivery (15.3% compared with 9.6%, pooled RR 1.32, 95% CI 1.14–1.54). However, pooled data adjusted for tobacco use and other confounding factors showed no statistically significant increased risk for low birth weight (pooled RR 1.16, 95% CI 0.98–1.37) or preterm delivery (pooled RR 1.08, 95% CI 0.82–1.43). CONCLUSION: Maternal marijuana use during pregnancy is not an independent risk factor for adverse neonatal outcomes after adjusting for confounding factors. Thus, the association between maternal marijuana use and adverse outcomes appears attributable to concomitant tobacco use and other confounding factors.

Interval from loop electrosurgical excision procedure to pregnancy and pregnancy outcomes.

OBJECTIVE: Previous studies have shown mixed results for pregnancy outcomes after loop electrosurgical excision procedure (LEEP); however, evidence is lacking regarding the pregnancy outcome of spontaneous abortion with respect to time elapsed from LEEP to pregnancy. We investigated risks of spontaneous abortion and preterm birth as they relate to time elapsed from LEEP to pregnancy. METHODS: A 10-year, multicenter cohort study of women who underwent LEEP was performed between 1996 and 2006. Trained research nurses conducted telephone interviews with all patients to complete data extraction unavailable in charts. Median time from LEEP to pregnancy for spontaneous abortion compared with no spontaneous abortion and preterm birth before 34 and before 37 weeks of gestation compared with term birth were estimated. Patients with time intervals less than 12 months compared with 12 months or more from LEEP to pregnancy were then compared with identify adjusted odds ratios for spontaneous abortion and preterm birth. RESULTS: Five hundred ninety-six patients met inclusion criteria. Median time from LEEP to pregnancy was significantly shorter for women with a spontaneous abortion (20 months [interquartile range 11.2–40.9] compared with 31 months [interquartile range 18.7–51.2]; P=.01) but did not differ for women with a term birth compared with preterm birth. Women with a time interval less than 12 months compared with 12 months or more were at significantly increased risk for spontaneous abortion (17.9% compared with 4.6%; adjusted odds ratio 5.6; 95% confidence interval 2.5–12.7). No increased risk was identified for preterm birth before 34 weeks of gestation or before 37 weeks of gestation. CONCLUSION: Women with a shorter time interval from LEEP to pregnancy are at increased risk for spontaneous abortion but not preterm birth. LEVEL OF EVIDENCE: II

Maternal marijuana use and neonatal morbidity

OBJECTIVE Marijuana use is becoming increasingly common in the obstetric population; however, it is unknown whether it is associated with poor neonatal outcomes. We sought to determine the prevalence and risk factors for marijuana use in pregnancy and to evaluate whether marijuana use is independently associated with poor neonatal outcomes. STUDY DESIGN This was a retrospective cohort study of all consecutive, nonanomalous, term deliveries at 1 institution over a 4-year study period. Women with marijuana use during pregnancy, either by self-report or positive urine drug screen, were compared with women who did not use marijuana. The primary outcome was a composite neonatal morbidity including birthweight less than 2500 g, neonatal intensive care unit admission, 5-minute Apgar score less than 7, and umbilical artery pH less than 7.10. Univariate, bivariate, and multiple logistic regression analyses were performed. RESULTS Among the 8138 women in the cohort, 680 (8.4%) used marijuana during pregnancy. Women who used marijuana were younger; more likely to be of African American race; have inadequate prenatal care; and use tobacco, alcohol, and other drugs. Medical comorbidities did not differ between groups. After adjusting for smoking, other drug use, and African American race, the composite and all individual markers of poor neonatal outcome were not significantly higher among women who used marijuana during pregnancy. CONCLUSION Marijuana use is common in pregnancy but may not be an independent risk factor for poor neonatal outcomes in term pregnancies.

Contraception and Pregnancy Planning in Women With Congenital Heart Disease.

Opinion statementThe cardiovascular risk of pregnancy among women with congenital heart disease is heterogeneous, ranging from negligible to prohibitively high. Nonetheless, many of these patients do not report being counseled about the potential risks, and the incidence of unintended pregnancy is high. These women should be counseled on safe and effective contraceptive options. Long-acting reversible contraceptives, including the intrauterine devices and etonogestrel implant, are highly effective and safe for all cardiac patients. These are good options for pregnancy planning for women at elevated risk of cardiovascular complications during pregnancy, who are taking potentially teratogenic medications, or who have contraindications to estrogen-containing methods. Pregnancy management begins with pre-conceptual risk stratification and counseling regarding individual cardiovascular and fetal risks. As significant lapse in care is common at the time of transition to adult congenital cardiology care, these discussions ideally begin in pediatric clinics and continue upon transfer of care to adult congenital cardiology clinics.

Adult Congenital Heart Disease in Pregnancy.

&NA; With the success of modern surgical techniques for congenital heart disease, the population of women of childbearing age with congenital heart disease is growing. Because of the significant hemodynamic load of pregnancy, labor, and delivery, women with congenital heart disease require preconceptual risk assessment and expert multidisciplinary care throughout pregnancy. The aim of this review is to discuss the management of cardiovascular, obstetric, and fetal care issues that are commonly encountered during pregnancy in women with congenital heart disease. Target Audience Obstetricians gynecologists, family physicians Learning Objectives After completing this activity, the learner will be better able to discuss the importance of preconceptual risk assessment of pregnancy risk for women with adult congenital heart disease; identify disease-specific complications associated with pregnancy in women with adult congenital heart disease; identify common fetal risks associated with pregnancy in women with adult congenital heart disease; and explain the importance of delivery planning in women with adult congenital heart disease.

Impact of Preeclampsia on Clinical and Functional Outcomes in Women With Peripartum CardiomyopathyCLINICAL PERSPECTIVE

Background— Preeclampsia is a risk factor for the development of peripartum cardiomyopathy (PPCM), but it is unknown whether preeclampsia impacts clinical or left ventricular (LV) functional outcomes. This study sought to assess clinical and functional outcomes in women with PPCM complicated by preeclampsia. Methods and Results— This retrospective cohort study included women diagnosed with PPCM delivering at Barnes-Jewish Hospital between 2004 to 2014. The primary outcome was one-year event-free survival rate for the combined end point of death and hospital readmission. The secondary outcome was recovery of LV ejection fraction. Seventeen of 39 women (44%) with PPCM had preeclampsia. The groups had similar mean LV ejection fraction at diagnosis (29.6 with versus 27.3 without preeclampsia; P=0.5). Women with preeclampsia had smaller mean LV end-diastolic diameters (5.2 versus 6.0 cm; P=0.001), greater relative wall thickness (0.41 versus 0.35 mm Hg; P=0.009), and lower incidence of eccentric remodeling (12% versus 48%; P=0.03). Clinical follow-up was available for 32 women; 5 died of cardiovascular complications within 1 year of diagnosis (4/15 with versus 1/17 without preeclampsia; P=0.16). In time to event analysis, patients with preeclampsia had worse event-free survival during 1-year follow-up (P=0.047). Echocardiographic follow-up was available in 10 survivors with and 16 without preeclampsia. LV ejection fraction recovered in 80% of survivors with versus 25% without preeclampsia (P=0.014). Conclusions— PPCM with concomitant preeclampsia is associated with increased morbidity and mortality and different patterns of LV remodeling and recovery of LV function when compared with patients with PPCM that is not complicated by preeclampsia.

The Utility of 12-Hour Urine Collection for the Diagnosis of Preeclampsia: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature and synthesize data on the diagnostic performance of a 12-hour urine collection for proteinuria in pregnant women with suspected preeclampsia. DATA SOURCES: We performed a literature search of PubMed, Embase, Scopus, ClinicalTrials.gov, and CINAHL through February 2014 using key words related to gestational hypertension, preeclampsia, and proteinuria. METHODS OF STUDY SELECTION: Studies that contained results of both the 12-hour and 24-hour urine collection in the same patients were eligible. TABULATION, INTEGRATION, AND RESULTS: Three independent reviewers abstracted test performance characteristics from each study for the performance of a 12-hour urine collection for the diagnosis of proteinuria defined as 300 mg in 24 hours. Diagnostic meta-analysis was performed to obtain summary statistics. Heterogeneity was assessed using the Cochrane Q or I2. Receiver operating characteristic curve analysis was used to assess the optimal diagnostic cutpoint for proteinuria from a 12-hour urine collection. Stratified analysis was performed based on whether patients were on bed rest during urine collection. A total of seven studies met inclusion criteria. The 12-hour urine protein was overall highly predictive of proteinuria on 24-hour urine collection area under receiver operating characteristic curve: 0.97 (95% confidence interval [CI] 0.95–0.98). The pooled sensitivity was 92% (95% CI 86–96) and specificity was 99% (95% CI 75–100). The optimal cutpoint based on the receiver operating characteristic curve was 150 mg of protein on 12-hour collection. CONCLUSION: A 12-hour urine collection compares favorably with a 24-hour urine collection for the diagnosis of proteinuria in women with suspected preeclampsia and has the advantage of convenience and improved clinical efficiency.

Accuracy of Estimated Blood Loss in Predicting Need for Transfusion after Delivery.

OBJECTIVE The definition of postpartum hemorrhage (PPH) was developed more than 50 years ago. Since then, the obstetric population has changed dramatically. We sought to determine how well we estimated blood loss (EBL) and find thresholds predicting need for transfusion. STUDY DESIGN We performed a prospective cohort study from 2010 to 2012, comparing those who needed transfusion postpartum and those who did not. EBL, calculated EBL (cEBL), and change in hematocrit were calculated for patients who did not receive transfusion, and EBL was calculated for those who did receive transfusion, stratified by delivery type. Receiver operator curves were created and optimal thresholds of EBL to predict transfusion were estimated. RESULTS Among 4,804 patients, transfusion was required for 0.65% of vaginal and 8.7% of cesarean deliveries. Median EBL was higher in women requiring transfusion. A weak correlation was noted between EBL and cEBL for all deliveries. Thresholds of 500 mL blood loss for vaginal delivery and 1,000 mL for cesarean had the best predictive ability for transfusion. CONCLUSION In this modern obstetric, cohort EBL is weakly correlated with cEBL, suggesting that accuracy of clinical estimates of blood loss is modest. However, EBL predicts need for transfusion, with optimal thresholds of 500 mL for a vaginal delivery and 1,000 mL in a cesarean. This validates the traditional definitions of PPH in our modern population.