Suzanne Coleman

Does advanced maternal age affect pregnancy outcome in women with mild hypertension remote from term

OBJECTIVES Our purpose was to compare maternal and perinatal outcomes of mature women with those in younger women with pregnancies complicated by mild hypertension remote from term. STUDY DESIGN A matched cohort design was used. A total of 379 mature pregnant women (> or = 35 years old) with mild hypertension remote from term were matched for race, gestational age, and proteinuria status at enrollment with 379 adult controls aged 20 to 30 years also with mild hypertension remote from term. All were enrolled in an outpatient management program that included automated blood pressure measurements and daily assessment of weight, proteinuria, and fetal movement. RESULTS The mean gestational age at enrollment was 32.7 +/- 3.0 weeks for both groups (range 24 to 36 weeks). By matching 20.6% of patients in each group had > or = 1+ proteinuria on urinary dipstick at enrollment, and 77.3% of patients in each group were white. Chronic hypertension was more common in the mature group (22.4% vs 14.5%, p = 0.007). The mean gestational age at delivery (37.2 +/- 2.3 vs 37.2 +/- 2.2 weeks), the mean pregnancy prolongation (28.1 +/- 21.0 vs 28.4 +/- 22.0 days), and the mean birth weights (2864 +/- 770 vs 2906 +/- 788 gm) were similar between the mature and younger groups (all p > 0.05). There were no differences regarding abruptio placentae (2 vs 3 cases) or thrombocytopenia or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome (7 vs 9 cases), and there were no cases of eclampsia. There were five stillbirths in the mature group and none in the younger group (p = 0.063). CONCLUSION Outpatient management of mild hypertension remote from term in the mature pregnant women was associated with similar maternal outcomes but with a nonstatistically higher stillbirth rate compared with the younger pregnant woman.

A Randomized Multicenter Study to Determine the Efficacy of Activity Restriction for Preterm Labor Management in Patients Testing Negative for Fetal Fibronectin

OBJECTIVE:To assess the impact of activity restriction (AR) on the incidence of preterm birth in women treated for preterm labor testing negative for fetal fibronectin (fFN).STUDY DESIGN:Women who were diagnosed with preterm labor and tocolyzed with magnesium sulfate were concurrently screened with fFN for the purpose of subsequent management. Included were consenting patients with negative fFN, gestational age 23 0/7–33 6/7 weeks, cervical dilation ≤3 cm, and minimal vaginal bleeding. Patients were randomized to AR or no AR. Primary study outcome was incidence of preterm delivery and interval from randomization to delivery.RESULTS:A total of 73 women with negative fFN were randomized (36 with AR, 37 without AR). The overall preterm birth rate was 40%, with 44.4% of patients with AR and 35.1% of patients without AR delivering preterm, p=0.478.CONCLUSION:Maternal AR did not impact pregnancy outcome. The incidence of preterm birth in symptomatic women testing fFN negative was higher than previously reported.

Clinical and Cost-Effectiveness of Continuous Subcutaneous Terbutaline Versus Oral Tocolytics for Treatment of Recurrent Preterm Labor in Twin Gestations

OBJECTIVE: To compare the clinical and cost-effectiveness of treating recurrent preterm labor with continuous subcutaneous terbutaline versus oral tocolytics in twin gestations.STUDY DESIGN: In a retrospective, matched-cohort design, twin pregnancies treated as outpatients with continuous subcutaneous terbutaline were identified from a perinatal database, then matched 1:1 by gestational age at recurrent preterm labor to those receiving oral tocolytics. There were 353 patients per treatment group. A cost model was used to compare antepartum hospital, nursery, and outpatient charges.RESULTS: Infants of the subcutaneous terbutaline group had greater gestational age at delivery, higher birth weights, and less frequent neonatal intensive care unit admission. Charges for antepartum hospitalization and nursery were significantly less in the subcutaneous terbutaline group, while charges for outpatient services were less for the oral group. Mean total estimated charges were US

Home Subcutaneous Metoclopramide Therapy for Hyperemesis Gravidarum

17,109 less for those receiving subcutaneous terbutaline.CONCLUSION: Improved clinical outcomes and decreased nursery utilization suggest cost-effectiveness of outpatient continuous subcutaneous terbutaline versus oral tocolytics for the treatment of recurrent preterm labor.

A comparison of gestational days gained with oral terbutaline versus continuous subcutaneous terbutaline in women with twin gestations.

OBJECTIVE:To describe the use of subcutaneous (s.c.) metoclopramide in the outpatient treatment of hyperemesis gravidarum.STUDY DESIGN:In a retrospective design, women who received continuous s.c. metoclopramide for treatment of hyperemesis gravidarum were identified from a national database. Data analysis included weight at start and stop of treatment, frequency of resolution of symptoms, and side effects of medication. In addition, data were collected on adjuvant therapies.RESULTS:Between January and December of 1997, there were 646 women with hyperemesis gravidarum who received continuous s.c. metoclopramide on an outpatient basis. A total of 413 patients (63.9%) had complete resolution of symptoms. Seventy-five percent of patients had received one or more antiemetic medications before initiation of s.c. metoclopramide. A total of 192 patients (30.5%) reported at least one side effect related to treatment. The majority of reported side effects were considered mild and did not require discontinuation of s.c. metoclopramide.CONCLUSION: S.c. metoclopramide appears to be a safe, effective treatment for hyperemesis gravidarum. Outpatient treatment may result in decreased costs compared with inpatient hospitalization.

Recurrent preterm birth in women treated with 17 α-hydroxyprogesterone caproate: the contribution of risk factors in the penultimate pregnancy

OBJECTIVE: To compare gestational days gained with oral versus subcutaneous terbutaline for maintenance tocolysis.STUDY DESIGN: In retrospective fashion 386 women enrolled in an outpatient preterm labor identification program met the following criteria: twin gestation, development of threatened preterm labor resulting in treatment with oral terbutaline, and subsequent recurrence of threatened preterm labor resulting in treatment with continuous subcutaneous terbutaline. The primary outcome was gestational days gained with oral terbutaline versus gain with continuous subcutaneous terbutaline.RESULTS: There were significantly more days gained during subcutaneous treatment than during oral treatment (34.0±19.8 versus 19.3±15.3 days). Thirty-three percent of desired prolongation was achieved with oral terbutaline, whereas 79% of desired prolongation was achieved with subcutaneous terbutaline(p<0.001). Patients gained a mean of 53.4±21.4 days overall with outpatient tocolysis. The mean gestational age at delivery was 35.2±1.9 weeks.CONCLUSION: Continuous subcutaneous terbutaline was superior to oral terbutaline in prolonging gestation in women with twin gestations.

Pregnancy and Economic Outcomes in Patients Treated for Recurrent Preterm Labor

Objective: Examine rates of recurrent, spontaneous preterm birth (PTB) in women treated prophylactically with 17 α-hydroxyprogesterone caproate (17P) when the penultimate PTB was due to preterm labor (PTL) or preterm premature rupture of the membranes (pPROM). Methods: Retrospective, descriptive, database study of 1183 singleton gestations that initiated prophylactic 17P at <21 weeks with a penultimate PTB. Primary outcomes examined were rates of recurrent PTB at <37 and <32 weeks’ gestation in the PTL (n = 939) and pPROM (n = 244) cohorts. Results: Recurrent PTB <37 weeks occurred in 38% versus 28.3% of the PTL and pPROM cohorts, respectively (p <0.005). Rates of recurrent PTB <32 weeks were similar. Logistic regression revealed three risk factors increased the odds of recurrent PTB: >1 previous PTB (OR 1.8 [95% CI: 1.33–2.44]); penultimate birth at 28–33.9 weeks’ gestation (OR 1.61 [95% CI: 1.22–2.13]); and, PTL as the indication for delivery in the penultimate PTB (OR 1.66 [95% CI: 1.16–2.37]). Conclusion: Several historical factors increase the risk for recurrent PTB in women receiving 17P. Contrary to earlier studies of PTL and pPROM recurrence, women receiving prophylactic 17P with a penultimate PTB due to pPROM are at lower risk of recurrent PTB than those with a history of PTL.

The impact of maternal age on pregnancy outcome in singleton pregnancies

OBJECTIVE: To compare clinical and cost-effectiveness of treating recurrent preterm labor (RPTL) with oral nifedipine versus continuous subcutaneous terbutaline infusion (SQT).STUDY DESIGN: Women with singleton gestations prescribed nifedipine for tocolysis following first diagnosis of preterm labor were identified. Women hospitalized with RPTL at <34 weeks were matched by gestational age (GA) after resuming nifedipine (NIF group) with women prescribed SQT (SQT group) after stabilization. Healthcare utilization costs were modeled and compared.RESULTS: This study analyzed 142 matched pairs. GA at RPTL (matched variable) was 30.4±2.6 weeks. GA at delivery was earlier in the NIF group versus the SQT group (35.7±3.1 weeks versus 36.6±2.1 weeks, p=0.004). Overall, infants from the NIF group had lower birth weights and higher nursery days than infants from the SQT group. Healthcare utilization costs were greater in the NIF group versus the SQT group (

Delayed-interval delivery in twin pregnancies

37,040±47,518 versus 26,546±25,386, p=0.014).CONCLUSION: Treating RPTL with SQT versus oral nifedipine resulted in a later GA at delivery, improved neonatal outcome, and increased cost-effectiveness.

Pregnancy prolongation in triplet pregnancies. Oral vs. continuous subcutaneous terbutaline.

Abstract Objective: To identify the impact of maternal age on pregnancy outcome in singleton gestations without a maternal history of previous preterm delivery. Study design: We retrospectively identified women who presented with preterm labor in the current pregnancy andsubsequently delivered between July 1995 and February 2000. Included were those with documented pregnancy outcome who delivered at ≥24 weeks of gestation. Data were analyzed as four age groups: Results: Pregnancy outcome was analyzed in 22,975 women. Overall, 38.4% experienced preterm delivery. There were no significant differences across the groups in the incidence of delivery because of spontaneous labor at >37 weeks of gestation. Significant findings are summarized in the table (all P 2 ). 20–34 35–39 ≥40 n = (2,061) 17,362) (2,961) (591) Delivery 46.5% 37.6% 36.6% 37.1% Delivery 6.1% 4.4% 5.9% 7.1% PTL @ delivery 36.0% 26.8% 23.4% 23.5% Cesarean delivery 11.3% 21.9% 32.3% 35.8% Conclusion: Our findings suggest that maternal age