Suzanne Demers

Prevention of perinatal death and adverse perinatal outcome using low-dose aspirin: a meta-analysis

To compare early vs late administration of low‐dose aspirin on the risk of perinatal death and adverse perinatal outcome.

Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture

To evaluate the best available evidence regarding the association between single‐layer closure and uterine rupture.

Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect.

OBJECTIVE To review the ability of imaging techniques to predict incomplete healing of uterine cesarean scars before the next pregnancy. STUDY DESIGN A systematic literature review searched for studies on women who underwent previous low-transverse cesarean, evaluated by hysterography, sonohysterography (SHG), or transvaginal ultrasound (TVU). The median prevalence of scar defects was computed with 95% confidence intervals (95% CIs). Odds ratio (OR, 95% CI) identified risk factors of incomplete healing. RESULTS The analysis included 21 studies. The proportions of suspected scar defects detected by hysterography, SGH, and TVU were 58% (33 to 70), 59% (58 to 85), and 37% (20 to 65), respectively. Two studies found that women with a large uterine scar defect had a higher risk of uterine rupture or uterine scar dehiscence than those with no scar defect or small scar defect (OR: 26.05 [2.36 to 287.61], p <0.001). The only reported risk factor for scar defect was the occurrence of more than one previous cesarean (OR: 2.24 [1.13, 4.45], p = 0.02). CONCLUSION Hysterography, SGH, and TVU can detect uterine scar defects in ~50% of women with previous cesarean.

Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis

A systematic review and metaanalysis were performed through electronic database searches to estimate the effect of uterine closure at cesarean on the risk of adverse maternal outcome and on uterine scar evaluated by ultrasound. Randomized controlled trials, which compared single vs double layers and locking vs unlocking sutures for uterine closure of low transverse cesarean, were included. Outcomes were short-term complications (endometritis, wound infection, maternal infectious morbidity, blood transfusion, duration of surgical procedure, length of hospital stay, mean blood loss), uterine rupture or dehiscence at next pregnancy, and uterine scar evaluation by ultrasound. Twenty of 1278 citations were included in the analysis. We found that all types of closure were comparable for short-term maternal outcomes, except for single-layer closure, which had shorter operative time (-6.1 minutes; 95% confidence interval [CI], -8.7 to -3.4; P < .001) than double-layer closure. Single layer (-2.6 mm; 95% CI, -3.1 to -2.1; P < .001) and locked first layer (mean difference, -2.5 mm; 95% CI, -3.2 to -1.8; P < .001) were associated with lower residual myometrial thickness. Two studies reported no significant difference between single- vs double-layer closure for uterine dehiscence (relative risk, 1.86; 95% CI, 0.44-7.90; P = .40) or uterine rupture (no case). In conclusion, current evidence based on randomized trials does not support a specific type of uterine closure for optimal maternal outcomes and is insufficient to conclude about the risk of uterine rupture. Single-layer closure and locked first layer are possibly coupled with thinner residual myometrium thickness.

Association between first-trimester placental volume and birth weight

OBJECTIVE To estimate the correlation between first-trimester placental volume, birth weight, small-for-gestational-age (SGA), and preeclampsia. METHODS A prospective study of women with singleton pregnancy at 11-13 weeks of gestation was conducted. First-trimester placental volume was measured using three-dimensional ultrasound and reported as multiple of median (MoM) for gestational age. Participants were followed until delivery where birth weight, placental weight, and occurrence of preeclampsia were collected. Non-parametric analyses were performed. RESULTS We reached a complete follow-up for 543 eligible women. First-trimester placental volume was significantly correlated with birth weight (correlation coefficient: 0.18; p < 0.0001) and placental weight (cc: 0.22; p < 0.0001) adjusted for gestational age. First-trimester placental volume was smaller in women who delivered SGA neonates (median MoM: 0.79; interquartile range: 0.62-1.00; p < 0.001) and greater in women who delivered large-for-gestational-age neonates (median MoM: 1.13; 0.95-1.49; p < 0.001) when compared to women with neonates between the 10th and 90th percentile (median MoM: 1.00; 0.81-1.25). First-trimester placental volume was not associated with the risk of preeclampsia (cc: 0.01; p = 0.87). CONCLUSION First-trimester placental volume is strongly associated with fetal and placental growth. However, we did not observe a correlation between placental volume and the risk of preeclampsia.

Comparison of two different sites of measurement for transabdominal uterine artery Doppler velocimetry at 11–13 weeks

To compare the feasibility of two transabdominal approaches for performing first‐trimester uterine artery (UtA) Doppler and to evaluate the correlation with pulsatility index (PI) in the second trimester.

Treatment of periodontal disease and prevention of preterm birth: systematic review and meta-analysis.

OBJECTIVE There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed to evaluate its effect on the risk of preterm birth and to explore the heterogeneity between studies. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials were performed. Studies in which women were randomized for periodontal treatment versus no treatment were included. Pooled risk ratios (RRs) with their 95% confidence intervals (CIs) were calculated using random-effect models. A sensitivity analysis was performed. RESULTS Twelve randomized trials were included in the meta-analysis. Pooled estimates showed no significant reduction of preterm birth with periodontal treatment (RR: 0.89; 95% CI: 0.73 to 1.08). However, the substantial heterogeneity among studies (I2 = 52%) could be explained either by the risk of bias, the level of income, or by the use of chlorhexidine mouthwashes as a cointervention. Daily use of chlorhexidine mouthwash was associated with a reduction of preterm birth (RR: 0.69; 95% CI 0.50 to 0.95), with moderate heterogeneity among the five studies included (I2 = 43%). CONCLUSION There is an important heterogeneity between randomized trials that evaluated the effect of periodontal treatment on the risk of preterm birth. Chlorhexidine mouthwash as a preventive agent should be further evaluated.

Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study

BACKGROUND Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy. OBJECTIVE This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery. STUDY DESIGN In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0-2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%. RESULTS We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0-2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate (P=.0001). CONCLUSION The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.

Laparoscopic Repair of Post-Cesarean Uterine Scar Defect

To the Editor: We read with interest the article by Marotta et al [1]. who reported repair of 13 uterine scar defects. However, we are skeptical as to what led to these surgical procedures. We do not understand why these women gave consent and what the expected benefits were. We are concerned that misunderstanding of our previous publications could have misled the authors. Ultrasonographic evaluation of low uterine scar in women who have previously delivered via cesarean section has gained in popularity over the past two decades. Uterine scar defect can be observed in most women who have undergone cesarean section; however, the clinical implications of this finding remain to be developed [2]. Using a combination of transabdominal and transvaginal ultrasound at 35 to 38 weeks of gestation, we found that a thin low uterine scar, defined as full low uterine scar thickness \2.3 mm or myometrial thickness \1.5 mm (not\2.8 mm, as reported by Marotta et al [1]) is predictive of risk of uterine rupture in women undergoing labor after a previous cesarean delivery [3,4]. However, these cutoff thicknesses have weak specificity inasmuch as we observed that .90% of women with a thin low uterine scar underwent labor or elective cesarean section without uterine scar dehiscence or uterine rupture. To our knowledge, there is only one small cohort study that evaluated the association between uterine scar defect diagnosed via ultrasound in non-pregnant women and the risk of uterine rupture at the next pregnancy [5]. Osser et al [5] have reported that most women (10 of 13) with a large scar defect have no sign of uterine scar dehiscence or uterine rupture in the next pregnancy, and this ultrasound finding should not lead to any changes in clinical practice. Spontaneous uterine rupture before or in early labor is extremely rare, and elective repeat cesarean delivery is not associated with high morbidity. Therefore, we would not recommend uterine scar defect repair before pregnancy to enable a vaginal birth in the next pregnancy. Moreover, it is possible that such repair could lead to greater risk of pelvic adhesions and greater risk of uterine bleeding at subsequent elective repeat cesarean section delivery.

Association between physical activity in early pregnancy and markers of placental growth and function.

OBJECTIVES It has been suggested that physical activity (PA) can influence the development of the placenta and the risk of placenta-mediated complications of pregnancy. We evaluated the association between PA and early markers of placental development. METHODS Ninety-four nulliparous women were invited to participate in a prospective observational cohort study. Assessment included measurement of placental growth factor (PlGF) and pregnancy-associated plasma protein-A (PAPP-A) concentrations (expressed in multiples of the median), an ultrasound at 11 to 13 weeks for measurement of placental volume and the mean uterine artery (UtA) pulsatility index, and a questionnaire on PA. The association between PA and these markers was evaluated using univariate and multivariate regression analyses. RESULTS We found a significantly lower concentration of PlGF and a trend towards lower placenta volume and lower PAPP-A concentration with increased PA frequency. The negative association between PA frequency and PlGF concentration remained significant after adjustment for potential confounding factors. CONCLUSION Our results suggest that PA in early pregnancy could negatively affect placental development. This finding could explain the association between PA and severe preeclampsia. This finding deserves confirmation in a larger cohort.