Tania F. Esakoff

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.

Objective. The overall annual incidence rate of caesarean delivery in the United Sates has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This studys goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality. Methods. A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries. Results.  If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years. Conclusions. If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

The association between birthweight 4000 g or greater and perinatal outcomes in patients with and without gestational diabetes mellitus

OBJECTIVE The objective of the study was to examine the association between birthweight of 4000 g or greater and perinatal outcomes in women with and without gestational diabetes mellitus (GDM). STUDY DESIGN This was a retrospective cohort study of 36,241 singleton pregnancies stratified by the diagnosis of GDM, with presence or absence of birthweight of 4000 g or greater. Outcomes examined included neonatal hyperbilirubinemia, hypoglycemia, respiratory distress syndrome (RDS), shoulder dystocia, and Erbs palsy. chi(2) tests and multivariable logistic regression analyses were used to control for confounders. RESULTS In women with GDM, neonates with a birthweight of 4000 g or greater, compared with those with a birthweight of less than 4000 g, had higher frequencies of hypoglycemia (5.3% vs 2.6%; P = .04), RDS (4.0% vs 1.5%; P = .03), shoulder dystocia (10.5% vs 1.6%; P < .001), and Erbs palsy (2.6% vs 0.2%; P < .001). Even without GDM, these outcomes occurred more frequently in infants with birthweight of 4000 g or greater. GDM increases the odds of adverse outcomes associated with birthweight of 4000 g or greater, particularly shoulder dystocia (adjusted odds ratios [aORs], 16.4 [GDM] vs 9.6 [non-GDM] and Erbs palsy (aORs, 41.9 [GDM] vs 6.7 [non-GDM]). CONCLUSION Birthweight of 4000 g or greater is associated with a higher incidence of adverse perinatal outcomes such that neonatal providers should be alerted.

Diagnosis and morbidity of placenta accreta

To examine the diagnostic precision of ultrasound examination for placenta accreta in women with placenta previa and to compare the morbidity associated with accreta to that of previa alone.

Fundal height: a useful screening tool for fetal growth?

Objective. To determine the utility of fundal height in screening for small-for-gestational-age (SGA) and large-for-gestational-age (LGA) neonates at term. Study design. This was a retrospective cohort study of 3627 women at University of California, San Francisco from 2002 to 2006 with term, singleton pregnancies specifically examining the 448 who had third trimester ultrasounds for size unequal to dates by fundal height. χ2 analyses determined the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of fundal height as a screening tool for abnormal intrauterine growth. Results. The sensitivity of fundal height was 16.6% for detecting actual birthweight (BWt) > 90th percentile (p < 0.001) and 17.3% for < 10th percentile (p < 0.001). Specificity ranged from 92.4 to 95.4%. Significant differences existed among subgroups by maternal weight, parity, age, and ethnicity. Sensitivity was lower for SGA among overweight/obese women but higher among multiparous women. Additionally, women ≥35 years showed higher sensitivity for extreme LGA, and several notable differences were found by ethnicity such as higher sensitivity for extreme LGA among Caucasian women. Conclusion. The sensitivity of fundal height for detecting abnormal intrauterine growth was less than 35% for all subgroups, although specificity was more ideal at >90%. Other modalities should be considered to screen for growth abnormalities.

PAMUS: placenta accreta management across the United States

Objective: There is lack of consensus regarding the optimal strategy for management of abnormal placentation. We set out to determine the actual practices of providers across the United States (U.S.). Methods: This was a cross-sectional survey of maternal-fetal medicine providers in the U.S. registered with the Society for Maternal Fetal Medicine (SMFM). Questions regarding management strategies for placenta accreta were addressed by the survey. Both univariable and multivariable analyses were performed to determine if a relationship between demographic factors and management strategies exists. Results: Approximately 64% of responders were male and 62% had been in practice less than or equal to 20 years. The respondents represented all the major regions of the U.S. and the majority had performed one to five cases in the past year. The gestational age at delivery varied by both the number of years in practice and by geographic location. About 35% of providers report the use of ureteral stents and 36% of providers use internal femoral artery balloons though this varied by region. Regional differences and recent experience play a role in whether to attempt placental removal first. Though the majority of providers believe hysterectomy is the only management option for accreta, 32% of providers have attempted conservative management. Conclusions: There is wide variation in the actual practices of physicians in the U.S. with regard to management of placenta accreta.

Perinatal outcomes in patients with gestational diabetes mellitus by race/ethnicity.

Objective. To determine if racial/ethnic differences exist in perinatal outcomes in women with gestational diabetes mellitus (GDM). Methods. This is a retrospective cohort study of singleton pregnancies with GDM cared for by the Sweet Success: California Diabetes and Pregnancy Program (CDAPP) between 2001 and 2004 at inpatient obstetric and neonatal services in California. There were a total of 26,411 women with gestational diabetes who were subgrouped by four races/ethnicities: Caucasian, African-American, Latina, and Asian. The chi-squared test was used to compare the dichotomous outcomes and p < 0.05 was used to indicate statistical significance. Multivariable logistic regression analyses were performed to control for potential confounders. Perinatal outcomes, including severity of GDM, cesarean delivery (CD), birthweight, preterm birth, intrauterine fetal demise (IUFD) and neonatal intensive care unit (NICU) admission were compared. Results. Compared to Caucasians, African-Americans had higher odds of primary CD [aOR = 1.29, 95% CI (1.05–1.59)] while lower odds were seen in Latinas [aOR = 0.84, 95% CI (0.75–0.94)] and Asians [aOR = 0.86, 95% CI (0.77–0.96)]. Asians had lower odds [aOR = 0.58 (95% CI 0.48–0.70)] of birthweight >4000 g. African-Americans had highest odds of IUFD [aOR = 5.93 95% CI (1.73–20.29)]. There were no differences in NICU admission. Conclusion. Perinatal outcomes in women diagnosed with GDM differ by racial/ethnic group. Such variation can be used to individually counsel women with GDM.

Screening or diagnostic: Markedly elevated glucose loading test and perinatal outcomes

Objective. To determine the diagnostic value of markedly elevated 50-g glucose loading test results (≥200 mg/dL) and associated perinatal outcomes. Method. This was a retrospective cohort study of 14 771 pregnancies screened for gestational diabetes mellitus (GDM) between 1988 and 2001. The positive predictive value of the 50-g oral glucose loading test (GLT) results as measured by plasma glucose value was examined. Perinatal outcomes were assessed for women with GLT results ≥200 mg/dL compared to GLT <200 mg/dL, stratified by the diagnosis of GDM. Statistical comparisons were made using the Chi-square test and Students t-test and potential confounding factors were controlled for using multivariable logistic regression analyses. A p value <0.05 and 95% confidence intervals were used to indicate statistical significance. Results. The positive predictive values for a GDM diagnosis were 62% for GLT results between 180 and 189 mg/dL, 79% for those between 200 and 209 mg/dL, and 100% for GLT results ≥230 mg/dL. Compared to women with a GLT result <200 mg/dL, among women not diagnosed with GDM but with a GLT ≥200 mg/dL the adjusted odds ratio (aOR) for cesarean delivery was 4.18 (95% confidence intervals, 1.15–15.2). These women also had higher aORs for preterm delivery <32 weeks (aOR = 8.05 (1.02–63.6)), shoulder dystocia (aOR = 15.14 (1.64–140)), and their neonates were more likely to have a 5-minute Apgar score <7 (aOR = 6.41 (1.23–33.3)). For women diagnosed with GDM and with a GLT ≥200 mg/dL, the aOR for cesarean delivery was also elevated compared to those with a GLT <200 mg/dL (aOR = 2.24 (1.19–4.21)). Conclusion. A GLT value of ≥200 mg/dL is not absolutely diagnostic for gestational diabetes but is associated with unfavorable perinatal outcomes.

Glucose challenge test: Screening threshold for gestational diabetes mellitus and associated outcomes

Objective. To examine whether women with an 1-hour 50-g glucose challenge test (GCT) for gestational diabetes mellitus (GDM) between 120 and 140 mg/dL and ≥140 mg/dL are at risk of perinatal complications. Study design. A retrospective cohort study of women with singleton pregnancies screened for GDM between 1988 and 2001 with a 1-hour 50-g GCT. Values of GCT were stratified into four subgroups: <120, 120–129, 130–139, and ≥140 mg/dL. Perinatal outcomes were compared using the Chi-square test and multivariable logistic regression analysis. Results. There were 13 901 women meeting the study criteria. Compared to women with a GCT of <120 mg/dL, women with a GCT of 130–139 mg/dL and ≥140 mg/dL were more likely to have preeclampsia and operative vaginal or cesarean deliveries. Neonates born to women with a GCT of 130–139 mg/dL also had higher odds of having a 5-minute Apgar score <7 (odds ratio (OR) = 1.51, 95% confidence interval (CI) 1.01–2.29), shoulder dystocia (OR = 2.02, 95% CI 1.16–2.55), birth trauma (OR = 1.47, 95% CI 1.06–2.02), and composite morbidity (OR = 1.25, 95% CI 1.03–1.51). Women with a GCT of ≥140 mg/dL had higher odds of macrosomia (OR = 1.32, 95% CI 1.13–1.54) and shoulder dystocia (OR = 1.68, 95% CI 1.11–2.55). Conclusion. Women with GCT results of 130–139 mg/dL appear to be at increased risk for perinatal morbidity. Thus, utilizing a diagnostic test in women with a GCT above 130 mg/dL should be considered.

Velamentous cord insertion: is it associated with adverse perinatal outcomes?

Abstract Introduction: Velamentous cord insertion (VCI) can be identified on prenatal ultrasound with an incidence of around 1%. We set out to examine the association between VCI and perinatal outcomes. Methods: This was a retrospective cohort study of 482 812 pregnancies using the California vital statistics birth cohort dataset linked with patient discharge dataset from 2006 during which 2327 (0.48%) were complicated by VCI. Outcomes examined included intrauterine fetal demise (IUFD), small for gestational age (SGA), preterm delivery, manual removal of the placenta and cesarean delivery. Statistical analysis was performed using Chi squared tests and multivariable logistic regression analyses. Results: Pregnancies with VCI, compared to those without, were associated with an increased risk of IUFD (2.6% versus 0.28%, p = 0.001), SGA (16.93% versus 10.17%, p = 0.001), preterm delivery <37 weeks (12.5% versus 9.10%, p = 0.001), manual removal of placenta (14.47% versus 0.76%, p = 0.01) and postpartum hemorrhage (6.66% versus 2.88%, p = 0.001). Adjusting for confounders, the adjusted odds of IUFD were more than nine times in pregnancies with VCI (aOR 9.56; 95% CI 6.76–13.5) than those without. Discussion: VCI is associated with an increased risk of adverse perinatal outcomes such as IUFD, SGA, preterm delivery <37 weeks, need for manual removal of placenta and post-partum hemorrhage. Routine identification of the placental cord insertion site should be considered. Close surveillance of these pregnancies should be undertaken. Future research should focus on the optimal management including the gestational age for delivery of these pregnancies.

Birth Plans: What Matters for Birth Experience Satisfaction

BACKGROUND To categorize individual birth plan requests and determine if number of requests and request fulfillment is associated with birth experience satisfaction. METHODS This is a sub-analysis of a prospective cohort study of 302 women with singleton pregnancies with and without birth plans. Women with a hard copy of their birth plans who completed a postdelivery satisfaction survey were included in this study. We described the number and type of birth plan requests and associated the number of requests and request fulfillment with overall satisfaction, expectations met, and sense of control. Differences between groups were analyzed using chi-square, Spearman rank correlation, and logistic regression. RESULTS One hundred and nine women presented to Labor and Delivery with a hard copy of their prewritten birth plan. We identified 23 unique requests. The most common requests were no intravenous analgesia (82%) and exclusive breastfeeding (74%). The requests most fulfilled were avoidance of episiotomy (100%) and no operative vaginal delivery (89%). Having a higher number of requests fulfilled correlated with greater overall satisfaction (p = 0.03), higher chance of expectations being met (p < 0.01), and feeling more in control (p < 0.01). Having a high number of requests was associated with an 80 percent reduction in overall satisfaction with the birth experience (p < 0.01). CONCLUSIONS Having a higher number of requests fulfilled was positively associated with birth experience satisfaction, while having a high number of requests was inversely associated with birth experience satisfaction. Further research is needed to understand how to improve birth plan-related birth experience satisfaction.