Teresa N. Sparks

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.

Labor induction with a foley balloon inflated to 30 mL compared with 60 mL: A randomized controlled trial

OBJECTIVE: To compare 30-mL and 60-mL Foley balloon inflation for labor induction and the effect on length of labor and mode of delivery. METHODS: Women with term, vertex, singleton pregnancies (n=192) and a Bishop score less than 5 were assigned randomly to receive a transcervical Foley balloon inflated to either 30 mL or 60 mL. Exclusion criteria were painful, regular contractions on admission, ruptured membranes, low-lying placenta, or prior hysterotomy. Randomization was stratified by parity, and health care providers were blinded to Foley balloon size. Primary outcome was delivery within 24 hours of Foley balloon placement. Secondary outcomes included delivery within 12 hours, time from Foley balloon placement to expulsion, cervical dilation after Foley balloon expulsion, maximum oxytocin dose, method of delivery, chorioamnionitis, meconium, cervical laceration, abruption, 5-minute Apgar score, and umbilical cord gases. RESULTS: A higher proportion of women randomly assigned to the 60-mL Foley balloon achieved delivery within 12 hours of placement compared with the 30-mL Foley balloon group (26% compared with 14%, P=.04). This difference was more pronounced among nulliparous women. There was no difference in median time interval to delivery or proportion of women who achieved delivery within 24 hours. Median cervical dilation after Foley balloon expulsion was higher in the 60-mL Foley balloon group (4 cm compared with 3 cm, P<.01). There were no differences in the frequencies of cesarean delivery, maternal morbidity, or neonatal outcomes. CONCLUSION: Labor induction using Foley balloons inflated to 60 mL was more likely to achieve delivery within 12 hours compared with 30-mL inflation. There were no differences in delivery within 24 hours, cesarean delivery, labor complications, or neonatal outcomes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00451308. LEVEL OF EVIDENCE: I

Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus

OBJECTIVE The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM). STUDY DESIGN A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized. RESULTS The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort (P < .001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P < .001), Latinas (15% to 50%, P < .001), and Asians (43% to 59%, P = .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% (P = .414). CONCLUSION GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.

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.

Impending macrosomia: will induction of labour modify the risk of caesarean delivery?

Please cite this paper as: Cheng Y, Sparks T, Laros R Jr, Nicholson J, Caughey A. Impending macrosomia: will induction of labour modify the risk of caesarean delivery? BJOG 2012;119:402–409.

Treating mild gestational diabetes mellitus: a cost-effectiveness analysis

OBJECTIVE This study investigated the cost-effectiveness of treating mild gestational diabetes mellitus (GDM). STUDY DESIGN A decision analytic model was built to compare treating vs not treating mild GDM. The primary outcome was the incremental cost per quality-adjusted life year (QALY). All probabilities, costs, and benefits were derived from the literature. Base case, sensitivity analyses, and a Monte Carlo simulation were performed. RESULTS Treating mild GDM was more expensive, more effective, and cost-effective at

Does risk of preeclampsia differ by twin chorionicity

20,412 per QALY. Treatment remained cost-effective when the incremental cost to treat GDM was less than

The cost-effectiveness of repeat HIV testing during pregnancy in a resource-limited setting.

3555 or if treatment met at least 49% of its reported efficacy at the baseline cost to treat of