Yu Ming Victor Fang

Increased neonatal morbidity despite pulmonary maturity for deliveries occurring before 39 weeks

Objective: To compare neonatal outcomes following deliveries <39 weeks after confirmation of fetal lung maturity with scheduled deliveries ≥39 weeks. Methods: A retrospective cohort study examining neonatal outcomes of women who were delivered following documented fetal pulmonary maturity at 36, 37, and 38 weeks compared to women undergoing a scheduled delivery at 39, 40, and 41 weeks. The χ2-test and Student’s t-test were used to compare categorical and continuous data, respectively. Results: Delivery prior to 39 weeks following fetal pulmonary maturity was associated with a 8.4% composite neonatal morbidity rate as compared to 3.3% for deliveries at 39 weeks or greater (relative risk [RR] 2.9; confidence interval [CI] 2.4–3.6). Neonatal respiratory morbidity was significantly higher (5.4%) for those delivering at less than 39 weeks with documented fetal pulmonary maturity as compared to 2.1% for those delivering at 39 weeks or greater (RR 3.0; CI 2.3–3.9). Increased neonatal morbidity persisted for those delivered prior to 39 weeks even after excluding all diabetics (p < 0.001). Significant increases in neonatal morbidity were noted for deliveries prior to 39 weeks regardless of the mode of delivery. Conclusion: Despite fetal pulmonary maturity, delivery before 39 weeks is associated with significantly increased neonatal morbidity when compared to scheduled deliveries at 39 weeks or greater.

Full-term neonatal intenstive care unit admission in an urban community hospital: the role of respiratory morbidity

Objective. To investigate the incidence of respiratory morbidity among full-term neonatal intenstive care unit (NICU) admissions and identify risk factors for such admissions. Methods. We performed a retrospective cohort study of NICU admissions between 1/06 and 12/08. We included neonates between 37 and 40 weeks with a diagnosis of transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, pneumothorax, and meconium aspiration syndrome. Obstetrical outcomes were compared with a control group of women during the same period whose neonates were not admitted to the NICU. Results. Two-hundred two infants admitted to the NICU with respiratory morbidity were compared with 9580 controls. TTN comprised the majority of the respiratory morbidity. Only RDS was associated with cesarean delivery. Conclusion. RDS remains a significant morbidity in full-term NICU admission. When compared with controls, admissions to our NICU with any respiratory morbidity were more likely to be delivered by cesarean to a mother with hypertension or diabetes during pregnancy.

Rates of intrauterine fetal demise and neonatal morbidity at term: determining optimal timing of delivery

Abstract Objective: To examine rates of unexplained intrauterine fetal demise (IUFD) and neonatal morbidity in uncomplicated term pregnancies to identify the optimal gestational age for delivery. Methods: A retrospective case control study was performed with singleton pregnancies delivered between 37 0/7 weeks and 42 6/7 weeks. Exclusion criteria were “complicated pregnancies”: emergency deliveries, maternal hypertension, diabetes, infection, fetal disease/malformations and placental abnormalities. Results: Nineteen thousand two hundred and sixty-four maternal/infant pairs were examined. The overall rate of NICU admission was 2.7% and the rate of unexplained IUFD was 2.02 per 1000 births. The lowest rate of IUFD was found at 39 weeks (1.40 per 1000 births). Odds ratios adjusted for maternal smoking, ethnicity, age and mode of delivery showed 2.74 (95% CI 0.35–21.83) risk of IUFD at 42 versus 39 weeks, 2.09 (1.47–2.98) risk of NICU admission at 37 versus 38 weeks, 2.54 (1.62–3.97) risk of respiratory morbidity at 37 versus 38 weeks and 3.38 (1.84–6.18) risk of transient tachypnea of the newborn or respiratory distress syndrome at 37 versus 38 weeks. Conclusions: Neonatal respiratory morbidity was lowest for deliveries at 38–39 weeks. IUFD was 2.74 times more likely at 42 weeks versus 39 weeks. Our findings support current guidelines advising clinicians when to deliver term pregnancies.

Rates of Intrauterine Fetal Demise and Respiratory Morbidity at Term: Determining Optimal Timing of Delivery [16C]

INTRODUCTION: Elective cesarean deliveries prior to 39 weeks gestation place infants at increased risk of morbidity. Idiopathic intrauterine fetal death (IUFD) has yet to be evaluated to determine the gestational age that is most protective against fetal death. Our aim was to examine rates of IUFD and neonatal morbidity in uncomplicated term pregnancies to identify the optimal gestational age of delivery. METHODS: A retrospective case control study was performed. Inclusion criteria were singleton term pregnancies who delivered between 37 0/7 weeks to 42 6/7 weeks. Exclusion criteria were all “complicated pregnancies”: emergency deliveries, presence of maternal hypertension, diabetes, infection, fetal disease or malformations, and placental abnormalities. RESULTS: 19,264 maternal/infant pairs were examined. The overall rate of NICU admission was 2.7% and IUFDs was 0.20%. The lowest rate for IUFD was found at 39 weeks (0.14% of deliveries at 39 weeks). The lowest rates for NICU admission, any respiratory morbidity, and diagnosis of TTN or RDS were each found at 38 weeks gestational age. Adjusted odds ratios (with 95% confidence intervals) showed 3.48 (1.24–9.79) risk of IUFD at 37 vs 39 weeks, 2.09 (1.47–2.98) risk of NICU admission at 37 vs 38 weeks, 2.54 (1.62–3.97) risk of respiratory morbidity at 37 vs 38 weeks, and 3.38 (1.84–6.18) risk of TTN/RDS at 37 vs 38 weeks. CONCLUSION: Neonatal respiratory morbidity was lowest for deliveries at 38–39 weeks. IUFD was 3.5 times more likely at 37 weeks vs 39 weeks, which was a significant finding. Our findings support current guidelines advising clinicians when to deliver term pregnancies.

Use of oral hypoglycemic and insulin agents in pregnant patients.

Although insulin remains the standard medication for the treatment of all types of patients with diabetes during pregnancy, oral hypoglycemics may be considered as alternative medications in the treatment of some types of diabetes in pregnancy.

Subsequent pregnancy after two uterine artery embolizations

Uterine artery embolization (UAE) was first described in 1995 as an effective alternative in the treatment of symptomatic uterine leiomyomas [1]. This procedure has remained a popular option for women wishing to avoid surgery (myomectomy or hysterectomy) and preserve the uterus [2]. For women wishing to maintain fertility, the safety of this procedure remains controversial. There have been a limited number of reports describing the surveillance and outcome of pregnancy after embolization. Complications such as fetal malpresentation, small for gestational age, premature delivery, cesarean delivery, and postpartum hemorrhage have been previously reported in pregnancies occurring after a single UAE [3]. Here, we describe the first reported case of pregnancy after undergoing two prior uterine artery embolizations. A 34-year-old G2P0010 was referred to our practice for a perinatal consultation at 16 weeks due to a history of two prior uterine artery embolizations. The patient experienced menometrorrhagia with severe anemia secondary to extensive uterine leiomyomas 2 years prior to conception. Treatment options were offered including a myomectomy to preserve fertility. She ultimately chose UAE to avoid a laparotomy. 1 year after her initial uterine artery embolization procedure, she continued to experience menometrorrhagia with anemia and was found to have persistent leiomyomas. After extensive counseling, she chose a second uterine artery embolization procedure. An MRI obtained 3 months following the second procedure revealed significantly smaller, devascularized leiomyomas. 6 months later, she underwent a hysteroscopic resection of a submucosal fibroid. She spontaneously conceived an intrauterine pregnancy about 1 year after the second UAE procedure. The patient was extensively counseled regarding the potential risks including small for gestational age, premature delivery, cesarean delivery, and postpartum hemorrhage, which have been previously described with pregnancy following a single uterine artery embolization procedure. She elected to continue her pregnancy. She underwent close follow-up with monthly serial growth ultrasounds, and twice weekly fetal testing beginning at 32 weeks. Biometry and growth were appropriate for gestational age throughout the pregnancy and her antepartum course remained uncomplicated. At 40 weeks and 6 days, the patient presented for a scheduled induction of labor. She subsequently underwent a primary low transverse cesarean section for arrest of dilatation and delivered a healthy male infant, weighing 3,288 g. Her postpartum course was uncomplicated. Uterine artery embolization is a treatment option that is increasingly used for women who experience symptoms of menorrhagia and/or pelvic pressure due to uterine leiomyoma [4, 5]. The effectiveness of this minimally invasive and uterine preserving procedure makes UAE an attractive option. Currently, myomectomy is the only recommended surgical option for women with leiomyomas who desire future fertility [4]. However, one study found that 30% of patients who underwent UAE desired future fertility [6]. Embolization has also been employed in the management of postpartum hemorrhage and uterine arteriovenous S. F. Ravangard (&) Department of Obstetrics and Gynecology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA e-mail: Sravangard@resident.uchc.edu