bluuebunny/crossref_metadata_2025 huggingface dataset:
The Combined Influence of Maternal Medical Conditions on the Risk of Fetal Growth Restriction [34N]
Authors: Fresch Robert J. , DeFranco Emily , Stephen Kendal
Published: April 2020

INTRODUCTION:

Common maternal medical co-morbidities such as hypertensive disorders, diabetes, tobacco use, and extremes of maternal age, BMI, and gestational weight gain (GWG), are known individually to impact fetal growth restriction (FGR) risk. We aim to examine the risk of FGR in women with multiple maternal medical co-morbidities to determine the cumulative risk imposed on pregnancy.

METHODS:

In this population-based retrospective cohort study we analyzed data from Ohio live birth records from 2006–2015 to estimate the influence of individual and combinations of maternal co-morbidities on rates of FGR (birthweight <10th percentile for gestational age) and severe FGR (<5th percentile). The exposures were individual and combinations of maternal medical conditions (chronic hypertension, gestational hypertension, pre-gestational diabetes, tobacco use, advanced maternal age, underweight, and insufficient GWG) and outcomes were rates and adjusted relative risk (aRR) of FGR.

RESULTS:

There were 1,463,506 live births in Ohio during the study period, of which 734,672 (50.2%) had one or more maternal medical condition. Pregnancies complicated by multiple co-morbidities had higher rates of FGR compared to those with a single medical condition. The rate and aRR range of FGR <10%ile and FGR <5%ile ranged from 8.8–18.4% (aRR 0.91–1.51) and 4.3–9.3% (aRR 0.84–2.22), respectively in pregnancies with single medical conditions, which increased to 10.4–57.9% (aRR 1.03–3.16) and 5.9–36.9% (aRR 1.11–7.03), respectively in pregnancies complicated by multiple medical co-morbidities.

CONCLUSION:

A greater number of maternal medical co-morbidities during pregnancy is associated with increasing cumulative risk of fetal growth restriction, which may be useful in patient counseling and screening for FGR.
The Role of Hospital Specific Labor Curves in Promoting a Culture of Intended Vaginal Birth [37N]
Authors: Neale Donna M. , Yenokyan Gayane
Published: April 2020

INTRODUCTION:

To describe the labor curve in nulliparous women at term with a singleton fetus in the vertex presentation (NTSV) at a community hospital.

METHODS:

IRB approved, retrospective cohort study of NTSV presenting for labor management from January 1, 2016 – December 31, 2017 (N=1,638). Cervical examination upon admission and every cervical examination until delivery were extracted from the labor flow sheet and delivery summary in the electronic medical record. A linear mixed effect model with random intercept for each woman and random slope for time was used for modeling of cervical exam trajectories with time since first examination. Within-woman correlation and variability of trajectories across women were determined.

RESULTS:

1,084 women delivered vaginally (VD) and 554 women delivered via cesarean section (CD). For the cohort, dilation increased 0.39 cm/hour in the first 12 hours, 0.46 cm/hour between 12–24 hours and 0.41 cm/hour after 24 hours. When comparing delivery type, rate of progression in the first 12 hours for the VD group was 0.45 cm/hour vs 0.26/hour (P<.001) for the CD group. Rate of progression at 12–24 hours in the VD group was 0.53 cm/hours vs 0.34 cm/hour (P<.001) in the CD group.

CONCLUSION:

The change in cervical dilation needed to achieve vaginal delivery in a nulliparous woman is slower than was previously suggested by the Friedman curve. Furthermore, the labor curve in women who delivered vaginally is markedly different from the curve of women who delivered via cesarean section as early as the first 12 hours of labor.
Comparison of Outcome Measures in a US Birth Cohort Against Those in the National Maternity and Perinatal Audit Report [09O]
Authors: Souter Vivienne , Painter Ian , Nethery Elizabeth , Sitcov Kristin
Published: April 2020

INTRODUCTION:

The aim of this study was to compare outcome measures in a US birth cohort against those reported in the 2019 National Maternity and Perinatal Audit (NMPA) Clinical Report.

METHODS:

This retrospective cohort study evaluated outcome measures for hospital births between 04/01/2016 and 03/31/2017 in a multicenter perinatal quality collaborative (OB COAP) based in the Northwest US, and compared them to rates in Great Britain's 2019 publically available NMPA Clinical Report. Outcome measures included mode of delivery, episiotomy, low Apgar (<7 at 5 minutes), 3rd/4th degree laceration, vaginal birth after cesarean (one previous cesarean only), and neonatal unit admission, for term singleton births, and neonatal unit admission for late preterm births (34+0–36+6 weeks).

RESULTS:

A total of 27,267 births were included in the OB COAP cohort. Compared to unadjusted aggregate rates in the NMPA report, OB COAP had higher rates of cesarean birth (29.3% versus 25.7%), spontaneous vaginal birth (65.9% versus 61.6%), and neonatal unit admission (7.0% versus 5.8%) in term births, and neonatal unit admission in late preterm births (50.3% versus 41.9%). OB COAP had lower rates of operative vaginal birth (4.8% versus 12.5%), vaginal birth after cesarean (14.6% versus 24.5%), and episiotomy (3.1% versus 21.9%). The rate of 3rd/4th degree lacerations was slightly lower in OB COAP (2.8% versus 3.5%) and low Apgar rates were similar (1.3% in OB COAP and 1.2% in NMPA).

CONCLUSION:

Striking differences in outcome measures between the US cohort and rates in the NMPA Clinical Report, highlight potential strategies for quality improvement.
External Cephalic Version in Twin Pregnancy [13N]
Authors: Felder Laura , McCurdy Rebekah , Berghella Vincenzo
Published: April 2020

INTRODUCTION:

Decreasing the primary cesarean delivery rate and associated maternal and fetal complications is a priority for many obstetric providers. External cephalic version is a procedure recommended for women with singleton pregnancies where the fetus is malpresenting as vaginal breech delivery is inherently riskier than either vaginal or cesarean delivery. However, little is known about this procedure in the context of twin gestations. Women with twin gestations where the presenting fetus is not cephalic are instead recommended to undergo scheduled cesarean delivery.

METHODS:

A systematic review of the following electronic databases was performed, searching from their inception until September, 2019: MEDLINE, Ovid, Scopus, and clinicaltrials.gov. All reported cases of external cephalic version in twin pregnancy were included. Maternal demographics, procedure details, and outcomes data were collected. The primary outcome was successful version of the presenting twin to the cephalic presentation. Statistical analysis involved calculating means, standard deviations, frequencies and percentages as appropriate.

RESULTS:

Two case reports and one case series, totaling 22 patients, met inclusion criteria. No randomized controlled trials were identified. All were dichorionic pregnancies. Successful external cephalic version of twin A occurred in 60% (13/22) of women and 50% (11/22) had a successful vaginal delivery. The majority were performed using regional anesthesia and a uterine relaxant (19/22). No serious adverse events occurred in any of the reports.

CONCLUSION:

External cephalic version appears to be safe and effective for dichorionic twins where the presenting twin is malpresenting. Additional randomized controlled trials are needed to further evaluate this intervention for this patient population.
Outcomes of Oophorectomy in Pregnancy: A Retrospective Cohort [28N]
Authors: Bouchelion Ashleigh , Bauer Alison Marie , Phillis Maria , Hackney David , Armstrong Amy
Published: April 2020

INTRODUCTION:

Adnexal masses are common in pregnancy. Our objective is to evaluate outcomes of oophorectomy in pregnant women.

METHODS:

This is a retrospective cohort study using data from the National Inpatient Sample between 2007 and 2013. Reproductive-aged women undergoing oophorectomy were identified using International Classification of Diseases – 9 diagnosis and procedure codes. Ectopic pregnancies were excluded. The risk of ovarian cancer was compared between pregnant and non-pregnant women undergoing oophorectomy. Secondary outcomes included surgical and pregnancy complications. Univariable analyses and multivariable regression were performed with adjustment for confounding factors.

RESULTS:

203,075 women aged 15–45 years undergoing oophorectomy were identified, of whom 17,285 (8.5%) were pregnant. Pregnancy was associated with a lower frequency of ovarian cancer diagnosis (0.9% vs 2.5%, P<.001, OR 0.4, 95% CI 0.3 – 0.4). This relationship persisted with multivariable regression (P<.001, aOR 0.3, 95% CI 0.3 – 0.4). Pregnant women were significantly less likely to undergo a laparoscopic procedure or to undergo hysterectomy, omentectomy, or lymph node dissection compared with non-pregnant women. Pregnant women were also significantly more likely to die during hospitalization; this relationship persisted in multivariable regression (0.16% vs 0.05%, P<.001, aOR 4.1, 95% CI 2.5 – 6.6). There were no significant differences in frequency of transfusion or venous thromboembolism. Of pregnant women, 82% delivered during hospitalization for oophorectomy, 78% of these delivered by cesarean.

CONCLUSION:

Oophorectomy in pregnancy is associated with a lower frequency of ovarian cancer diagnosis, though is associated with higher frequency of laparotomy and death during hospitalization.
Pregnancy Outcomes in Women With Percutaneous Nephrostomy Tube Placement for Renal Colic [32N]
Authors: Tabsch Kareem K. , Starikov Roman , Hirsch Kevin
Published: April 2020

INTRODUCTION:

Maternal and fetal outcomes in pregnant patients undergoing treatment of renal colic with percutaneous nephrostomy tubes (PCN) have not previously been described. We undertook this study to evaluate pregnancy outcomes in patients who had nephrostomy tubes placement during pregnancy.

METHODS:

Following IRB approval, we retrospectively identified women who had nephrostomy tubes placed during pregnancy at a single tertiary care center. Data were collected from maternal and newborn charts. Descriptive statistics were utilized to characterize pregnancy outcomes.

RESULTS:

During the study period (2014–2018), 41 patients underwent placement of nephrostomy tubes during pregnancy, however maternal and neonatal outcomes were available for only 13 patients. Median gestational age at PCN placement was 28.2 weeks. Prior to PCN placement, renal stones were identified on imaging in 53% of patients and median creatinine was 0.6 (range 0.44–1.06). Urinary tract infection (positive urine culture) was identified in 46% of patients. Median number of hospital days during pregnancy was 9 (range 3–19 days). 31% of patients delivered prior to 37 weeks (median 37, range 32w6d-40w4d). A total of 5 (38%) infants required NICU admission and 2 (15%) were diagnosed with neonatal abstinence syndrome (NAS).

CONCLUSION:

Although limited by follow up data, this is the largest case series to date describing PCN in pregnancy. The underlying renal disease necessitating PCN is associated with prolonged hospital stays, NICU admission, and treatment for NAS. Given these findings, our group is planning to conduct prospective studies to characterize pregnancy outcomes in women with symptomatic renal colic during pregnancy.
Super-utilizers of Inpatient Care in an Obstetric Population [33N]
Authors: Keselowsky Kerri , Rosen Todd , Hadaya Ola , Khan Shama , Ananth Cande
Published: April 2020

INTRODUCTION:

Super-utilizers (SUs) are patients who use a disproportionate amount of resources. Approximately 1–3% of adult patients account for 30% of hospital spending. Programs have been developed to improve healthcare delivery to SUs and decrease costs. Our objective was to create distribution curves of hospital charges (HC) and length of stay (LOS) in the obstetric population and characterize and compare SUs and typical utilizers (TUs).

METHODS:

We performed a retrospective cohort study of 500 patients at a tertiary center between 2012 and 2014. Data were collected 266 days prior to the estimated date of confinement (EDC) and up to 42 days post-delivery. Medical diagnoses, obstetric details, demographics, HC, and LOS were collected.

RESULTS:

Distribution curves for HC and LOS were positively skewed. SUs were defined as patients with charges greater than $75,000; they comprised 7% of patients (n=36) and accounted for 30% of charges. SUs averaged higher HC ($172,257 vs $30,524, P<.05) and longer LOS (22.6 vs 3.2 days, P<.05). They had earlier deliveries (34.5 vs 38.5 weeks, P<.05), higher cesarean section rates (69% vs 35%, P<.05), more chronic conditions (0.97% vs 0.48%, P<.05), and pregnancy complications (2.08% vs 0.67%, P<.05). The most common complications in SUs were preterm labor (33.3% vs 5.4%, P<.05) and preterm premature rupture of membranes (25% vs 3.9%, P<.05).

CONCLUSION:

There is unequal use of resources in the obstetric population and SUs are at risk for adverse outcomes. These data can guide our community to serve our most vulnerable patients through prevention, research, and care that specifically targets SUs.
Timing of Delivery in Intrahepatic Cholestasis of Pregnancy With Total Bile Acids ≥100 µmol/L: A Decision Analysis [38N]
Authors: Frank Zoe C. , Nienow-Birch Mary N. , Lo Jamie , Shaffer Brian L. , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

Our study models the trade-off between preterm neonatal morbidity and stillbirth for women with intrahepatic cholestasis of pregnancy (ICP) with total bile acids ≥100 µmol/L in order to determine the optimal gestational age for delivery.

METHODS:

A decision analytic model was created to compare the outcomes of delivery at 33 through 40 weeks gestation in women with total bile acids (TBA) ≥100 µmol/L. Baseline risks of stillbirth and spontaneous delivery were derived from the literature and adjusted for peak TBA. It was assumed that betamethasone was given within 48 hours of all planned preterm deliveries and before a percentage of spontaneous ones. We assumed a population of 10,000 women with ICP and calculated total quality-adjusted life years (QALYs) for each strategy, taking into account both maternal and neonatal perspectives. Univariate sensitivity analysis was performed for all variables to test the robustness of the model.

RESULTS:

In women with peak TBA ≥100 µmol/L, delivery at 34 weeks maximized QALYs. Compared to delivery at 36 weeks, it resulted in 1302.4 more QALYs, 98.2 fewer stillbirths, and 21 more cases of cerebral palsy in our theoretical cohort of 10,000 women. Sensitivity analysis demonstrated that when the relative risk of stillbirth given TBA ≥100 µmol/L fell from a baseline of 30.5 to below 26.2, delivery at 35 weeks became optimal. Monte Carlo analysis demonstrated that when variation was incorporated into the model, delivery at 34 weeks was the dominant strategy 45% of the time.

CONCLUSION:

In women with ICP with TBA ≥100 µmol/L, delivery at 34 weeks maximizes QALYs.
Association Between Antepartum Depression Score and Breastfeeding Outcomes [05O]
Authors: Chapman Erica R. , Colina Andreina , Berens Pamela D.
Published: April 2020

INTRODUCTION:

Despite abundant evidence supporting breastfeeding benefits, over 15% of women do not initiate breastfeeding and many stop earlier than recommended. Postpartum depression has a negative association with breastfeeding outcomes. Antepartum depression could have a similar effect.

METHODS:

Our retrospective chart review included all women from the University of Texas Physicians obstetrical practice who completed an Edinburgh Postnatal Depression Scale (EPDS) and delivered between January 2017 and February 2018. IRB approval was obtained. Of 988 potentially qualifying women, 176 were included [exclusions included no EPDS during pregnancy (809) or maternal breastfeeding contraindication (3)]. Dependent variables were breastfeeding initiation and duration through the postpartum visit. Antepartum depression was defined as a pregnancy EPDS greater than or equal to 13. Multivariable logistic regression was used to determine association between antepartum depression and breastfeeding outcomes.

RESULTS:

No significant association was found between antepartum depression scores and breastfeeding outcomes. Unadjusted OR 0.62 (95% CI 0.25–1.08); adjusted OR 1.08 (95% CI 0.39–3.03) for breastfeeding initiation. Unadjusted OR 0.80 (95% CI 0.36–1.78) adjusted OR 1.02 (95% CI 0.42–2.48). Women with antepartum underlying mood disorders did have significantly reduced odds of initiation and duration of breastfeeding [initiation adjusted OR 0.24 (95% CI 0.08–0.72), duration adjusted OR 0.25 (0.08–0.75)].

CONCLUSION:

We found no association between antepartum depression scores and breastfeeding outcomes. Women with underlying mood disorders had significantly reduced odds of initiating and continuing breastfeeding at the postpartum visit. Addressing underlying mood disorders during pregnancy might be a novel strategy to increase breastfeeding rates.
Category II Fetal Monitoring in Fetuses With Congenital Heart Defects: Are They Any Different? [06O]
Authors: Bailey Erin , Lopez Julia , Smith Sarah , Woolfolk Candice , Cahill Alison , Raghuraman Nandini
Published: April 2020

INTRODUCTION:

The majority of literature investigating continuous electronic fetal monitoring (EFM) excludes anomalous fetuses. The objective of this study was to determine if Category II EFM characteristics differed between fetuses with and without congenital heart defects (CHD).

METHODS:

This was a retrospective IRB-approved cohort study of singleton, term pregnancies admitted for induction or labor with an antenatal diagnosis of fetal CHD between 2017–2019. We excluded fetuses with genetic abnormalities. Cases were matched by race and obesity in a 1:2 ratio to a historic control of term pregnancies with structurally normal fetuses. EFM characteristics in the 1 hour before delivery were extracted. The primary outcome was incidence of Category II EFM features; secondary outcome was total deceleration area (TDA).

RESULTS:

47 cases of fetal CHD were matched to 94 controls. There was no difference in advanced maternal age, other baseline demographics, or mode of delivery between groups. Fetuses with CHD were less likely to have prolonged decelerations (6.4 vs 25.5%, P<.01) or any periods of tachycardia (4.3 vs 17.0, p 0.03) compared to normal fetuses. Other Category II features were similar between groups including incidence of recurrent late and variable decelerations and minimal variability. There was no difference in TDA between groups.

CONCLUSION:

Prolonged decelerations and tachycardia were less common in CHD fetuses. The incidence of other Category II features were similar to nonanomalous fetuses. These results suggest that structural heart defects do not increase the risk of concerning EFM patterns. Future studies should evaluate the risk of acidemia with Category II EFM and CHD.
Explaining the (Over)Use of Electronic Fetal Monitoring: Evidence From a Study of Work Flow on the Unit [14O]
Authors: Low Lisa Kane , Chuey Meagan , Abdelnabi Samia , De Vries Raymond
Published: April 2020

INTRODUCTION:

Guidelines from ACOG, AWHONN, and ACNM recommend against the routine use of electronic fetal monitoring (EFM) for low risk, healthy labors, recognizing the limited evidence of improved outcomes and its contribution to cesarean births. Yet the vast majority of healthy labors continue to be monitored with EFM rather than intermittent auscultation (IA). We explore the reasons for this disjuncture, going beyond the untested assumption that liability concerns drive EFM use to examine the place of EFM in the workflow of maternity care units.

METHODS:

A mixed methods study, at a large medical center, using 1) observations on the unit (121 hours), 2) interviews and focus groups with nurses, midwives, obstetricians, and administrators (n=47), 3) chart review, and 4) a short survey of care providers (n=140).

RESULTS:

Four areas favor EFM use: The work environment (incorrect assumptions about what others on the care team want; EFM as default order; economic and time efficiency); Patients (limited knowledge of monitoring options); Technology (emphasis on EFM training over other approaches); Fear (of missing something, of blame from colleagues, of litigation).

CONCLUSION:

In light of the recognition – by ACOG and other professional societies – of the role of EFM in the overuse of cesarean sections – it is imperative that we understand continued reliance on this technology. Our study – the first of its kind – points to practical steps needed to reduce this reliance, including open communication among maternity care team members, change in EHR order sets, training in use of IA, and patient education.
Impact of Group Prenatal Care on Neonatal Outcomes in Women With Opioid Use Disorder [17O]
Authors: Lou Kristie , McDowell Misty , Slaven James E. , Grasch Jennifer , Quinney Sara K.
Published: April 2020

INTRODUCTION:

Opioid use disorder (OUD) is a growing problem that incurs several obstetric risks. The objective of this study was to determine the impact of group prenatal care (PNC) compared to conventional individual PNC on neonatal outcomes in women with OUD.

METHODS:

This was a retrospective cohort study evaluating a practice change to group PNC from individual PNC in pregnant patients with OUD at the Indiana University Maternal Recovery Program (MRP). IRB committee approval was obtained. Data were collected from pregnant patients at the MRP diagnosed with OUD, with initiation of care <32 weeks gestation, and receiving buprenorphine therapy. Our primary outcomes were the rate of neonatal abstinence syndrome (NAS) treatment requirement and NAS severity. Outcomes were compared between group and individual PNC patients using Student t-tests for continuous variables and chi-square tests for discrete variables.

RESULTS:

252 OUD patients presented for PNC at the MRP from September 2015 to August 2017. 104 OUD patients presented for PNC from September 2017 to October 2018, following a practice change to group PNC. Among those meeting inclusion and exclusion criteria (n=304), 76 underwent group PNC and 228 underwent individual PNC. The two groups were similar in maternal demographics, substance use history, delivery characteristics, and antenatal buprenorphine dosing. There was a significant difference in the rate of NAS treatment requirement between the two groups of 40.8% for group PNC, compared to 54.8% for individual PNC (P=.0353).

CONCLUSION:

Women receiving group PNC for OUD may benefit from improved neonatal outcomes, specifically a decreased rate of NAS treatment requirement.
In Search of Placenta and Umbilical Cord Risk Factors for Fetomaternal Hemorrhage: A Case-Control Study [18O]
Authors: Boller Marie , Hartt Angeleque , Hung Yun-Yi , Weintraub Miranda Ritterman , Moore Gaea S. , Schauer Galen M.
Published: April 2020

INTRODUCTION:

Fetomaternal hemorrhage (FMH) is an obstetric complication associated with adverse fetal and neonatal outcomes. Few reliable risk factors other than maternal trauma have been identified. Previous research has suggested an association between potentially obstructive umbilical cord abnormalities and FMH.

METHODS:

We conducted an IRB-approved case-control study within Kaiser Permanente Northern California between January 2008 and December 2017 to investigate whether cord abnormalities were associated with FMH. Cases were defined by adverse fetal or neonatal outcomes related to hypovolemia in the setting of a positive maternal flow cytometry for fetal hemoglobin. Controls were selected based on a negative flow result at time of delivery and available placental pathology report for review, matched to gestational age and year of delivery of cases. Delivery records and pathology reports were analyzed for 56 cases and 132 controls.

RESULTS:

There was at least one cord abnormality for 23.2% of cases and 25.8% of controls (P=.71). There were no significant differences between the two groups in placental weight percentile, cord length, or cord diameter. Marginal and velamentous cord insertion occurred slightly more frequently in controls compared to cases. Cord hypercoiling was found in 7.1% of cases vs 5.3% of controls (P=.74).

CONCLUSION:

We did not identify gross placental or cord characteristics associated with FMH. However, case numbers were too small for statistical significance and our study was limited to placentas sent to pathology, which may have biased our control group towards cord lesions. Further research is required to identify whether an association exists between cord abnormalities and FMH.
Interpretation of the Fetal Heart Rate Tracing: Fetal Electrocardiogram Versus Standard Monitoring [20O]
Authors: Monson Martha , Heuser Cara C. , Esplin Isaac , Einerson Brett , Butler Allison , Esplin Sean M.
Published: April 2020

INTRODUCTION:

A limitation of traditional intrapartum fetal heart rate (FHR) assessment includes variation in tracing interpretation between readers. We have shown that an external fetal electrocardiogram (fECG) monitoring device generates more interpretable FHR data compared to standard external Doppler monitoring (SEM), particularly in women with BMI >30. We hypothesized that fECG would provide more consistent interpretation of 10-minute FHR segments intrapartum compared to SEM.

METHODS:

Secondary analysis of randomized controlled trial at 4 Utah hospitals. 218 patients with singleton, term pregnancies, were enrolled at labor admission and randomized to fECG or SEM. We identified subjects where 10-minute FHR tracing segments were evaluated by at least 2 reviewers blinded to study device allocation. We calculated Krippendorff's alpha as a measure of inter-rater reliability. Permutation tests were performed to determine whether the derived alpha on randomized device was statistically significant.

RESULTS:

We identified 206 eligible patient tracings (97 fECG, 109 SEM). Maternal demographics and clinical outcomes were similar. Both devices generated moderate disagreement for FHR Category assignment (fECG -0.36, SEM -0.37). fECG and SEM showed moderate agreement for Acceleration (0.47, 0.46) and Prolonged Deceleration (0.41, 0.58) interpretation. fECG exhibited higher agreement for Baseline FHR (0.95, 0.92) and Recurrent Variable Deceleration interpretation (0.4, 0.15). SEM demonstrated higher agreement compared to fECG regarding FHR variability (0.14, 0.08), variable deceleration (0.6, 0.15) and late deceleration (0.7, 0.22) interpretation.

CONCLUSION:

Considerable heterogeneity exists with respect to FHR interpretation agreement, regardless of FHR monitoring device type. fECG monitoring does not provide more consistent FHR interpretation compared to SEM.
Maternal and Neonatal Outcomes Among Pregnant Women With Myasthenia Gravis [22O]
Authors: Nicholls-Dempsey Laura , Abenhaim Haim A.
Published: April 2020

INTRODUCTION:

Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction marked by weakness and fatiguability of skeletal muscle. MG has an unpredictable course in pregnancy. Our purpose was to evaluate the effect of MG on maternal and neonatal outcomes.

METHODS:

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2015, we conducted a population-based retrospective cohort study consisting of women who delivered during that period. Multivariate logistic regression was used to compare maternal and neonatal outcomes among pregnancies in women with and without MG, while adjusting for baseline maternal characteristics. IRB approval was not required for this study.

RESULTS:

During the 17-year study period, 1087 deliveries were to women with MG. Women with MG were more likely to be older, Caucasian, obese, have Medicare insurance and be discharged from an urban teaching hospital. Women with MG were also more likely to be smokers, have chronic hypertension, pre-gestational diabetes, hypothyroidism and display chronic steroid use. Women with MG were at greater risk for acute respiratory failure (OR 15.7, 95% CI 10.6–23.3) and increased length of hospital stay (OR 2.6, 95% CI 2.0–3.3). No significant difference was observed in the risk of preterm premature rupture of membranes, cesarean section or instrumental vaginal delivery. Neonates of women with MG were also more likely to be premature (OR 1.4, 95% CI 1.1–1.6).

CONCLUSION:

MG in pregnancy is a high-risk pregnancy condition associated with adverse maternal and newborn outcomes. Management in a tertiary care center with obstetrical, neurological and anesthesia collaboration is recommended.
Trial of Labor After Two Cesarean Sections Versus Repeat Cesarean Section: A Retrospective Cohort Study [37P]
Authors: Horgan Rebecca , Hossain Saif , Fulginiti Adriana , Massaro Robert , Graebe Robert
Published: April 2020

INTRODUCTION:

Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals no longer offer a trial of labor after cesarean section (TOLAC). We sought to assess maternal and neonatal outcomes amongst women with two prior cesarean sections who opted to undergo TOLAC versus repeat cesarean section.

METHODS:

This retrospective cohort study was undertaken at a community medical center from January 1st 2008 to December 31st 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, history of uterine rupture, placenta previa or invasive placentation, non-vertex presentation, or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test.

RESULTS:

A total of 796 patients fulfilled study criteria. 69% of women who underwent TOLAC (N=85) had a successful vaginal delivery. There were no differences in neonatal intensive care unit admissions (5.7% vs 5.9%, P=1.0) or mean APGAR scores at one (P=.38) and five (P=.42) minutes amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (2.3% vs 2.1%, P=.71), bowel injury (0% vs 0.1%, P=1.0), bladder injury (1.1% vs 0.1%, P=.21), immediate postpartum infection (0% vs 0.8%, P=1.0) and hysterectomy (0% vs 0.1%, P=1.0).

CONCLUSION:

TOLAC following two cesarean sections has comparable maternal and neonatal morbidity with repeat cesarean section.
Racial Disparities in Neonatal Mortality Among Both Singleton and Multiple Gestations [32O]
Authors: Copeland Timothy P. , Handal-Orefice Roxane C.
Published: April 2020

INTRODUCTION:

Previous studies have noted racial disparities in neonatal mortality. This study seeks to clarify the extent to which multiple gestation moderates the association between race and mortality risk.

METHODS:

Kid's Inpatient Database (2016), which includes a nationally representative sample of all births, was used for this analysis. A multivariate logistic regression controlling for hospital-level factors (i.e. region, size, ownership, teaching status, and local population density) and patient insurance type was used to assess the interaction between race and neonatal mortality among liveborn singleton (n=2,682,478) and twin (n=82,201) deliveries without congenital anomalies. Neonatal death among twins was defined as at least one neonatal death within each pair.

RESULTS:

White twin neonates (n=50,003) had 4.86 times the odds of death (95% CI 4.31, 5.48) compared to white singleton neonates (n=1,523,110). Black neonates had twice the odds of death compared to white singleton neonates (n=398,006; 95% CI 1.88, 2.25) and twin neonates (n=14,569; 95% CI 1.67, 2.40). Hispanic neonates also had an elevated mortality risk in both singleton (n=589,260; aOR 1.20; 95% CI 1.03, 1.27) and twin (n=12,927; aOR 1.51; 95% CI 1.10, 1.68) contexts relative to whites. Mortality among Asian singletons (n=172,103) was not significantly different from white singletons, but Asian twins (n=4,702) had 1.56 times the odds of death (95% CI 1.08, 2.25) compared to white twins.

CONCLUSION:

Black and Hispanic singleton and twin neonates without congenital anomalies had higher mortality rates compared to white neonates. The association between race and neonatal mortality is further moderated by multiple gestations.
Rates of Indicated Nulliparous, Term, Singleton, Vertex Cesarean Deliveries Among Practice Models [31P]
Authors: Brown Inga E. , Wang Tiffany , Kawakita Tetsuya , Moxley Michael
Published: April 2020

INTRODUCTION:

There has been an increased focus on strategies to reduce the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate since March 2014 when the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine published Obstetric Care Consensus (OCC) guidelines on the safe prevention of the primary cesarean delivery. The purpose of this study was to determine if performance of NTSV cesarean deliveries meeting OCC guidelines differed between provider practice models at Virginia Hospital Center (VHC).

METHODS:

We conducted an IRB-approved retrospective cohort study of all NTSV cesarean deliveries from January 2014 to December 2017 at VHC. A third-party reviewer determined if the indication for each delivery met OCC guidelines. Adherence was compared according to practice model (in-house providers with resident involvement, in-house providers without resident involvement, and non-in-house providers without resident involvement). Fisher exact test was used to determine whether performance of NTSV cesarean deliveries meeting OCC guidelines differed among practice models.

RESULTS:

There were 1,833 NTSV cesarean deliveries, of which 743 (40.5%) met OCC guidelines for delivery and 1,090 (59.5%) did not. Performance of NTSV cesarean deliveries meeting OCC guidelines was statistically different among provider practice models. Providers without resident involvement, in-house providers without resident involvement, and in-house providers with resident involvement had 37% (472 out of 1,271), 47% (178 out of 379), and 51% (93 out of 183), respectively, of NTSV cesarean deliveries meeting OCC guidelines (P<.001).

CONCLUSION:

In-house provider coverage and resident involvement are associated with increased performance of NTSV cesarean deliveries meeting OCC guidelines.
Preventing the Primary Cesarean: Adherence to SMFM/ACOG Guidelines by Use of Intrauterine Pressure Catheter [29P]
Authors: Gilmore Emma , Escobar Christina , Anzai Yuzuru , Arslan Alan , McClelland Spencer
Published: April 2020

INTRODUCTION:

In order to reduce the primary Cesarean delivery (CD) rate, SMFM and ACOG offer guidelines for diagnosing arrest of dilation (AOD) and failed induction of labor (FIOL). At our institution, adherence to these guidelines is low, at 28%, but there is limited understanding of contributing factors. The intrauterine pressure catheter (IUPC) is a recognized, helpful component of labor induction protocols, but few studies have examined whether its use is related to CD rates and adherence to labor guidelines. The objective of this study is to evaluate IUPC utilization and its relationship to SMFM/ACOG guideline adherence rates.

METHODS:

A retrospective cohort analysis was conducted at our institution of all singleton primary CDs performed for AOD or FIOL between March 1st 2014 and July 3rd 2018. Cases were defined as being adherent or non-adherent to published guidelines. A chi square test was used to compare the association of guideline adherence to IUPC use.

RESULTS:

Baseline characteristics were similar between adherent and non-adherent groups. For CDs that were non-adherent to ACOG guidelines, IUPCs were utilized in 208/767 cases (27.1%). For CDs that were adherent to ACOG guidelines, IUPCs were utilized in 123/295 cases (41.7%) (P less than 0.001).

CONCLUSION:

We observed a significantly greater rate of IUPC use in CDs that were adherent to SMFM/ACOG guidelines. Overall, adherent physicians performed fewer CDs. This finding suggests that IUPC utilization may be a helpful adjunct for improving labor management and lowering primary CD rates. Interventions around physician education are needed to increase appropriate IUPC use.
Preventing the Primary Cesarean Delivery—Adherence to Labor Arrest Guidelines [28P]
Authors: Cate Jennifer , Haynes Meagan Campol , Arkfeld Christopher , Lee Illuzzi Jessica , Campbell Katherine Harper , Raab Cheryl
Published: April 2020

INTRODUCTION:

The ACOG/SMFM Safe Prevention of Primary Cesarean Delivery guidelines suggest minimum criteria at which cesarean should be performed for labor arrest with the goal of reducing primary cesarean delivery rates. This study evaluates current adherence to these criteria at an academic medical center with two different campuses in order to quantify variation in the modifiable proportion of the cesarean rate and to target quality improvement initiatives.

METHODS:

We analyzed cesareans deliveries performed for arrest of dilation, arrest of descent and failed induction among singleton, term, cephalic live births at a large academic center with two campuses from September 2018 to August 2019. Using the ACOG/SMFM guidelines, the labor course for each cesarean was examined to determine if minimum criteria were met.

RESULTS:

During the study period, there were 1716 cesarean deliveries with 286 performed for labor arrest disorders: 94 for arrest of dilation, 120 for arrest of descent, and 72 for failed induction of labor. At campus A, 27% met criteria for arrest of dilation, 46% for arrest of descent, and 45% for failed induction; at campus B, 95% met criteria for arrest of dilation, 61% for arrest of descent, and 60% for failed induction. Over the study period, the primary cesarean rates at campus A and B were 19.4% and 13.4%, respectively.

CONCLUSION:

The adherence to criteria for arrest disorders was suboptimal and varied significantly across campuses. Quality improvement initiatives targeted to improve adherence to criteria for labor arrest disorders have the potential to impact primary cesarean delivery rates.
Maternal Outcomes of Trial of Labor After Cesarean Delivery Compared With Elective Repeat Cesarean Delivery [23P]
Authors: Gold Stacey L. , Downs Sarah , Kawakita Tetsuya , Ghofranian Atoosa
Published: April 2020

INTRODUCTION:

The vaginal birth after cesarean (VBAC) calculator developed by the MFMU Network helps to identify the likelihood of VBAC. It is not clear if undergoing a trial of labor after cesarean section (TOLAC) is associated with adverse maternal outcomes if the VBAC success rate is low. We compared maternal outcomes of TOLAC to those of elective repeat cesarean delivery after stratifying by the VBAC likelihood.

METHODS:

This was a retrospective cohort study of all women whose primary cesarean delivery and subsequent singleton delivery occurred at our academic center. Data from the second pregnancy were analyzed. The likelihood of VBAC success was categorized using the MFMU VBAC calculator, (less than 60% and 60–100%). The primary outcome was a composite of maternal complications (uterine rupture, postpartum hemorrhage). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS:

Of 626 women, 469 (75%) and 157 (25%) had VBAC likelihood of 60–100% and less than 60%, respectively. Women with VBAC likelihood less than 60% and likelihood of 60–100% who had underwent TOLAC were compared with those who had an elective repeat cesarean. Both groups had similar rates of the primary outcomes; likelihood less than 60% (25% vs. 16.5%; adjusted OR 1.51 [95% CI 0.60–3.78]) and likelihood 60–100% (14.3% vs 13.8%; adjusted OR 1.04 [95% CI 0.60–1.79]).

CONCLUSION:

Women with a history of a primary cesarean delivery, who underwent TOLAC compared to those who had an elective repeat cesarean had similar odds of maternal adverse outcomes regardless of the VBAC likelihood.
Labor Induction at 39 Weeks Versus Expectant Management in Women With Prior Cesarean Delivery [22P]
Authors: Shepherd Megan C. , Lee Alan , Olson Gayle , Saad Antonio , Saade George R.
Published: April 2020

INTRODUCTION:

To compare maternal and neonatal outcomes between elective induction (EIOL) and expectant management (EM) in low risk women with a prior cesarean delivery.

METHODS:

Records of women with a prior cesarean and whose plan of delivery was a trial of labor (TOLAC) were reviewed. Patients who reached 39 weeks and were low risk were included and divided into 2 groups. Those who were induced electively between 39 weeks 0 days and 39 weeks 6 days (EIOL) versus those who were not (EM). Low risk was defined as absence of a maternal or fetal indication for delivery prior to 41 weeks 6 days. The primary outcome was a composite of adverse neonatal outcomes. Secondary outcomes included repeat cesarean delivery (CD) and maternal morbidities.

RESULTS:

From July 2014–July 2019, 552 low risk women underwent TOLAC: 317 women in the EM and 235 in the EIOL group. The primary outcome occurred in 5.38% in the EM group and 3.40% in the EIOL group (OR 0.62, 95% CI 0.23–1.55). The frequency of CD was 31.86% in the EM group and 26.38% in the EIOL group (OR 0.766, 95% CI 0.52–1.13).

CONCLUSION:

Elective induction of labor at 39 weeks among low risk women with a history of prior cesarean section was not associated with an increase in perinatal morbidity, and was associated with lower rates of hysterotomy-associated complications and medically-indicated delivery. It is reasonable to offer elective induction of labor at 39 weeks to women who are candidate for TOLAC.
Induction of Labor at 39 Weeks Versus Expectant Management With One Previous Cesarean Delivery [20P]
Authors: Yao Ruofan , Cryer Alicia , Davis-Nelson Shareece
Published: April 2020

INTRODUCTION:

This study aims to determine the risks and benefits of induction of labor (IOL) at 39 weeks compared with expectant management (EM) until 42 weeks in pregnancies complicated by one previous cesarean delivery.

METHODS:

Retrospective cohort analysis of singleton non-anomalous pregnancies in the US between January 2015 and December 2017. Analyses included only pregnancies with a history of one previous cesarean delivery. Perinatal outcomes of pregnancies induced at 39 weeks were compared to pregnancies that were induced, augmented or otherwise had vaginal delivery between 40–42 weeks. Unlabored cesarean deliveries were excluded. Outcomes of interest included: cesarean delivery, blood transfusion, chorioamnionitis, adult ICU admission, uterine rupture, hysterectomy, Apgar score <3, prolonged neonatal ventilation, NICU admission, neonatal seizure and neonatal death. Logistic-binomial regression analysis was performed to calculate the relative risk (RR) for the outcomes of interest, adjusting for confounding variables.

RESULTS:

There were 53,924 pregnancies included for analysis with 11,052 women in the IOL group. Compared with EM, IOL at 39 weeks decreased the risk of chorioamnionitis (1.9% vs 3.1%, P<.001; aRR: 0.61 (95% CI 0.53, 0.71). Conversely, IOL increased the risk of cesarean delivery (45.5% vs 27.9%, P<.001; aRR: 1.69, 95% CI 1.64, 1.73). Furthermore, there were 1,102 (2.4%) additional cases of preeclampsia, and 47 (0.1%) additional cases of eclampsia in the EM group. There were no differences in other perinatal outcomes.

CONCLUSION:

In pregnancies complicated by one previous cesarean delivery, induction of labor at 39 weeks reduced the risk of chorioamnionitis while increasing the risk of cesarean delivery.
Induction of Labor and Risk of Third- and Fourth-Degree Perineal Tears [18P]
Authors: Al-Wahaibi Suhaila , Czuzoj-Shulman Nicholas , Abenhaim Haim A.
Published: April 2020

INTRODUCTION:

The rate of induction of labor (IOL) at term has been increasing over the years. Our objective was to evaluate the risk of third- and fourth-degree perineal tears associated with term induction of labor.

METHODS:

We conducted a population-based, retrospective cohort study using the United States' Nationwide Inpatient Sample to evaluate the risk of third- and fourth-degree perineal tears in women who underwent IOL at term between 2005 and 2014. We included all term livebirths and excluded, preterm births, previous cesarean deliveries, multifetal gestations, and non-cephalic presentation. Women who underwent an IOL at term were identified using ICD-9 coding. Patient characteristics were compared between those women being induced at term with those who weren't, and logistic regression analysis were carried out to estimate the adjusted effect of IOL at term with risk of 3rd and 4th perineal tears

RESULTS:

Among 5,982,945 eligible live births, 1,035,003 (17.3%) underwent an IOL at term, increasing from 15.7% to 18.5%. Women with an IOL were more likely to be older, Caucasian, and with comorbid illnesses. Compared with women who did not undergo an IOL, women in the IOL group had lower risk of cesarean deliveries, 0.89 (0.88–0.89), 2nd degree tears, 0.89 (0.89–0.90), 3rd degree tears, OR 0.81 (95% CI 0.79–0.82) and 4th degree tears, OR 0.84 (95% CI 0.82–0.87).

CONCLUSION:

Induction of labor at term results in significantly lower risk of third- and fourth-degree perineal tears among all deliveries as well as among women with vaginal deliveries.
Implementation of Pre-cesarean Checklist for Labor Arrest and Failed Induction [16P]
Authors: Greenberg Jessica , Pardanani Setul , Bowman Donna
Published: April 2020

INTRODUCTION:

National and Stamford Hospital cesarean delivery (CD) rates, at 32% and 40.4% respectively, remain high. A large contributor to the primary CD rate is labor arrest, including failed induction of labor (IOL). Use of new guidelines for diagnosing these conditions have been shown to decrease the CD rate. This study aims to assess adherence to new definitions and the impact of a pre-cesarean checklist at our institution.

METHODS:

A retrospective chart review for primary CD in nulliparous, singleton, term, vertex (NSTV) pregnancies performed for labor arrest, including failed IOL, from January 2018 to August 2019. In January 2019 a paper pre-cesarean checklist, adapted from a previously published checklist was introduced to labor and delivery to allow physicians to review labor arrest criteria. Calculated primary CD rates for labor arrest pre and post implementation were compared using chi square analysis.

RESULTS:

The primary cesarean delivery (pCD) rate in NSTV pregnancies for labor arrest was 14.1% in 2018 and 12.5% in 2019 (P=.5). Of the 55 pCD for labor arrest in 2019, 17 (30.9%) filled out the pre-cesarean checklist. Only 18 (32.79%) met criteria for labor arrest/failed IOL.

CONCLUSION:

At our institution, CD in NSTV pregnancies for labor arrest or failed IOL do not meet contemporary definitions. Introduction of a paper pre-cesarean checklist to evaluate labor arrest has not affected the CD rate. However, use of the checklist was limited, thus there remains significant room for a decrease in the cesarean rate if adherence can be improved.