Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: a comparison

OBJECTIVE

To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD).

STUDY DESIGN

We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters.

RESULTS

We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65).

CONCLUSION

Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.

Fetal anomalies and long-term effects associated with substance abuse in pregnancy: a literature review

OBJECTIVES

Substance abuse in pregnancy remains a major public health problem. Fetal teratogenicity results from the effect of these substances during fetal development, particularly when used in combination. This review will focus on and attempt to clarify the existing literature regarding the association of substance abuse on the development of congenital anomalies and the long-term implications in exposed offspring.

METHODS

Systematic review of available English literature using the PubMed database of all peer-reviewed articles on the subject.

RESULTS

A total of 128 articles were included in this review. Alcohol was the most common substance associated with fetal anomalies, particularly facial dysmorphisms and alterations in the central nervous system development. Adverse maternal environments associated with risky behaviors and lack of adequate prenatal care precludes the timely detection of fetal anomalies, confounding most studies linking causality. In addition, although methodological differences and limited availability of well-designed trials exist, substance abuse in pregnancy has been associated with adverse long-term outcomes in infant growth, behavior, cognition, language and achievement.

CONCLUSION

The literature summarized in this review suggests that drug exposure during pregnancy may increase the risk of congenital anomalies and long-term adverse effects in exposed children and adolescents. These conclusions must be tempered by the many confounders associated with drug use. A multidisciplinary approach is paramount for appropriate counseling regarding the known immediate and long-term risks of substance abuse in pregnancy.

Stercoral Perforation of the Colon during Pregnancy: A Case Report and Review of the Literature

Stercoral perforation of the colon, though rare, is associated with high mortality. Review of the literature identified only three prior cases reported during pregnancy. We report a case on a multiparous female presenting at 31 weeks of gestation with acute abdominal pain. Computed tomography suggested a sigmoid colon perforation. An urgent exploratory laparotomy was performed where feculent peritonitis and a stercoral perforation of the sigmoid colon was confirmed. A cesarean delivery and sigmoid colectomy with descending end colostomy was performed. While the newborn had an uncomplicated course, the mother developed an intra-abdominal abscess requiring operative management.

Society for maternal-fetal medicine (SMFM) clinical guideline #7: nonimmune hydrops fetalis

OBJECTIVE

Nonimmune hydrops is the presence of ≥2 abnormal fetal fluid collections in the absence of red cell alloimmunization. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities, followed by structural fetal anomalies, complications of monochorionic twinning, infection, and placental abnormalities. We sought to provide evidence-based guidelines for the evaluation and management of nonimmune hydrops fetalis.

METHODS

A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through June 2014. Priority was given to articles reporting original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American Congress of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation methodology was employed for defining strength of recommendations and rating quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence.

RESULTS AND RECOMMENDATIONS

Evaluation of hydrops begins with an antibody screen (indirect Coombs test) to determine if it is nonimmune, detailed sonography of the fetus(es) and placenta, including echocardiography and assessment for fetal arrhythmia, and middle cerebral artery Doppler evaluation for anemia, as well as fetal karyotype and/or chromosomal microarray analysis, regardless of whether a structural fetal anomaly is identified. Recommended treatment depends on the underlying etiology and gestational age; preterm delivery is recommended only for obstetric indications including development of mirror syndrome. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic etiology, an etiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilize and treat critically ill newborns. The prognosis depends on etiology, response to therapy if treatable, and the gestational age at detection and delivery. Aneuploidy confers a poor prognosis, and even in the absence of aneuploidy, neonatal survival is often <50%. Mirror syndrome is a form of severe preeclampsia that may develop in association with fetal hydrops and in most cases necessitates delivery.

Serum 25-hydroxyvitamin D, calcium, and calcium-regulating hormones in preeclamptics and controls during first day postpartum

The evidence for a link between vitamin D and preeclampsia is conflicting. There is a paucity of studies reporting simultaneous 25-hydroxyvitamin D (inactive form) and 1,25-dihydroxyvitamin D (biologically active form). We investigated if levels of serum 25-hydroxyvitamin D, calcium-regulating hormones (1,25-dihydroxyvitamin D, parathyroid hormone), and calcium differ significantly between preeclamptics and controls. On postpartum day one, 98 subjects (44 with preeclampsia, 54 controls) were recruited among women admitted to the postdelivery unit, and their serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, parathyroid hormone, serum calcium, and serum albumin levels were prospectively measured. The majority of participants (70%) had serum 25-hydroxyvitamin D level<20 ng/mL; 53% had <15 ng/mL. Mean serum 25-hydroxyvitamin D level was similar between cases and controls (p=0.50). Mean total serum calcium adjusted for albumin and magnesium was similar between cases and controls (p=0.78). Mean serum 1,25-dihydroxyvitamin D and parathyroid hormone levels were normal, and there were no differences between cases and controls. The only significant differences found between preeclamptic cases and controls were mean body mass index, parity, and season of blood draw. Vitamin D levels did not differ among preeclamptic cases and controls.

Bakri balloon in the management of postpartum hemorrhage: a review

OBJECTIVE

The purpose of this review is to ascertain the indications, techniques, and the associated morbidity with the use of Bakri balloon.

MATERIAL AND METHODS

A literature search using the PubMed database was conducted from 2001 to 2013. We calculated 95% confidence intervals (CIs) for complications.

RESULTS

We identified 12 publications that met the inclusion criteria. Four reports provided the frequency of Bakri use during the study period, with the overall rate being 0.20% (138/69, 174; 95% CI, 0.17-0.25%). Two-thirds of use followed cesarean delivery (67%; 182/273). Uterine atony was specified as the underlying etiology of postpartum hemorrhage in 75% (9/12) of publication. The rate of balloon displacement was 10% (95% CI, 6-16%) and need for transfusion, 43% (95% CI, 32-55%). Hysterectomy was undertaken in 6% (95% CI, 4-10%).

CONCLUSIONS

There is a paucity of publications on Bakri balloon. Before its utilization is recommended in guidelines, a randomized clinical trial comparing uterotonics alone versus with balloon is warranted.

Placental abruption and fetal intraventricular hemorrhage after airbag deployment: a case report

BACKGROUND

There has been very limited documentation of the adverse maternal and/or fetal consequences of airbag deployment in association with motor vehicle accidents.

CASE

A 20-year-old woman, gravida 1, para 0, at 31+ 4 weeks' gestation, was involved in a motor vehicle accident. The car had been hit from the passenger side at an estimated speed of 45 miles per hour. The vehicle was noted to have rolled over, along with deployment of the driver's side and passenger's airbags. Via star low transverse cesarean, the patient was delivered of a very pale-appearing, 1,890g infant with Apgars of 1 and 7 at 1 and 5 minutes of life, respectively. There was an approximate 50% abruption noted on placental evaluation, as well as a 2 x 3-cm area ofecchymosis at the uterinefundus. The neonate's immediate postdelivery hematocrit was 17%. A cranial ultrasound was notable for a grade III germinal matrix hemorrhage with progressive hydrocephalus. Serial ultrasounds showed interval increases in the amount of clots within the lateral ventricles.

CONCLUSION

Airbag deployment can be associated with placental abruption and fetal intracranial hemorrhage.

Correlation of ultrasound estimated with dye-determined or directly measured amniotic fluid volume revisited

BACKGROUND/AIMS

To examine the relationship of the amniotic fluid index (AFI) and single deepest pocket (SDP) with an AFV as modelled by Brace or Magann.

METHODS

AFI and SDP were evaluated for their correlation with an actual AFV using the Spearman correlation coefficient.

RESULTS

482 AFI and 468 SDP pregnancies were evaluated. There was a significant association between the AFI and SDP and an actual AFV (p < 0.0001). The AFI range of 5.1-20 was better correlated than 5.1-24 for normal AFVs Brace (κ = 0.175) and Magann (κ = 0.356) versus 5.1-24 (κ = 0.150 and κ = 0.319), respectively. The agreement level t for the AFI (κ = 0.175) and SDP (κ = 0.126) using Brace was slight and for the AFI (κ = 0.356) and SDP (κ = 0.295) using Magann was fair.

CONCLUSIONS

Both the AFI and SDP were correlated with actual AFV using both models. AFI of 5.1-20 better categorizes normal volumes. Although the Magann model correlates AFI/SDP and AFV better, the superiority is minimal.

Shoulder dystocia: definitions and incidence

Though subjective in nature, both the American College of Obstetricians and Gynecologists practice bulletin and the Royal College of Obstetricians and Gynaecologists green guideline are in agreement on the descriptor of shoulder dystocia: requirement of additional obstetric maneuvers when gentle downward traction has failed to affect the delivery of the shoulders. The rate of shoulder dystocia is about 1.4% of all deliveries and 0.7% for vaginal births. Compared to non-diabetics (0.6%), among diabetics, the rate of impacted shoulders is 201% higher (1.9%); newborns delivered by vacuum or forceps have 254% higher likelihood of shoulder dystocia than those born spontaneously (2.0% vs. 0.6%, respectively). When the birthweight is categorized as <4000, 4000-4449, and >4500 g, the likelihood of shoulder dystocia in the US vs. other countries varies significantly. Future studies should focus on lowering the rate of shoulder dystocia and its associated morbidities, without concomitantly increasing the rate of cesarean delivery.

Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends

Epidemiological knowledge of the incidence, prevalence, and temporal changes of neonatal brachial plexuses palsy (NBPP) should assist the clinician, avert unnecessary interventions, and help formulate evidence-based health policies. A summary of 63 publications in the English language with over 17 million births and 24,000 NBPPs is notable for six things. First, the rate of NBPP in the US and other countries is comparable: 1.5 vs. 1.3 per 1000 total births, respectively. Second, the rate of NBPP may be decreasing: 0.9, 1.0 and 0.5 per 1,000 births for publications before 1990, 1990-2000, and after 2000, respectively. Third, the likelihood of not having concomitant shoulder dystocia with NBPP was 76% overall, though it varied by whether the publication was from the US (78%) vs. other countries (47%). Fourth, the likelihood of NBPP being permanent (lasting at least 12 months) was 10-18% in the US-based reports and 19-23% in other countries. Fifth, in studies from the US, the rate of permanent NBPP is 1.1-2.2 per 10,000 births and 2.9-3.7 per 10,000 births in other nations. Sixth, we estimate that approximately 5000 NBPPs occur every year in the US, of which over 580-1050 are permanent, and that since birth, 63,000 adults have been afflicted with persistent paresis of their brachial plexus. The exceedingly infrequent nature of permanent NBPP necessitates a multi-center study to improve our understanding of the antecedent factors and to abate the long-term sequela.

Exercise and yoga during pregnancy: a survey

The primary objective of this survey was to ascertain the opinions, practices and knowledge about exercise, including yoga, during pregnancy; the secondary objective to compare the responses among women with body mass index (BMI) <30 kg/m(2) versus ≥30 kg/m(2). Survey consisted of 20 multiple choice questions assessing demographics and exercise practices, and five questions testing their knowledge about it during pregnancy (ACOG Committee Opinion # 267). Of the 500 surveys distributed, 84% (422) responses were analyzed. While 86% of women responded that exercise during pregnancy is beneficial, 83% felt it was beneficial to start prior to pregnancy, and walking was considered the most beneficial (62%). The majority (64%) of respondents were currently exercising during pregnancy and 51% exercised 2-3 times/week. Among the five questions testing knowledge about prenatal exercise, majority (range 60 to 92%) were aware of ACOG recommendations. About half had a BMI ≥30. Knowledge about benefits of exercise during pregnancy did not differ significantly between obese and non-obese. Yoga was tried significantly more among non-obese, 65% believed it is beneficial, and 40% had attempted yoga before pregnancy. In our population, the majority believes that exercise, including yoga, is beneficial and they are active.

A multicenter assessment of 1,177 cases of shoulder dystocia: lessons learned

The purposes of this review were to describe deliveries complicated by shoulder dystocia (SD) at three tertiary centers and discern the differences between SD with and without brachial plexus injury (BPI). The inclusion criteria for this multicenter, retrospective study were singletons, delivered vaginally with SD. To discern the risk factors for SD with and without injury, a case (SD and BPI) versus control (3 SD without injury at the same institution) design was used. Multiple linear regression was employed. Over a 7-year period, among 46,637 vaginal deliveries, SD occurred in 1,177 cases (2.5%) and BPI was noted in 11%. The results of multiple regression indicate that gestational age, operative delivery, and the number of maneuvers and concomitant fracture (4%) were statistically associated with BPI following SD (p < 0.001). SD was not associated with BPI in 89% and 88% of the cases that were resolved with McRoberts maneuver and suprapubic pressure, whereas only 0.2% of cases were litigated.

Prenatal detection of fetal growth restriction in newborns classified as small for gestational age: correlates and risk of neonatal morbidity

We examined the rate of detecting small for gestational age (SGA; birth weight < 10%) as intrauterine growth restriction (IUGR) prenatally at four centers and determined risks of composite neonatal morbidity (CNM) and mortality among detected versus undetected (no antenatal diagnosis of IUGR). A multicenter cohort study of 11,487 nonanomalous, singleton live births with sonographic exam before 22 weeks was performed. Of 11,487 births, 8% (n = 929) were SGA that met the inclusion criteria, with 25% of them being prenatally detected. The CNM among SGA births that were prenatally detected as IUGR was higher (23.3%) than undetected SGA (9.7%), but this difference was no longer significant following adjustments for confounding factors. Among preterm births (< 37 weeks), undetected SGA had significantly higher CNM (risk ratio [RR] 10.0, 95% confidence interval [CI] 6.3, 16.1) for deliveries at 24 to 33 weeks and RR 3.0, 95% CI 1.7, 5.4 for 34 to 36 weeks). In summary, only a quarter of SGA births were detected prenatally as IUGR and among preterm SGA, the CNM is significantly higher when SGA births are undetected as IUGR.

Orientation of the uterine fundus in reference to the longitudinal axis of the body: a 3-dimensional sonographic study

OBJECTIVES

The aim of this pilot study was to measure the angle of rotation of the uterus at the fundus from horizontal using 3-dimensional sonography in women presenting for annual gynecologic examinations.

METHODS

A total of 51 patients participated in the study. All patients underwent transvaginal sonography, and 3-dimensional volumes were acquired. The cervicouterine angle and the angle of rotation at the fundus were measured.

RESULTS

The uteri were noted to be anteverted in 64.7%, retroverted in 25.5%, and euverted in 9.8%. They were noted to be pointing toward the right side of the pelvis in 49.0%, to the left side in 39.2%, and at the midline in 11.8%. The median cervicouterine angle was 122° (interquartile range [IQR], 105°-137°). The median angle of rotation at the fundus away from horizontal in either a clockwise or counterclockwise direction on the transverse B-plane was 10.4° (IQR, 7.1°-19.0°), with a maximal angle of 43°, and on the coronal C-plane, it was 10.0° (IQR, 3.0°-20.0°), with a maximal angle of 43°. Noneuverted uteri were more likely to be rotated at the fundus.

CONCLUSIONS

Our study reveals that, contrary to traditional thinking, the uterus can be rotated at the fundus in relation to the body (z-axis) along the longitudinal axis of the cervical canal.

Compliance with regulations on weight gain 6 months after delivery in active duty military women

OBJECTIVE

To determine factors associated with active duty military women being within Navy weight standards 6 months following childbirth.

METHODS

Inclusion criteria for this study were active duty women who delivered a nonanomalous fetus at a Naval Hospital and who remained in the area and their weight was recorded 6 months following childbirth. Multivariate logistic regressions, adjusted for 14 covariates, determined the factors for achieving acceptable weight.

RESULTS

Among 1,009 women who participated in this prospective cohort study, 68% began within Navy body weight standards and 52% had a normal body mass index (BMI) (<25). Six months after childbirth, 48% were within Navy body weight standards and 32% had a BMI <25. Only 2 factors, BMI at first visit and cesarean delivery, significantly influenced the percentage of women who met the weight standards at 6 months.

CONCLUSIONS

Lowering the prepregnancy BMI and avoiding a cesarean delivery may improve the percentage of active duty women who meet weight standards 6 months after childbirth.

Periviable births: epidemiology and obstetrical antecedents

Confusion in terminology and non-standardized definitions can arguably be classified as the most important characteristics that lead to disparate study findings. While such situations abound in all of perinatal epidemiology, the study of "periviable birth" is a classic case in point. The most common term used to describe periviable birth has been extremely low birthweight (ELBW), often defined as newborns with birthweight below 1000g; yet, we identified 11 other descriptors for periviable birth. Due to the multitude of definitions, the reported incidence of periviable births varies from 0.03% to 1.9% (a relative difference of 7025%). Antecedent risk factors for periviable birth, though geographically heterogeneous, include nulliparity and multiple gestations, each accounting for one-third and one-fourth of all periviable births, respectively. Spontaneous preterm labor precedes 34% of these deliveries and premature rupture of membranes in 25%. The pregnancy was complicated by hypertensive disease in 21% and bleeding and chorioamnionitis in 18% each. Over 50% of these births are cesarean deliveries. Six clinical interventions before delivery that may improve outcomes include transfer of patient to a tertiary center, administration of antenatal corticosteroids, tocolytics, or antibiotics after premature rupture of membranes, assessment of fetal well-being with electronic fetal heart rate monitoring, and willingness to perform a cesarean delivery after the limit of viability is reached. While there is an accessible predictive model for mortality and long-term morbidities for newborns delivered at 22-25 weeks with weights of 400-1000g, it is hampered by the need to know the birthweight. In addition to reaching a consensus regarding what birthweight-gestational age thresholds determine a periviable birth, the acute need to optimize neonatal outcomes remains a paramount target worthy of future research, and efforts to advance obstetrical medicine are needed to minimize the likelihood of its occurrence.

Evidence-based surgery for cesarean delivery: an updated systematic review

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.