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Pacheco LD, Clifton RG, Saade GR, Weiner SJ, Parry S, Thorp JM, Longo M, Salazar A, Dalton W, Tita ATN, Gyamfi-Bannerman C, Chauhan SP, Metz TD, Rood K, Rouse DJ, Bailit JL, Grobman WA, Simhan HN, Macones GA. Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery. N Engl J Med 2023; 388:1365-1375. [PMID: 37043652 PMCID: PMC10200294 DOI: 10.1056/nejmoa2207419] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Prophylactic use of tranexamic acid at the time of cesarean delivery has been shown to decrease the calculated blood loss, but the effect on the need for blood transfusions is unclear. METHODS We randomly assigned patients undergoing cesarean delivery at 31 U.S. hospitals to receive either tranexamic acid or placebo after umbilical-cord clamping. The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days post partum, whichever came first. Key secondary outcomes were estimated intraoperative blood loss of more than 1 liter (prespecified as a major secondary outcome), interventions for bleeding and related complications, the preoperative-to-postoperative change in the hemoglobin level, and postpartum infectious complications. Adverse events were assessed. RESULTS A total of 11,000 participants underwent randomization (5529 to the tranexamic acid group and 5471 to the placebo group); scheduled cesarean delivery accounted for 50.1% and 49.2% of the deliveries in the respective groups. A primary-outcome event occurred in 201 of 5525 participants (3.6%) in the tranexamic acid group and in 233 of 5470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% confidence interval [CI], 0.74 to 1.07; P = 0.19). Estimated intraoperative blood loss of more than 1 liter occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI, 0.79 to 1.05). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82 to 0.97); the change in the hemoglobin level was -1.8 g per deciliter and -1.9 g per deciliter, respectively (mean difference, -0.1 g per deciliter; 95% CI, -0.2 to -0.1); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI, 1.02 to 1.61). The frequencies of thromboembolic events and other adverse events were similar in the two groups. CONCLUSIONS Prophylactic use of tranexamic acid during cesarean delivery did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT03364491.).
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Qureshey EJ, Chen HY, Wagner SM, Chauhan SP, Fishel Bartal M. Factors associated with long-acting reversible contraception usage: Results from the National Survey of Family Growth. Int J Gynaecol Obstet 2023; 161:71-78. [PMID: 36181291 DOI: 10.1002/ijgo.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to identify factors associated with long-acting reversible contraception (LARC) usage. METHODS The current cross-sectional study used data from the National Survey of Family Growth from 2011 to 2019. Respondents aged 15 to 44 years were included. Those with previous sterilization, infertility, or pregnant were excluded. The outcome evaluated was use of a LARC. RESULTS Of 61 543 814 women, 44 287 911 (72.0%) met inclusion criteria. The rate of LARC use was 13.4%. Factors associated with an increased likelihood of LARC usage were married/living with a partner (adjusted relative risk [aRR], 1.18 [95% CI, 1.02-1.37]), perceived good health (aRR, 1.44 [95% CI, 1.13-1.84]), year of survey 2017 to 2019 (aRR, 1.53, [95% CI, 1.28-1.83]), one or two past pregnancies (aRR, 1.62 [95% CI, 1.24-2.12]) or three or more past pregnancies (aRR, 1.67 [95% CI, 1.22-2.28]), age at first live birth <20 years (aRR, 1.58 [95% CI, 1.20-2.08]) or 20 to 24 years (aRR, 1.45 [95% CI, 1.13-1.87]), age at onset of sexual activity 13-19 years (aRR, 1.50 [95% CI, 1.26-1.78]), and a 0- to 5-month period of nonintercourse in the past year (aRR, 1.63 [95% CI, 1.40-1.90]). Factors associated with decreased LARC usage were age ≥ 35 years (aRR, 0.74 [95% CI, 0.65-0.85]), being non-Hispanic Black (aRR, 0.75 [95% CI, 0.62-0.89]) or non-Hispanic other (aRR, 0.72 [95% CI, 0.59-0.88]), intending to have children (aRR, 0.65 [95% CI, 0.57-0.74]), and never being sexually active (aRR, 0.10 [95% CI, 0.06-0.16]). CONCLUSIONS Using a nationally representative sample of women in the United States, the authors identified modifiable factors associated with LARC use. Results may be used to plan interventional trials to increase LARC usage.
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Fishel Bartal M, Huntley ES, Chen HY, Huntley BJF, Wagner SM, Sibai BM, Chauhan SP. Factors associated with exclusive formula feeding among individuals with low-risk pregnancies in the United States. Birth 2023; 50:90-98. [PMID: 36639828 DOI: 10.1111/birt.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/01/2022] [Accepted: 12/22/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Better understanding of the factors associated with formula feeding during the hospital stay can help in identifying potential lactation problems and promote early intervention. Our aim was to ascertain factors associated with exclusive formula feeding in newborns of low-risk pregnancies. METHODS A population-based, retrospective study using the United States vital statistics datasets (2014-2018) evaluating low-risk pregnancies with a nonanomalous singleton delivery from 37 to 41 weeks. People with hypertensive disorders, or diabetes, were excluded. Primary outcome was newborn feeding (breast vs exclusive formula feeding) during hospital stay. Adjusted relative risks (aRRs) with 95% confidence intervals (CI) were calculated. RESULTS Of the 19 623 195 live births during the study period, 11 605 242 (59.1%) met inclusion criteria and among them, 1 929 526 (16.6%) were formula fed. Factors associated with formula feeding included: age < 20 years (aRR 1.31 [95% CI 1.31-1.32]), non-Hispanic Black (1.42, 1.41-1.42), high school education (1.69, 1.69-1.70) or less than high school education (1.94, 1.93, 1.95), Medicaid insurance (1.52, 1.51, 1.52), body mass index (BMI) < 18.5 (1.10, 1.09-1.10), BMI 25-29.9 (1.09, 1.09-1.09), BMI 30-34.9 (1.19, 1.19-1.20), BMI 35-39.9 (1.31, 1.30-1.31), BMI ≥ 40 (1.43, 1.42-1.44), multiparity (1.29, 1.29-1.30), lack of prenatal care (1.49, 1.48-1.50), smoking (1.75, 1.74-1.75), and gestational age (ranged from 37 weeks [1.44, 1.43-1.45] to 40 weeks [1.11, 1.11-1.12]). CONCLUSIONS Using a large cohort of low-risk pregnancies, we identified several modifiable factors associated with newborn feeding (eg, prepregnancy BMI, access to prenatal care, and smoking cessation). Improving the breast feeding initiation rate should be a priority in our current practice to ensure equitable care for all neonates.
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Fishel Bartal M, Blackwell SC, Pedroza C, Lawal D, Amro F, Samuel J, Chauhan SP, Sibai BM. Oral combined hydrochlorothiazide and lisinopril vs nifedipine for postpartum hypertension: a comparative-effectiveness pilot randomized controlled trial. Am J Obstet Gynecol 2023; 228:571.e1-571.e10. [PMID: 36787814 DOI: 10.1016/j.ajog.2023.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and diuretics may be underutilized for postpartum hypertension because of their teratogenicity during pregnancy. OBJECTIVE We evaluated whether combined oral hydrochlorothiazide and lisinopril therapy produced superior short-term blood pressure control when compared with nifedipine among postpartum individuals with hypertension requiring pharmacologic treatment. STUDY DESIGN We performed a pilot randomized controlled trial (October 2021 to June 2022) that included individuals with chronic hypertension or hypertensive disorders of pregnancy with 2 systolic blood pressure measurements ≥150 mm Hg and/or diastolic blood pressure measurements ≥100 mm Hg within 72 hours after delivery. Participants were randomized to receive either combined hydrochlorothiazide and lisinopril therapy or nifedipine therapy after stratifying the participants by diagnosis (chronic hypertension vs hypertensive disorders of pregnancy). The primary outcome was stage 2 hypertension (systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg) determined using a home blood pressure monitor on days 7 to 10 after delivery or at readmission to the hospital for blood pressure control. The secondary outcomes included severe maternal morbidity (any of the following: intensive care unit admission; hemolysis, elevated liver enzymes, low platelet count syndrome; eclampsia; stroke; cardiomyopathy; or maternal death), need for intravenous medications after randomization, hospital length of stay, blood pressure during first clinic visit, medication compliance, and adverse events. A pilot trial with 70 individuals was planned given the limited available data on combined hydrochlorothiazide and lisinopril therapy use in postpartum care. We calculated relative risks and 95% credible intervals in an intention-to-treat analysis. Finally, we conducted a preplanned Bayesian analysis to estimate the probability of benefit or harm with a neutral informative prior. RESULTS Of 111 eligible individuals, 70 (63%) agreed and were randomized (31 in the hydrochlorothiazide and lisinopril group and 36 in the nifedipine group; 3 withdrew consent after randomization), and the characteristics were similar at baseline between the groups. The primary outcome was unavailable for 9 (12.8%) participants. The primary outcome occurred in 27% of participants in the hydrochlorothiazide and lisinopril group and in 43% of the participants in the nifedipine group (posterior adjusted relative risk, 0.74; 95% credible interval, 0.40-1.31). Bayesian analysis indicated an 85% posterior probability of a reduction in the primary outcome with combined hydrochlorothiazide and lisinopril therapy relative to nifedipine treatment. No differences were noted in the secondary outcomes or adverse medication events. CONCLUSION The results of the pilot trial suggest a high probability that combined hydrochlorothiazide and lisinopril therapy produces superior short-term BP control when compared with nifedipine. These findings should be confirmed in a larger trial.
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Kazzi N, Nazeer S, Ciomperlik H, Biebighauser J, Denham C, Sibai BM, Chauhan SP. Predicted survival of extremely premature neonates: differences in estimates at counseling versus delivery. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Nazeer S, Chen HY, Ashby Cornthwaite JA, Bitar G, Sibai BM, Chauhan SP, Bartal MF. Adverse outcomes among pregnancies with large for gestational age neonates: stratified by diabetes status. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Al-hafez L, Khanuja K, Figueroa HM, Al-Kouatly HB, Chauhan SP, Berghella V. Misoprostol with balloon compared to oxytocin with balloon in high-risk pregnancy: a randomized controlled trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Stephens AJ, Lee KH, Barton JR, Chauhan SP, Baker AL, Sibai BM. Development of the Sepsis-Associated Adverse Outcomes in Pregnancy Score. Am J Perinatol 2023; 40:128-136. [PMID: 35750320 DOI: 10.1055/a-1884-1001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE This study aimed to develop and evaluate a scoring system-called the Sepsis-Associated Adverse Outcomes in Pregnancy (SAAP) Score-to identify individuals with maternal infection that have composite maternal adverse outcomes (CMAO). STUDY DESIGN Using the International Classification of Disease codes, we identified pregnant and postpartum (up to 6 weeks after birth) individuals admitted at our center with a primary diagnosis of infection. The primary outcome was CMAO which included any of the following: maternal intensive care unit admission, surgical intervention, vasopressor use, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, dialysis, organ failure, venous thromboembolism, or maternal death. Regularized logistic regression was used to identify variables that best discriminate CMAO status. Variables were chosen for inclusion following evaluation of statistical and clinical significance. Model performance was evaluated using area under the curve (AUC) with 95% confidence intervals (CIs), sensitivity, specificity, and predictive values. RESULTS Of the 23,235 deliveries during the study period, 227 (0.9%) individuals met inclusion criteria and among them CMAO occurred in 39.2% (95% CI: 33.1-45.7%). The SAAP score consisted of six variables (white blood cell count, systolic blood pressure, respiratory rate, heart rate, lactic acid, and abnormal diagnostic imaging) with scores ranging from 0 to 11 and a score of ≥7 being abnormal. An abnormal SAAP score had an AUC of 0.80 (95% CI: 0.74-0.86) for CMAO. The sensitivity and specificity of the SAAP score for CMAO was 0.71 (95% CI: 0.60-0.80) and 0.73 (95% CI: 0.64-0.80), respectively. The positive predictive value was 0.62 (95% CI: 0.52-0.72) and negative predictive value was 0.79 (95% CI: 0.71-0.86). CONCLUSION Pending external validation, the sixth variable SAAP score may permit early recognition of pregnant and postpartum individuals with infection who are likely to develop adverse maternal outcomes. KEY POINTS · Sepsis is a leading cause of maternal morbidity and mortality.. · Early recognition improves maternal sepsis outcomes.. · The SAAP score may permit early recognition of maternal adverse outcomes due to infection..
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Bitar G, Sibai BM, Chen HY, Backley S, Chauhan SP, Bartal MF. Pregnancy associated stroke and hypertension: a national cohort evaluating temporal trends, risk factors, and mortality. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Roberts AW, Robinson A, Pearson P, Castillo PD, Pokluda M, Sibai BM, Chauhan SP, Blackwell SC. Correlation of COVID positivity on L&D with community positivity and wastewater monitoring. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Zullo F, Di Mascio D, Raghuraman N, Chauhan SP, Wagner SM, Figueroa HM, Cahill AG, Gupta M, Berghella V, Brunelli R, Giancotti A, Blackwell SC. Three-tiered fetal heart rate interpretation system and adverse outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Kazzi N, Lee LO, Chen HY, Brown K, Moreno MB, Narayan M, Watson O, Roath C, Murphy L, Sibai BM, Chauhan SP. Spinal-induced hypotension and time from spinal-to-delivery in scheduled cesarean deliveries: the association with neonatal acidosis. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bitar G, Cornthwaite J, Ashby Cornthwaite JA, Nazeer S, Ghafir D, Sadek S, Ghorayeb T, Daye N, Chauhan SP, Sibai BM, Bartal MF. Pregnancy outcomes in people with diabetes using continuous glucose monitoring. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Ibarra C, Qureshey EJ, Chen HY, Wagner SM, Ashimi S, Ross PJ, Blackwell SC, Sibai BM, Chauhan SP. LARC uptake in high-risk pregnancies with decision aid versus routine care: one-year postpartum follow-up. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bartal MF, Ashby Cornthwaite JA, Ghafir D, Ward C, Nazeer S, Blackwell SC, Pedroza C, Chauhan SP, Sibai BM. The association between continuous glucose metrics and adverse outcomes in individuals undergoing gestational diabetes screening. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Chen WJ, Rector AM, Guxens M, Iniguez C, Swartz MD, Symanski E, Ibarluzea J, Ambros A, Estarlich M, Lertxundi A, Riano-Galán I, Sunyer J, Fernandez-Somoano A, Chauhan SP, Ish J, Whitworth KW. Susceptible windows of exposure to fine particulate matter and fetal growth trajectories in the Spanish INMA (INfancia y Medio Ambiente) birth cohort. ENVIRONMENTAL RESEARCH 2023; 216:114628. [PMID: 36279916 PMCID: PMC9847009 DOI: 10.1016/j.envres.2022.114628] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
While prior studies report associations between fine particulate matter (PM2.5) exposure and fetal growth, few have explored temporally refined susceptible windows of exposure. We included 2328 women from the Spanish INMA Project from 2003 to 2008. Longitudinal growth curves were constructed for each fetus using ultrasounds from 12, 20, and 34 gestational weeks. Z-scores representing growth trajectories of biparietal diameter, femur length, abdominal circumference (AC), and estimated fetal weight (EFW) during early (0-12 weeks), mid- (12-20 weeks), and late (20-34 weeks) pregnancy were calculated. A spatio-temporal random forest model with back-extrapolation provided weekly PM2.5 exposure estimates for each woman during her pregnancy. Distributed lag non-linear models were implemented within the Bayesian hierarchical framework to identify susceptible windows of exposure for each outcome and cumulative effects [βcum, 95% credible interval (CrI)] were aggregated across adjacent weeks. For comparison, general linear models evaluated associations between PM2.5 averaged across multi-week periods (i.e., weeks 1-11, 12-19, and 20-33) and fetal growth, mutually adjusted for exposure during each period. Results are presented as %change in z-scores per 5 μg/m3 in PM2.5, adjusted for covariates. Weeks 1-6 [βcum = -0.77%, 95%CrI (-1.07%, -0.47%)] were identified as a susceptible window of exposure for reduced late pregnancy EFW while weeks 29-33 were positively associated with this outcome [βcum = 0.42%, 95%CrI (0.20%, 0.64%)]. A similar pattern was observed for AC in late pregnancy. In linear regression models, PM2.5 exposure averaged across weeks 1-11 was associated with reduced late pregnancy EFW and AC; but, positive associations between PM2.5 and EFW or AC trajectories in late pregnancy were not observed. PM2.5 exposures during specific weeks may affect fetal growth differentially across pregnancy and such associations may be missed by averaging exposure across multi-week periods, highlighting the importance of temporally refined exposure estimates when studying the associations of air pollution with fetal growth.
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Bart Y, Meyer R, Yoeli R, Mazaki-Tovi S, Tsur A, Levin G, Sibai BM, Chauhan SP, Bartal MF. Fetal malpresentation following mechanical labor induction. Int J Gynaecol Obstet 2022; 161:1012-1018. [PMID: 36527251 DOI: 10.1002/ijgo.14629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/20/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate whether the risk of fetal malpresentation following mechanical labor induction could be accurately predicted. METHODS A retrospective study, including all individuals who underwent labor induction at a single tertiary medical center between March 2011 and May 2021. Cohorts of pharmacological (n = 16 480) and mechanical labor induction (n = 6864) were compared, determining malpresentation rate following induction. Individuals with and without fetal malpresentation following balloon placement were compared. RESULTS Malpresentation following balloon placement occurred in 62 patients (0.9%). Those patients with malpresentation following balloon placement were older, had higher body mass index during labor, higher parity, polyhydramnios, higher fetal station at the start of labor induction, and delivered at an earlier gestational age compared with control patients. The combined presence of at least three of these risk factors was associated with a malpresentation rate of 8% (7/88) and yielded a positive likelihood ratio of 9.48 (95% confidence interval [CI] 4.57-19.7). A prediction model using these variables was not sufficiently accurate to predict the risk of malpresentation following balloon labor induction; a calculated area under the generated receiver operating characteristic curve was 0.78 (95% CI 0.72-0.84). CONCLUSION Several risk factors were identified for malpresentation following mechanical labor induction, although these were of low predictive value.
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Mendez-Figueroa H, Bell CS, Wagner SM, Pedroza C, Gupta M, Mulder I, Lee K, Blackwell SC, Bartal MF, Chauhan SP. Postpartum hemorrhage drills or simulations and adverse outcomes: a systematic review and Bayesian meta-analysis. J Matern Fetal Neonatal Med 2022; 35:10416-10427. [PMID: 36220264 DOI: 10.1080/14767058.2022.2128659] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare the rates of adverse outcomes with postpartum hemorrhage (PPH) before and after implementation of drills or simulation exercises. STUDY ELIGIBILITY CRITERIA We included all English studies that reported on rates of PPH and associated complications during the pre- and post-implementation of interventional exercises. STUDY APPRASIAL AND SYNTHESIS METHODS Two investigators independently reviewed the abstracts, and full articles for eligibility of all studies. Inconsistencies related to study evaluation or data extraction were resolved by a third author. The co-primary outcomes were the rate of PPH and of any transfusion; the secondary outcomes included admission to the intensive care unit (ICU), transfusion ≥ 4 units of packed red blood cells, hysterectomy, or maternal death. Study effects were combined by Bayesian meta-analysis and reported as risk ratios (RR) and 95% credible intervals (Cr). RESULTS We reviewed 142 full length articles. Of these, 18 publications, with 355,060 deliveries-150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period-were included in the meta-analysis. Using the Newcastle-Ottawa Scale, only three studies were considered good quality, and none of them were done in the US. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US). CONCLUSIONS Interventions to reduce the sequelae of PPH are associated with decrease in adverse outcomes. The conclusion, however, ought not to be accepted reflexively for the US population. All of the studies on the topic done in the US are of poor quality and the associated probability of reduction in sequelae are consistently lower than those done in other countries. SYNOPSIS Since the putative benefits of PPH drills or simulation exercises are based on poor quality pre- and post-intervention trials, policies recommending them ought to be revisited.
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Fishel Bartal M, Clifford CC, Bentum NAA, Ogunye AA, Chen H, Chauhan SP, Sibai BM. Risk Factors and Outcomes in People with Stroke Associated with Pregnancy: a retrospective single‐center cohort. Int J Gynaecol Obstet 2022; 161:861-869. [PMID: 36333879 DOI: 10.1002/ijgo.14556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/17/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe timing, antecedent events, and outcomes in pregnancy-related stroke (PAS). METHODS Retrospective single-center cohort of all PAS within 42 days of delivery from September 2010 to May 2021. Data were abstracted from medical records. RESULTS Among 51 500 births, we identified 91 cases of PAS, with a stroke rate of 177 per 100 000 births. Of all PAS, 62% (n = 56) were hemorrhagic, 56% (n = 51) occurred postpartum, 49% (n = 45) occurred in patients with hypertensive disorders of pregnancy (HDP), and 36% (n = 33) had surgical interventions. There were nine deaths, with a case fatality rate of 9.9%. Of the survivors (n = 82), 37 (45.1%) had residual deficits. Patients with HDP were more likely to have a postpartum stroke than those without HDP (crude relative risk 1.72, 95% confidence interval 1.16-2.55). Among patients with HDP, 89% had at least one severe range blood pressure (BP), with a peak systolic BP of 187.8 ± 27.9 mm Hg and a peak diastolic BP of 109.4 ± 18.4 mm Hg. There was no difference in presenting symptoms (P = 0.120), residual deficits (P = 0.609), or mortality (P = 0.739) between those with or without HDP. CONCLUSIONS At a referral hospital, PAS was uncommon but was associated with a high mortality rate. An improved understanding of the modifiable risk factors is warranted to avert the sequelae of PAS.
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Jayakumaran J, Angarita AM, Chauhan SP, Owen J, Khan KS, Saccone G, Berghella V. Outcomes among participants vs nonparticipants of randomized trials during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2022; 4:100695. [PMID: 35853585 DOI: 10.1016/j.ajogmf.2022.100695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This study aimed to evaluate the outcomes among individuals who were eligible and approached for participation in a randomized controlled trial during pregnancy, comparing those who enrolled with those who declined participation. DATA SOURCES MEDLINE, Scopus, CINAHL, the Cochrane Library, and Ovid were searched from study inception to May 2022. STUDY ELIGIBILITY CRITERIA This study included all obstetrical randomized controlled trials that reported clinical outcomes for both participants and nonparticipants. METHODS The primary outcome captured the presence of morbidity. It was a composite of the primary outcome of each study comparing the participant arm with the nonparticipant arm. If a primary outcome was not clearly defined, a surrogate was developed on the basis of the core outcomes for the clinical condition studied. The risk of bias was assessed with the Newcastle-Ottawa Scale. Subgroup analyses for relevant obstetrical and neonatal outcomes were performed. The summary comparisons were reported as odds ratios with 95% confidence intervals computed using random-effects meta-analysis with heterogeneity evaluated using the I2 statistic. A funnel plot was used to examine publication bias, and there was no asymmetry. RESULTS After reviewing more than 1100 abstracts, 17 obstetrical randomized controlled trials (103,610, with 26,293 participants and 77,317 nonparticipants) met our inclusion criteria and were analyzed. Of note, 9 studies were not rated as high quality, primarily for failing to control for confounding factors. Trial interventions were categorized as antepartum (n=11), intrapartum (n=5), or postpartum (n=1). Overall, participants in obstetrical randomized controlled trials had no difference in outcomes compared with nonparticipants (n=17: odds ratio, 0.88; 95% confidence interval, 0.52-1.49; I2=90%). Moreover, there was no difference seen when only randomized controlled trials that reported a primary outcome were included (n=12: odds ratio, 0.76; 95% confidence interval, 0.38-0.1.49; I2=93%). In addition, there was no difference noted in the subgroup where the randomized controlled trial intervention was not available to nonparticipants (n=7: odds ratio, 0.91; 95% confidence interval, 0.45-1.85; I2=68%). CONCLUSION Pregnant individuals who agreed to participate in randomized controlled trials had no difference in outcomes compared with those who decline participation. Pregnant individuals should be provided with this reassuring information when offered to participate in a randomized controlled trial. Moreover, this information may improve patient recruitment into randomized controlled trials.
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Qureshey EJ, Bicocca MJ, Chauhan SP, Nowlen C, Soto EE, Sibai BM, Stafford I. Moderate-to-Severe Polyhydramnios: Cutoffs for Deepest Vertical Pocket Corresponding to Amniotic Fluid Index. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2827-2834. [PMID: 35225371 DOI: 10.1002/jum.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Society for Maternal-fetal medicine Consult Series (#46) states "antenatal fetal surveillance is not required for mild idiopathic" polyhydramnios defined as amniotic fluid index (AFI) of 24 cm or a deepest vertical pocket (DVP) between 8 and 11 cm. The objective of this study was to determine the cutoff for DVP which correlates with AFI ≥ 30 cm. METHODS This retrospective study of singleton third trimester ultrasounds included a study group randomly divided into test and validation. In the test group, DVP cutoffs correlating with AFI ≥ 30 cm which was used to define moderate-severe polyhydramnios were calculated in two ways, rounded to the nearest whole number: 1) a receiver operating curve and Youden's J statistic (DVP-Youden) and 2) calculation of the DVP percentile that corresponded with AFI of 30 cm (DVP-Percentile). Using the validation group, diagnostic characteristics were DVP-Youden and DVP-Percentile for diagnosis of AFI ≥ 30 cm and were compared against SMFM cutoffs (DVP-SMFM). RESULTS Seventy one thousand eight hundred and ninety three ultrasound exams in the 3rd trimester had assessment of AFI and DVP. Moderate-severe polyhydramnios occurred in 286 (1.2%) in test group and 571 (1.2%) in validation group. AFI of 30 cm corresponded to the 98.9th percentile, which in turn correlated to a DVP of 10 cm (DVP-Percentile). The calculated cutoff for moderate-severe polyhydramnios was 8 cm for DVP-Youden. CONCLUSION Using 8.0 cm rather than 12.0 cm increased the detection of moderate-severe polyhydramnios to 100% with a false positive rate under 5%. For those utilizing DVP for amniotic fluid evaluation, identification of a DVP ≥ 8.0 cm should prompt further evaluation with complete AFI.
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Stanfield VR, Chauhan SP, Huntley BJF. References supporting recommendations in American College of Obstetricians and Gynecologists obstetrical practice bulletins. Am J Obstet Gynecol MFM 2022; 4:100669. [PMID: 35644524 DOI: 10.1016/j.ajogmf.2022.100669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/06/2022] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
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Pineles BL, Mendez-Figueroa H, Chauhan SP. Diagnosis of fetal growth restriction in a cohort of small-for-gestational-age neonates at term: neonatal and maternal outcomes. Am J Obstet Gynecol MFM 2022; 4:100672. [PMID: 35667554 DOI: 10.1016/j.ajogmf.2022.100672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Small-for-gestational-age neonates (birthweight of <10th percentile for gestational age) are significantly more likely to have multiple adverse outcomes than appropriate-for-gestational-age neonates (birthweight of 10th-90th percentile). Most small-for-gestational-age neonates are undetected during pregnancy (ie, not diagnosed as fetal growth restriction), but the sequela of being undetected remains uncertain. OBJECTIVE The primary objective of this study was to compare the composite neonatal adverse outcomes among singleton pregnancies that were at least 37 weeks and delivered small-for-gestational-age neonates, which were diagnosed as either fetal growth restriction during pregnancy (detected small for gestational age) or not (undetected small for gestational age). STUDY DESIGN This was a secondary analysis of a retrospective cohort, the Consortium for Safe Labor. Singleton births at 37.0 to 41.6 weeks of gestation without congenital anomalies born small for gestational age were included in the analysis. The primary outcome was the rate of composite neonatal adverse outcome, defined as any of the following: Apgar score of <5 at 5 minutes, cardiopulmonary resuscitation at birth, respiratory distress syndrome, continuous positive airway pressure, mechanical ventilation, neonatal seizures, hypoxic-ischemic encephalopathy or diagnosis of asphyxia, intraventricular hemorrhage, necrotizing enterocolitis, neonatal sepsis, or fetal or neonatal death. The secondary outcome was the rate of composite maternal adverse outcome, which included any of the following: postpartum hemorrhage, peripartum infection, thromboembolism, hysterectomy, uterine rupture, eclampsia, intensive care unit admission, or maternal death. Small for gestational age with a prenatal diagnosis of fetal growth restriction (detected small for gestational age) was compared with small for gestational age without a prenatal diagnosis of fetal growth restriction (undetected small for gestational age). Multivariate logistic regression models were used to compare groups. A P value of <.05 was considered statistically significant. Gestational age-specific risks of composite neonatal adverse outcome and perinatal death were computed for each week of gestation among ongoing pregnancies. RESULTS Of the 228,438 deliveries in the Consortium for Safe Labor, 18,607 (8.1%) met the inclusion criteria. Among these deliveries, 17,689 (95.0%) were undetected small for gestational age, and 918 (5.0%) were detected small for gestational age. The overall rate of composite neonatal adverse outcome was 3.0%. Moreover, the rate of composite neonatal adverse outcome was similar between undetected small for gestational age and detected small for gestational age (3.0% vs 3.9%, respectively; adjusted odds ratio, 1.33; 95% confidence interval, 0.88-2.00). Some components of the composite-respiratory distress syndrome, mechanical ventilation, and necrotizing enterocolitis-were significantly higher among undetected small for gestational age than among detected small for gestational age. The overall rate of composite maternal adverse outcome was 6.2%. The rate of composite maternal adverse outcome between undetected small for gestational age and detected small for gestational age (6.2% vs 5.1%, respectively; adjusted odds ratio, 0.84; 95% confidence interval, 0.60-1.18) was similar. In gestational age-specific comparisons of composite neonatal adverse outcome, no difference was found between the undetected small-for-gestational-age group and the detected small-for-gestational-age group except for in pregnancies >41 weeks. In pregnancies at 41.0 to 41.6 weeks, the rate of composite neonatal adverse outcome was significantly greater in detected small for gestational age than in undetected small for gestational age (10.0% vs 2.5%, respectively; P=.035). CONCLUSION Antenatal detection of small for gestational age was not associated with improved composite neonatal adverse outcomes, although some components of morbidity improved with detection. Maternal outcomes did not differ between detected small for gestational age and undetected small for gestational age.
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MESH Headings
- Birth Weight
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/epidemiology
- Female
- Fetal Growth Retardation/diagnosis
- Fetal Growth Retardation/epidemiology
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/etiology
- Infant, Small for Gestational Age
- Perinatal Death
- Pregnancy
- Respiratory Distress Syndrome, Newborn/diagnosis
- Respiratory Distress Syndrome, Newborn/epidemiology
- Respiratory Distress Syndrome, Newborn/etiology
- Retrospective Studies
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Chauhan SP, Gherman RB. Shoulder Dystocia: Challenging Basic Assumptions. Obstet Gynecol Clin North Am 2022; 49:491-500. [PMID: 36122981 DOI: 10.1016/j.ogc.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Most of our knowledge pertaining to this obstetric emergency has emanated from case reports and retrospective studies that have subsequently resulted in empirical management protocols. This article has identified the existence of large gaps in our clinical knowledge base regarding the prevention and resolution of shoulder dystocia, as well as its long-term sequelae. We have attempted to challenge current recommendations regarding whether prophylactic cesarean delivery should be performed based on estimated fetal weight alone or a prior history of shoulder dystocia, shoulder dystocia management techniques, what defines "excessive" traction, and the role of simulation training for all clinicians.
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Mendez-Figueroa H, Bicocca MJ, Bhalwal AB, Wagner SM, Chauhan SP, Fishel Bartal M. Preterm Cesarean Delivery for Nonreassuring Fetal Heart Rate Tracing: Risk Factors and Predictability of Adverse Outcomes. Eur J Obstet Gynecol Reprod Biol 2022; 276:207-212. [DOI: 10.1016/j.ejogrb.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/08/2022] [Accepted: 07/26/2022] [Indexed: 11/04/2022]
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