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Kominiarek MA, Espinal M, Cassimatis IR, Peace JM, Premkumar A, Toledo P, Shramuk M, Wafford EQ. Peripartum interventions for people with class III obesity: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101354. [PMID: 38494155 DOI: 10.1016/j.ajogmf.2024.101354] [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] [Received: 11/17/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE This study aimed to identify evidence-based peripartum interventions for people with a body mass index ≥40 kg/m2. DATA SOURCES PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions. STUDY ELIGIBILITY CRITERIA Cohort and randomized controlled trials that implemented an intervention and evaluated peripartum outcomes of people with a body mass index ≥40 kg/m2 were included. The primary outcome depended on the intervention but was commonly related to wound morbidity after cesarean delivery (ie, infection, separation, hematoma). METHODS Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios with 95% confidence intervals and heterogeneity (I2 statistics) were reported. RESULTS Of 20,301 studies screened, 30 studies (17 cohort and 13 randomized controlled trials) encompassing 10 types of interventions were included. The interventions included delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, 6 types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared with planned vaginal delivery did not improve outcomes according to 3 cohort studies. One cohort study compared 3 g with 2 g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 randomized controlled trials, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort and 6 randomized controlled trials) met the inclusion criteria for the meta-analysis. Two randomized controlled trials compared subcuticular closure with suture vs staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; risk ratio, 1.09; 95% confidence interval, 0.75-1.59; I2=9%). Prophylactic negative-pressure wound therapy was compared with standard dressing in 4 cohort and 4 randomized controlled trials, which found no differences in wound morbidity (cohort n=2200; risk ratio, 1.19; 95% confidence interval, 0.88-1.63; I2=66.1%) or surgical site infections (randomized controlled trial n=1262; risk ratio, 0.90; 95% confidence interval, 0.63-1.29; I2=0). CONCLUSION Few studies address interventions in people with a body mass index ≥40 kg/m2, and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic negative-pressure wound therapy after cesarean delivery for people with a body mass index ≥40 kg/m2.
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Affiliation(s)
- Michelle A Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Kominiarek and Espinal).
| | - Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Kominiarek and Espinal)
| | - Irina R Cassimatis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Dr Cassimatis)
| | - Jack M Peace
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (Dr Peace)
| | - Ashish Premkumar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL (Dr Premkumar)
| | - Paloma Toledo
- Department of Anesthesiology, University of Miami, Miami, FL (Dr Toledo)
| | - Maxwell Shramuk
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (Mr Shramuk)
| | - Eileen Q Wafford
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL (Ms Wafford)
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D'Souza R, Horyn I, Jacob CE, Zaffar N, Horn D, Maxwell C. Birth outcomes in women with body mass index of 40 kg/m 2 or greater stratified by planned and actual mode of birth: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 100:200-209. [PMID: 32997801 DOI: 10.1111/aogs.14011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/19/2020] [Accepted: 09/22/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Pregnant women with a body mass index (BMI) ≥40 kg/m2 are at an increased risk of requiring planned- and unplanned cesarean deliveries (CD). The aim of this systematic review is to compare outcomes in women with BMI ≥ 40 kg/m2 based on planned and actual mode of birth. MATERIAL AND METHODS Five databases were searched for English and French-language publications until February 2019, and all studies reporting on delivery outcomes in women with BMI ≥ 40 kg/m2 , stratified by planned and actual mode of birth, were included. Risk-of-bias was assessed using the Newcastle-Ottawa Scale. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis. RESULTS Ten observational studies were included. Anticipated vaginal birth vs planned CD (5 studies, n = 2216) was associated with higher risk for postpartum hemorrhage (13.0% vs 4.1%, P < .001, numbers needed to harm (NNH = 11), I2 = 0%) but lower risk for wound complications (7.6% vs 14.5%, P < .001, numbers needed to treat (NNT = 15), I2 = 58.3%). Planned trial of labor vs repeat CD (3 studies, n = 4144) was associated with higher risk for uterine dehiscence (0.94% vs 0.42%, P = .04, NNH = 200, I2 = 0%), endometritis (5.1% vs 2.2%, P < .001, NNH = 35, I2 = 0%), prolonged hospitalization (one study, 30.3% vs 26.0%, P = .003, NNH = 23), low five-minute Apgar scores (4.9% vs 1.7%, RR 2.95 (2.03, 4.28), NNH = 30, I2 = 0%) and birth trauma (1.1% vs 0.2%, P < .001, NNH = 111, I2 = 0%). Successful vaginal birth vs intrapartum CD (n = 3625) was associated with lower risk of postpartum hemorrhage (15.1% vs 70%, P < .001, NNT = 2, I2 = 0%), wound complications (one study, 0% vs 4.4%, P = .007, NNT = 23), prolonged hospitalization (one study, 1.9% vs 6.7%, 0.04, NNT = 21) and low five-minute Apgar scores (one study, 1.0% vs 5.6%, P = .03, NNT = 22), but more birth trauma (5.9% vs 0.6%, P = .005, NNH = 19, I2 = 0%). Compared groups had dissimilar demographic characteristics. Although studies scored 6-7/9 on risk-of-bias assessment, they were at high-risk for confounding by indication. CONCLUSIONS Evidence from observational studies suggests clinical equipoise regarding the optimal mode of delivery in women with BMI ≥ 40 kg/m2 and no prior CD. This question is best answered by a randomized trial. Based on an unplanned subgroup analysis, for women with BMI ≥ 40 kg/m2 and prior CD, repeat CD may be associated with better clinical outcomes.
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Affiliation(s)
- Rohan D'Souza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.,Lunenfeld Tanenbaum Research Institute, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | | | - Claude-Emilie Jacob
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Montreal, Montreal, QC, Canada
| | - Nusrat Zaffar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Daphne Horn
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Cynthia Maxwell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
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Tzadikevitch-Geffen K, Melamed N, Aviram A, Sprague AE, Maxwell C, Barrett J, Mei-Dan E. Neonatal outcome by planned mode of delivery in women with a body mass index of 35 or more: a retrospective cohort study. BJOG 2020; 128:900-906. [PMID: 32790132 DOI: 10.1111/1471-0528.16467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m2 who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS). DESIGN A retrospective cohort study of births between April 2012 and March 2014. SETTING A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada. POPULATION A cohort of 8752 women with a BMI of ≥35 kg/m2 who had a singleton birth at 38-42 weeks of gestation. METHODS Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS. MAIN OUTCOME MEASURE A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5-minute Apgar score of <7 or umbilical artery pH of <7.1. RESULTS During the study period, 8433 (96.4%) women had a trial of labour and 319 (3.6%) had a planned CS. Intrapartum CS was performed in 1644 (19.5%) cases. There was no association between planned mode of delivery and the primary outcome (aOR 0.80, 95% CI 0.59-1.07). The primary outcome was lower among women who had a successful trial of labour (aOR 0.67, 95% CI 0.50-0.91) and was higher among women who had a failed trial of labour (aOR 1.74, 95% CI 1.21-2.48), compared with women who underwent a planned CS. CONCLUSIONS In women with a BMI of ≥35 kg/m2 at a gestational age of 38-42 weeks, neonatal outcomes are comparable between planned vaginal delivery and planned CS, although a failed trial of labour is at risk of adverse neonatal outcome. TWEETABLE ABSTRACT Neonatal outcomes are not affected by planned mode of delivery in women who are obese, with a BMI of ≥35 kg/m2 .
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Affiliation(s)
- K Tzadikevitch-Geffen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - N Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - A Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - A E Sprague
- Better Outcomes Registry & Network Ontario, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - C Maxwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jfr Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - E Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
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McGuire B, Lucas DN. Planning the obstetric airway. Anaesthesia 2020; 75:852-855. [DOI: 10.1111/anae.14987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 12/16/2022]
Affiliation(s)
- B. McGuire
- Department of Anaesthesia Ninewells Hospital Dundee UK
| | - D. N. Lucas
- Department of Anaesthesia Northwick Park Hospital Middlesex UK
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Parambi A, Davies‐Tuck M, Palmer KR. Comparison of maternal and perinatal outcomes in women with super obesity based on planned mode of delivery. Aust N Z J Obstet Gynaecol 2018; 59:387-393. [DOI: 10.1111/ajo.12870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/30/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Anisha Parambi
- Department of Obstetrics and GynaecologyMonash Health Melbourne Australia
| | | | - Kirsten R. Palmer
- Department of Obstetrics and GynaecologyMonash Health Melbourne Australia
- Department of Obstetrics and GynaecologyMonash University Melbourne Australia
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Borghesi Y, Labreuche J, Duhamel A, Pigeyre M, Deruelle P. Risk of cesarean delivery among pregnant women with class III obesity. Int J Gynaecol Obstet 2016; 136:168-174. [DOI: 10.1002/ijgo.12032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/09/2016] [Accepted: 11/02/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Yves Borghesi
- Department of Obstetrics; Centre Hospitalier Universitaire de Lille; Lille France
| | - Julien Labreuche
- Equipe d'Accueil 2694; Santé publique: épidémiologie et qualité des soins; Université de Lille; Centre Hospitalier Universitaire de Lille; Lille France
| | - Alain Duhamel
- Equipe d'Accueil 2694; Santé publique: épidémiologie et qualité des soins; Université de Lille; Centre Hospitalier Universitaire de Lille; Lille France
| | - Marie Pigeyre
- Department of Nutrition; Centre Hospitalier Universitaire de Lille; Lille France
- Unit 1190-European Genomic Institute of Diabetes; Université de Lille; Centre Hospitalier Universitaire de Lille; Lille France
| | - Philippe Deruelle
- Department of Obstetrics; Centre Hospitalier Universitaire de Lille; Lille France
- Equipe d'Accueil EA 4489; Université de Lille; Environnement Périnatal et Santé; Lille France
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Pregnancy Outcomes Among Obese Women and Their Offspring by Attempted Mode of Delivery. Obstet Gynecol 2016; 126:987-993. [PMID: 26444123 DOI: 10.1097/aog.0000000000001084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare maternal and neonatal morbidities among obese women and their offspring by attempted delivery approach. METHODS We performed a retrospective cohort study of 47,372 obese women at delivery (body mass index 30 or greater) eligible for vaginal delivery who were carrying singleton vertex fetuses at 37 weeks of gestation or greater. Prior cesarean delivery, congenital anomalies, and antepartum stillbirth were exclusion criteria. We analyzed outcomes by attempted delivery route and stratified by parity. The composite maternal outcome included intensive care admission, death, hemorrhage, transfusion, or thromboembolism. The neonatal composite included intensive care unit admission, death, seizure, ventilator use, birth injury, or asphyxia. Adjusted relative risks (RRs) and 95% confidence intervals (CIs) were calculated using Poisson regression. RESULTS Among nulliparous women attempting vaginal delivery (n=15,268), the success rate was 72.6% and among parous women (n=23,426), it was 93.7%. The maternal composite outcome rate was not statistically higher among nulliparous women (7.7% compared with 4.2% [adjusted RR 1.58, 95% CI 0.96-2.59]) but it was among parous women (7.6% compared with 2.5% [adjusted RR 2.45, 95% CI 1.23-4.90]) attempting vaginal delivery related to hemorrhage, blood transfusion, or both. In contrast, the neonatal composite outcome rate was lower in parous women (6.0% compared with 11.6% [adjusted RR 0.65, 95% CI 0.51-0.83]) but not in nulliparous women (10.2% compared with 12.4% [adjusted RR 0.91, 95% CI 0.74-1.12]) parous. CONCLUSION In obese nulliparous women, attempted vaginal delivery was not associated with increased composite maternal or neonatal morbidity. In obese parous women, attempted vaginal delivery was associated with increased composite maternal morbidity and lower composite neonatal morbidity. LEVEL OF EVIDENCE II.
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Sullivan EA, Dickinson JE, Vaughan GA, Peek MJ, Ellwood D, Homer CSE, Knight M, McLintock C, Wang A, Pollock W, Jackson Pulver L, Li Z, Javid N, Denney-Wilson E, Callaway L. Maternal super-obesity and perinatal outcomes in Australia: a national population-based cohort study. BMC Pregnancy Childbirth 2015; 15:322. [PMID: 26628074 PMCID: PMC4667490 DOI: 10.1186/s12884-015-0693-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 10/05/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Super-obesity is associated with significantly elevated rates of obstetric complications, adverse perinatal outcomes and interventions. The purpose of this study was to determine the prevalence, risk factors, management and perinatal outcomes of super-obese women giving birth in Australia. METHODS A national population-based cohort study. Super-obese pregnant women (body mass index (BMI) >50 kg/m(2) or weight >140 kg) who gave birth between January 1 and October 31, 2010 and a comparison cohort were identified using the Australasian Maternity Outcomes Surveillance System (AMOSS). Outcomes included maternal and perinatal morbidity and mortality. Prevalence estimates calculated with 95% confidence intervals (CIs). Adjusted odds ratios (ORs) were calculated using multivariable logistic regression. RESULTS 370 super-obese women with a median BMI of 52.8 kg/m(2) (range 40.9-79.9 kg/m(2)) and prevalence of 2.1 per 1 000 women giving birth (95% CI: 1.96-2.40). Super-obese women were significantly more likely to be public patients (96.2%), smoke (23.8%) and be socio-economically disadvantaged (36.2%). Compared with other women, super-obese women had a significantly higher risk for obstetric (adjusted odds ratio (AOR) 2.42, 95% CI: 1.77-3.29) and medical (AOR: 2.89, 95% CI: 2.64-4.11) complications during pregnancy, birth by caesarean section (51.6%) and admission to special care (HDU/ICU) (6.2%). The 372 babies born to 365 super-obese women with outcomes known had significantly higher rates of birthweight ≥ 4500 g (AOR 19.94, 95 % CI: 6.81-58.36), hospital transfer (AOR 3.81, 95 % CI: 1.93-7.55) and admission to Neonatal Intensive Care Unit (NICU) (AOR 1.83, 95% CI: 1.27-2.65) compared to babies of the comparison group, but not prematurity (10.5% versus 9.2%) or perinatal mortality (11.0 (95% CI: 4.3-28.0) versus 6.6 (95% CI: 2.6- 16.8) per 1 000 singleton births). CONCLUSIONS Super-obesity in pregnancy in Australia is associated with increased rates of pregnancy and birth complications, and with social disadvantage. There is an urgent need to further address risk factors leading to super-obesity among pregnant women and for maternity services to better address pre-pregnancy and pregnancy care to reduce associated inequalities in perinatal outcomes.
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Affiliation(s)
- Elizabeth A Sullivan
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
- School of Women's and Children's Health, The University of New South Wales, Sydney, Australia.
| | - Jan E Dickinson
- School of Women's and Infants' Health, The University of Western Australia, Perth, Australia.
| | - Geraldine A Vaughan
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
| | - Michael J Peek
- Department of Obstetrics and Gynaecology Medical School College of Medicine, Biology and Environment, The Australian National University, Canberra, Australia.
- Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra, Australia.
| | - David Ellwood
- School of Medicine, Griffith University, Queensland, Australia.
- Gold Coast University Hospital, Queensland, Australia.
| | - Caroline S E Homer
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom.
| | - Claire McLintock
- Obstetrics and Gynaecology, National Women's Health, Auckland City Hospital, Auckland, New Zealand.
| | - Alex Wang
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
| | - Wendy Pollock
- Judith Lumley Centre, La Trobe University, Melbourne, Australia.
- Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Lisa Jackson Pulver
- Muru Marri Indigenous Health Unit, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
| | - Zhuoyang Li
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
| | - Nasrin Javid
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
| | - Elizabeth Denney-Wilson
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway NSW, 2007, Sydney, Australia.
| | - Leonie Callaway
- Royal Brisbane and Women's Hospital, Brisbane, Australia.
- School of Medicine, The University of Queensland, Brisbane, Australia.
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Nair M, Soffer K, Noor N, Knight M, Griffiths M. Selected maternal morbidities in women with a prior caesarean delivery planning vaginal birth or elective repeat caesarean section: a retrospective cohort analysis using data from the UK Obstetric Surveillance System. BMJ Open 2015; 5:e007434. [PMID: 26038358 PMCID: PMC4458629 DOI: 10.1136/bmjopen-2014-007434] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To conduct a secondary analysis of data from the UK Obstetric Surveillance System (UKOSS) to estimate the rates of specific maternal risks associated with planned vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS). DESIGN A retrospective cohort analysis using UKOSS data from 4 studies conducted between 2005 and 2012. SETTING All hospitals with consultant-led maternity units in the UK. POPULATION Pregnant women who had a previous caesarean section. METHOD Women who had undergone a previous caesarean section were divided into 2 exposure groups: planned VBAC and ERCS. We calculated the incidence of each of the 4 outcomes of interest with 95% CIs for the 2 exposure groups using proxy denominators (total estimated VBAC and ERCS maternities in a given year). Incidences were compared between groups using χ(2) test or Fisher's exact test and risk ratios with 95% CI. MAIN OUTCOME MEASURES Severe maternal morbidities: peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation. RESULTS The risks of all complications examined in both groups were low. The rates of peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation were not significantly different between the 2 groups in absolute or relative terms. CONCLUSIONS While the risk of uterine rupture in the VBAC and ERCS groups is well understood, this national study did not demonstrate any other clear differences in the outcomes we examined. The absolute and relative risks of maternal complications were small in both groups. Large epidemiological studies could further help to assess whether the incidence of these rare outcomes would significantly differ between the VBAC and ERCS groups if a larger number of cases were to be examined. In the interim, this study provides important information to help pregnant women in their decision-making process.
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Affiliation(s)
- Manisha Nair
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kate Soffer
- Department of Obstetrics & Gynaecology, Luton and Dunstable University Hospital, Luton, UK
| | - Nudrat Noor
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Malcolm Griffiths
- Department of Obstetrics & Gynaecology, Luton and Dunstable University Hospital, Luton, UK
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Carassou-Maillan A, Mulliez A, Curinier S, Houlle C, Canis M, Lemery D, Gallot D. [Predictors of failed trial of labor in obese nulliparous]. ACTA ACUST UNITED AC 2014; 42:755-60. [PMID: 25442822 DOI: 10.1016/j.gyobfe.2014.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/26/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify predictors of failed trial of labour (TOL) in obese nulliparous at term. PATIENTS AND METHODS Retrospective study about 213 nulliparous with a body mass index (BMI) greater than 30kg/m(2) who delivered a vertex singleton after 37 weeks of gestation (WG). Planned caesarean sections were excluded. Maternal, sonographic, per-partum and neonatal characteristics were analyzed according to the mode of entry into labor and delivery route. Univariate and multivariate logistic regression analysis were performed. RESULTS The cesarean delivery rate was 28%. Induction of labor (aOR=4.3 [1.8-10.7]), prolonged pregnancy (aOR=10.8 [1.7-67.6]), macrosomia (aOR=5.6 [1.1-27.3]), meconium-stained amniotic fluid (aOR: 2.57 [1.03-6.42]), use of trinitrine (aOR=5.5 [1.39-21.6]) and neonatal head circumference greater than 35cm (aOR=3.1 [1.2-8.0]) were predictors of failed TOL. There was no significant correlation between failed TOL and preconceptional BMI. Univariate analysis revealed an association between excessive weight gain and failed TOL. DISCUSSION AND CONCLUSION Predictors of failed TOL are the same in obese and non-obese women. Preconceptional BMI does not predict failed TOL in this nulliparous obese population.
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Affiliation(s)
- A Carassou-Maillan
- Pôle gynéco-obstétrique-reproduction humaine, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - A Mulliez
- Département d'information médicale, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - S Curinier
- Pôle gynéco-obstétrique-reproduction humaine, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - C Houlle
- Pôle gynéco-obstétrique-reproduction humaine, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - M Canis
- Pôle gynéco-obstétrique-reproduction humaine, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - D Lemery
- Pôle gynéco-obstétrique-reproduction humaine, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - D Gallot
- Pôle gynéco-obstétrique-reproduction humaine, CHU Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France; R2D2-EA7281, faculté de médecine, université d'Auvergne, place Henri-Dunant, 63000 Clermont-Ferrand, France.
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Kobayashi N, Lim BH. Induction of labour and intrapartum care in obese women. Best Pract Res Clin Obstet Gynaecol 2014; 29:394-405. [PMID: 25441151 DOI: 10.1016/j.bpobgyn.2014.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 07/23/2014] [Indexed: 10/24/2022]
Abstract
The rising incidence of obesity in pregnancy has a significant impact on the provision of health services around the world. Due to the pathophysiological processes associated with the condition, the obese pregnant woman is at increased risks of induction of labour, caesarean section, post-partum haemorrhage, infection, longer hospital stay, macrosomia and higher perinatal morbidity and mortality. Labour is more likely to be prolonged and dysfunctional, leading to the requirements for higher doses of oxytocin and increased risks of operative deliveries and morbidity. A multidisciplinary approach to the planning of antenatal, intrapartum and postnatal care is vital to ensure a safe outcome for the obese pregnant woman and her baby. The need for supervision and attendance by senior obstetric staff is increased, emphasising the need to identify the appropriate place of birth for this high-risk group of women, placing a significant strain on the resources of health-care providers.
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Affiliation(s)
- Namiko Kobayashi
- Department of Obstetrics and Gynaecology, Royal Hobart Hospital, Liverpool Street, Hobart, TAS 7000, Australia.
| | - Boon H Lim
- Department of Obstetrics and Gynaecology, Royal Hobart Hospital, Liverpool Street, Hobart, TAS 7000, Australia.
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McAlister BS. A case study of maternal response to the implied antepartum diagnosis of inevitable labor dystocia. J Obstet Gynecol Neonatal Nurs 2013; 42:138-47. [PMID: 23323692 DOI: 10.1111/1552-6909.12005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Two pregnant women, one obese and one of extremely small stature, received antepartum recommendations from their health care providers to schedule cesarean births. In response, both women sought providers who would support their desire to attempt vaginal birth. The women's perspectives on their birth experiences along with the pertinent medical record data from their pregnancies and births provide a reminder about the inherent normalcy of birth amid the current culture of interventive obstetrical practices.
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Affiliation(s)
- Barbara S McAlister
- Texas Woman's University, The Houston J. and Florence A. Doswell College of Nursing, 5500 Southwestern Medical Avenue, Dallas, TX 75235, USA.
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Halliday LE, Peek MJ, Ellwood DA, Homer C, Knight M, McLintock C, Jackson-Pulver L, Sullivan EA. The Australasian Maternity Outcomes Surveillance System: an evaluation of stakeholder engagement, usefulness, simplicity, acceptability, data quality and stability. Aust N Z J Obstet Gynaecol 2012; 53:152-7. [PMID: 23216366 DOI: 10.1111/ajo.12020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 10/07/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Australasian Maternity Outcomes Surveillance System (AMOSS) conducts active, prospective surveillance of severe maternal conditions in Australia and New Zealand (ANZ). AMOSS captures greater than 96% of all births, and utilises an online, active case-based negative reporting system. AIM To evaluate AMOSS using the United States Centres for Disease Control (MMWR 2001; 50 (RR13): 1-35.) surveillance system evaluation framework. METHODS Data were gathered using multiple methods, including an anonymous online survey administered to 353 AMOSS data collectors, in addition to review of case data received during 2009-2011, documented records of project board and advisory group meeting minutes, publications, annual reports and the AMOSS database. RESULTS AMOSS is a research system characterised by its simplicity and efficiency. The socio-demographic, risk factor and severe morbidity clinical data collected on rare conditions are not duplicated in other routine data systems. AMOSS is functioning well and has sustained buy-in from clinicians, stakeholders and consumers and a high level of acceptability to data collectors in ANZ maternity units. CONCLUSIONS AMOSS is the only existing national system of surveillance for rare and severe maternal conditions in ANZ and therefore serves an important function, utilising data collected from reliable sources, in an effective, efficient and timely way.
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Affiliation(s)
- Lesley E Halliday
- School of Public Health and Community Medicine, UNSW Medicine, University of NSW, Sydney, NSW, Australia.
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Hull K, Montgomery KS, Vireday P, Kendall-Tackett K. Maternal obesity from all sides. J Perinat Educ 2012; 20:226-32. [PMID: 22942626 DOI: 10.1891/1058-1243.20.4.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This column features excerpts from a recent series of articles from the Lamaze International research blog, Science & Sensibility. The eight-part series examined the issue of maternal obesity from various perspectives, incorporating writings from Kimmelin Hull, a physician assistant, a Lamaze Certified Childbirth Educator, and the community manager of Science & Sensibility; Kristen Montgomery, a nursing professor at the University of North Carolina-Charlotte; Pamela Vireday, a childbirth educator and blogger; and Kathleen Kendall-Tackett, a health psychologist, lactation consultant, and writer/speaker. The authors of the blog series, titled "Maternal Obesity from All Sides," reviewed current research about risks associated with maternal obesity as well as the humanistic issues and lived experiences of pregnant women of size.
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Soltanifar S, Russell R. The National Institute for Health and Clinical Excellence (NICE) guidelines for caesarean section, 2011 update: implications for the anaesthetist. Int J Obstet Anesth 2012; 21:264-72. [PMID: 22541846 DOI: 10.1016/j.ijoa.2012.03.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 03/26/2012] [Indexed: 10/28/2022]
Abstract
In 2004 the first National Institute for Health and Clinical Excellence guidelines on caesarean section were published with the aim of providing evidence-based recommendations for best practice. With the publication of new evidence, the guidelines have been revised with the second edition released in 2011. This review highlights the changes that have been made which are of specific relevance to obstetric anaesthetists including planned caesarean section compared with vaginal birth in healthy women with an uncomplicated pregnancy; management of the morbidly adherent placenta; mother-to-child transmission of maternal infections; maternal request for caesarean section; decision-to-delivery interval for emergency caesarean section; timing of antibiotic administration and childbirth after caesarean section.
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Affiliation(s)
- S Soltanifar
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
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Abstract
The prevalence of obesity in pregnancy is rising exponentially; about 15–20% of pregnant women now enter pregnancy with a BMI which would define them as obese. This paper provides a review of the strong links between obesity and adverse pregnancy outcome which operate across a range of pregnancy complications. For example, obesity is associated with an increased risk of maternal mortality, gestational diabetes mellitus, thromboembolism, pre-eclampsia and postpartum haemorrhage. Obesity also complicates operative delivery; it makes operative delivery more difficult, increases complications and paradoxically increases the need for operative delivery. The risk of the majority of these complications is amplified by excess weight gain in pregnancy and increases in proportion to the degree of obesity, for example, women with extreme obesity have OR of 7·89 for gestational diabetes and 3·84 for postpartum haemorrhage compared to their lean counterparts. The consequences of maternal obesity do not stop once the baby is born. Maternal obesity programmes a variety of long-term adverse outcomes, including obesity in the offspring at adulthood. Such an effect is mediated at least in part via high birthweight; a recent study has suggested that the odds of adult obesity are two-fold greater in babies weighing more than 4 kg at birth. The mechanism by which obesity causes adverse pregnancy outcome is uncertain. This paper reviews the emerging evidence that hyperglycaemia and insulin resistance may both play a role: the links between hyperglycaemia in pregnancy and both increased birthweight and insulin resistance have been demonstrated in two large studies. Lastly, we discuss the nature and rationale for possible intervention strategies in obese pregnant women.
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