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Stavridis K, Pisimisi M, Triantafyllidou O, Kalampokas T, Vlahos N, Kastora SL. The association of assisted reproductive technology with fetal malpresentation: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2024; 37:2313143. [PMID: 38316567 DOI: 10.1080/14767058.2024.2313143] [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: 10/21/2023] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Since its introduction, assisted reproductive technology (ART) has developed into a common clinical practice around the world; yet it still raises a lot of questions. Throughout time, many researchers have investigated its association with several obstetric incidences and its consequences on perinatal outcomes. The aim of the current meta-analysis was to estimate the correlation between ART procedures and malpresentation of the fetus in singleton pregnancies. METHODS The study was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) guidelines and prospectively registered under the PROSPERO database (CRD42023458084). Five databases (Embase, MEDLINE®, APA PsycInfo, Global Health, Health Management Information Consortium (HMIC)) and two additional sources were searched from inception to 31 May 2023. Quality of the included studies was assessed using the ROBINS-1 scale, whilst quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. Summative and subgroup data as well as heterogeneity were generated by the Cochrane platform RevMan Web. RESULTS Overall, 11 studies were included in the study with a total of 3,360,134 deliveries. Results indicate a higher risk of malpresentation at delivery in fetuses conceived through ART than those conceived naturally (RR: 1.50, (95% confidence interval (CI):1.30, 1.73)). This risk decreased when adjustments for potential confounders were applied (RR = 1.12, 95% CI 1.02, 1.23). CONCLUSIONS Based on observational studies, this meta-analysis indicated that singleton pregnancies conceived through ART are associated with higher risk of malpresentation than those conceived naturally, albeit the difference was lower when potential confounders were examined. Thus, future large studies are required to better understand possible reversible and irreversible factors of this relationship.
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Affiliation(s)
- Konstantinos Stavridis
- 2nd Department of Obstetrics and Gynecology, "Aretaieion" University Hospital, Athens, Greece
| | - Maria Pisimisi
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Olga Triantafyllidou
- 2nd Department of Obstetrics and Gynecology, "Aretaieion" University Hospital, Athens, Greece
| | - Theodoros Kalampokas
- 2nd Department of Obstetrics and Gynecology, "Aretaieion" University Hospital, Athens, Greece
| | - Nikolaos Vlahos
- 2nd Department of Obstetrics and Gynecology, "Aretaieion" University Hospital, Athens, Greece
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van Dijk MR, van der Marel AF, van Rheenen-Flach LE, Ganzevoort W, Moll E, Scheele F, Velzel J. YouTube as a Source of Patient Information on External Cephalic Version: Cross-Sectional Study. JMIR Form Res 2024; 8:e50087. [PMID: 38843520 PMCID: PMC11190616 DOI: 10.2196/50087] [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: 06/19/2023] [Revised: 11/14/2023] [Accepted: 04/25/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND With the global increase of cesarean deliveries, breech presentation is the third indication for elective cesarean delivery. Implementation of external cephalic version (ECV), in which the position of the baby is manipulated externally to prevent breech presentation at term, remains suboptimal. Increasing knowledge for caretakers and patients is beneficial in the uptake of ECV implementation. In recent decades, the internet has become the most important source of information for both patients and health care professionals. However, the use and availability of the internet also bring about concerns since the information is often not regulated or reviewed. Information needs to be understandable, correct, and easily obtainable for the patient. Owing to its global reach, YouTube has great potential to both hinder and support spreading medical information and can therefore be used as a tool for shared decision-making. OBJECTIVE The objective of this study was to investigate the available information on YouTube about ECV and assess the quality and usefulness of the information in the videos. METHODS A YouTube search was performed with five search terms and the first 35 results were selected for analysis. A quality assessment scale was developed to quantify the accuracy of medical information of each video. The main outcome measure was the usefulness score, dividing the videos into useful, slightly useful, and not useful categories. The source of upload was divided into five subcategories and two broad categories of medical or nonmedical. Secondary outcomes included audience engagement, misinformation, and encouraging or discouraging ECV. RESULTS Among the 70 videos, only 14% (n=10) were defined as useful. Every useful video was uploaded by educational channels or health care professionals and 80% (8/10) were derived from a medical source. Over half of the not useful videos were uploaded by birth attendants and vloggers. Videos uploaded by birth attendants scored the highest on audience engagement. The presence of misinformation was low across all groups. Two-thirds of the vloggers encouraged ECV to their viewers. CONCLUSIONS A minor percentage of videos about ECV on YouTube are considered useful. Vloggers often encourage their audience to opt for ECV. Videos with higher audience engagement had a lower usefulness score compared to videos with lower audience engagement. Sources from medically accurate videos should cooperate with sources with high audience engagement to contribute to the uptake of ECV by creating more awareness and a positive attitude of the procedure, thereby lowering the chance for a cesarean delivery due to breech presentation at term.
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Affiliation(s)
- Merle R van Dijk
- Department of Obstetrics and Gynecology, Onze Lieve Vrouwen Gasthuis, Amsterdam, Netherlands
| | | | | | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centre, Amsterdam, Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, Netherlands
| | - Etelka Moll
- Department of Obstetrics and Gynecology, Onze Lieve Vrouwen Gasthuis, Amsterdam, Netherlands
| | - Fedde Scheele
- Department of Obstetrics and Gynecology, Onze Lieve Vrouwen Gasthuis, Amsterdam, Netherlands
- Faculty of Science, Athena Institute, Vrije Universiteit, Amsterdam, Netherlands
| | - Joost Velzel
- Department of Obstetrics and Gynecology, Northwest Clinics, Alkmaar, Netherlands
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Londero AP, Xholli A, Massarotti C, Fruscalzo A, Cagnacci A. Factors influencing the effect of external cephalic version: a retrospective nationwide cohort analysis. Arch Gynecol Obstet 2023; 308:1127-1137. [PMID: 36068364 PMCID: PMC10435405 DOI: 10.1007/s00404-022-06763-2] [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: 04/19/2022] [Accepted: 08/19/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE This study aims to assess the factors associated with the success and failure rate of the external cephalic version (ECV) in breech fetuses. Secondary outcomes were fetal presentation in labor and mode of delivery. METHODS This cross-sectional study examined the live birth certificates from 2003 through 2020 from US states and territories that implemented the 2003 revision. A total of 149,671 singleton pregnancies with information about ECV success or failure were included. The outcome was ECV success/failure, while the exposures were possible factors associated with the outcome. RESULTS The successful ECV procedures were 96,137 (64.23%). Among the successful ECV procedures, the prevalence of spontaneous vaginal delivery was 71.63%. Among the failed ECV procedures, 24.74% had a cephalic presentation at delivery, but 63.11% of these pregnancies were delivered by cesarean section. Nulliparity, female sex, low fetal weight centile, high pre-pregnancy BMI, high BMI at delivery, and high maternal weight gain during pregnancy were associated with an increased ECV failure (p < 0.001). African American, American Indian and Alaska Native race categories were significant protective factors against ECV failure (p < 0.001). Maternal age had a U-shape risk profile, whereas younger maternal age (< 25 years) and old maternal age (> 40 years) were significant protective factors against ECV failure (p < 0.001). CONCLUSIONS A high prevalence of successful ECV procedures and subsequent spontaneous vaginal delivery were found. The present results found nulliparity, maternal race, maternal age, female fetal sex, low fetal weight, and maternal anthropometric features correlated to ECV results. These findings can potentially improve the knowledge about the factors involved in ECV, allowing more informed counseling to the women undergoing this procedure.
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Affiliation(s)
- Ambrogio P Londero
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, IRCCS-Policlinico San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, GE, Italy.
| | - Anjeza Xholli
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, IRCCS-Policlinico San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, GE, Italy
| | - Claudia Massarotti
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, IRCCS-Policlinico San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, GE, Italy
| | - Arrigo Fruscalzo
- Clinic of Obstetrics and Gynecology, University Hospital of Fribourg, Fribourg, Switzerland
| | - Angelo Cagnacci
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, IRCCS-Policlinico San Martino, Largo Rosanna Benzi, 10, 16132, Genoa, GE, Italy
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Londero AP, Massarotti C, Xholli A, Fruscalzo A, Cagnacci A. Assisted Reproductive Technology and Breech Delivery: A Nationwide Cohort Study in Singleton Pregnancies. J Pers Med 2023; 13:1144. [PMID: 37511757 PMCID: PMC10381648 DOI: 10.3390/jpm13071144] [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: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Since essential factors have changed in recent years in assisted reproduction technologies (ARTs), this study reassessed the association between ART and breech presentation. We primarily aimed to estimate the correlation between ART and breech at delivery. Secondary purposes were to evaluate the correlation between other subfertility treatments (OSTs) and breech and to assess possible confounding factors and temporal trends. This study investigated the 31,692,729 live birth certificates from US states and territories in the 2009-2020 period. The inclusion criteria were singleton births reporting the method of conception and the presentation at delivery. The outcome was the breech presentation at delivery, while the primary exposure was ART, the secondary exposure was OST, and the potential confounding factors from the literature were considered. ART (OR 2.32 CI.95 2.23-2.41) and OST (OR 1.79 CI.95 1.71-1.87) were independent and significant risk factors for breech at delivery (p < 0.001). This study confirmed breech presentation risk factors maternal age, nulliparity, tobacco smoke, a previous cesarean delivery (CD), neonatal female sex, gestational age, and birth weight. Black race and Hispanic origin were verified to be protective factors. We found breech prevalence among ART and OST to be stable during the study period. Meanwhile, newborn birth weight was increased, and the gap between breech and other presentations in ART was reduced. Our results indicate that singleton pregnancies conceived by ART or OST were associated with a higher risk of breech at delivery. Well-known risk factors for the breech presentation were also confirmed. Some of these factors can be modified by implementing interventions to reduce their prevalence (e.g., tobacco smoke and previous CD).
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Affiliation(s)
- Ambrogio P Londero
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DiNOGMI), University of Genoa, 16132 Genova, Italy
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Claudia Massarotti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DiNOGMI), University of Genoa, 16132 Genova, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Anjeza Xholli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Arrigo Fruscalzo
- Clinic of Obstetrics and Gynecology, HFR Fribourg, 1700 Fribourg, Switzerland
| | - Angelo Cagnacci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DiNOGMI), University of Genoa, 16132 Genova, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
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Chen AX, Hunt RW, Palmer KR, Bull CF, Callander EJ. The impact of assisted reproductive technology and ovulation induction on breech presentation: A whole of population‐based cohort study. Aust N Z J Obstet Gynaecol 2023. [DOI: 10.1111/ajo.13663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/15/2023] [Indexed: 03/29/2023]
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Fruscalzo A, Londero AP, Gerleve H, Riedel N, Jaspers KD. Short-term neonatal outcomes in vaginal breech delivery: Results of a retrospective single-centre study. Eur J Obstet Gynecol Reprod Biol 2022; 279:122-129. [DOI: 10.1016/j.ejogrb.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/06/2022] [Accepted: 10/25/2022] [Indexed: 11/25/2022]
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Hamaoui J, Stefaniak N, Segond H. The influence of vestibular system and fetal presentation on handedness, cognitive and motor development: A comparison between cephalic and breech presentation. Dev Sci 2022; 26:e13317. [PMID: 36029182 DOI: 10.1111/desc.13317] [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: 03/21/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022]
Abstract
Genetics are undoubtedly implicated in the ontogenesis of laterality. Nonetheless, environmental factors, such as the intrauterine environment, may also play a role in the development of functional and behavioral lateralization. The aim of this study was to test the Left-Otolithic Dominance Theory (LODT; Previc, 1991) by investigating a hypothetical developmental pattern where it is assumed that a breech presentation, which is putatively associated with a dysfunctional and weakly lateralized vestibular system, can lead to weak handedness and atypical development associated with language and motor difficulties. We used the ALSPAC cohort of children from 7 to 10 years of age to conduct our investigation. Our results failed to show an association between the vestibular system and fetal presentation, nor any influence of the latter on hand preference, hand performance, or language and motor development. Bayesian statistical analyses supported these findings. Contrary to our LODT-derived hypotheses, this study offers evidence that fetal presentation does not influence the vestibular system's lateralization and seems to be a poor indicator for handedness. Nonetheless, we found that another non-genetic factor, prematurity, could lead to atypical development of handedness. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jad Hamaoui
- Laboratoire de Psychologie des Cognitions (UR 4440), Université de Strasbourg, France
| | - Nicolas Stefaniak
- Laboratoire Cognition Santé Société (UR 6291), Université de Reims Champagne-Ardenne, France
| | - Hervé Segond
- Laboratoire de Psychologie des Cognitions (UR 4440), Université de Strasbourg, France
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Zhou Z, Wu J, Zhang G, Yang J. Spontaneous cephalic version and risk factors for persistent breech presentation: a longitudinal retrospective cohort study. J Matern Fetal Neonatal Med 2022; 35:9452-9459. [PMID: 35236215 DOI: 10.1080/14767058.2022.2041596] [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: 10/18/2022]
Abstract
AIMS To address the rate of spontaneous version in breech presentation until term and explore the risk factors for persistent breech presentation diagnosed by the second-trimester ultrasound examination. METHODS This is a retrospective cohort study of pregnant women with a singleton pregnancy who had their ultrasound examination conducted at the time of 22-26 weeks of gestation in the Guangzhou Women and Children's Medical Center. Cox regressions were applied to determine the strength of association between selected risk factors and persistent breech presentation. RESULTS Among 25,313 pregnant women eligible for analysis, the prevalence of breech presentation was 36.8% (9,306/25,313) at 22-26 weeks of gestation, 4.2% (376/8,876) of which would remain in the breech presentation at the onset of labor (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17-0.88). Multiparity (aOR, 0.39, 95% CI, 0.30-0.52) and longer gestational weeks at delivery (aOR, 0.50, 95% CI, 0.44-0.56) were associated with a lower risk of persistent breech presentation (PBP). Female fetus, lateral or fundal placenta, and known uterine malformation was each associated with an increased odd of 1.4 (aOR, 95% CI, 1.11-1.70), 2.4 (aOR, 95% CI,1.50-3.73), 3.1 (aOR, 95% CI, 1.71-5.53) and 8.7 (aOR, 95% CI, 3.84-19.84) times in the persistent breech presentation, respectively. CONCLUSION The prevalence of the breech presentation was 36.8% between 22 and 26 weeks of gestation, and approximately 4% would have been in the persistent breech presentation until the onset of labor. Higher educational attainment, multiparity and longer gestational weeks at delivery were significantly decreasing the risk of persistent breech presentation. While the pregnant women with age >40 years, female fetus, lateral or fundal placenta and known uterine malformation were associated increased risk of persistent breech presentation.
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Affiliation(s)
- Zehong Zhou
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinjuan Wu
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Guanglan Zhang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinying Yang
- Longgang District Maternal & Child Healthcare Hospital of Shenzhen City, Shenzhen, China
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Race and ethnicity are among the predisposing factors for fetal malpresentation at term. Am J Obstet Gynecol MFM 2021; 3:100405. [PMID: 34091061 DOI: 10.1016/j.ajogmf.2021.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/21/2021] [Accepted: 05/25/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Fetal malpresentation complicates approximately 3% to 4% of all term births. It requires special considerations for delivery and exposes the mother and neonate to obstetrical interventions and potential adverse outcomes, such as umbilical cord prolapse, head entrapment and birth trauma, hypoxic ischemic encephalopathy, cesarean delivery, and cesarean delivery-related complications. We set out to explore the maternal and fetal factors associated with noncephalic malpresentation at term, with specific interest on the impact of maternal race and ethnicity on fetal malpresentation. STUDY DESIGN This was a retrospective analysis of the Centers for Disease Control and Prevention Natality Live Birth database for the years from 2016 through 2018. All term, singleton deliveries for the following racial and ethnic groups were included: non-Hispanic White, non-Hispanic Black, Asian, and Hispanic. Race and ethnicity were assigned based on self-identification and individuals with >1 racial category were excluded from the analysis. Malpresentation was defined as a noncephalic presentation at term and included breech and transverse presentations. The malpresentation group included all noncephalic births and cephalic births that occurred following successful external cephalic version, whereas all other cephalic births served as controls. A multivariable logistic regression analysis was used to assess the rate of malpresentation, with adjustment for potential confounders including maternal age, race and ethnicity, parity, birthweight, fetal malformations, malformations of the central nervous system (CNS), and chromosomal anomalies. The results are displayed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Statistical significance was set at a P value of <.05. Institutional review board approval was not required because the de-identified data are publicly available through a data use agreement. RESULTS There were 9,692,203 term, singleton births during the study period. The malpresentation group included 354,689 births (3.66% of the total). The Table shows the rate of malpresentation for various maternal and fetal factors. We found a substantial racial and ethnic disparity in the malpresentation rates. Non-Hispanic White women had the highest malpresentation risk, whereas non-Hispanic Black women had the lowest risk (3.93% vs 2.81%; aOR, 1.38; 95% CI, 1.36-1.39). Hispanic and Asian women were also at increased risk for malpresentation when compared with non-Hispanic Black women (aOR, 1.30; 95% CI, 1.29-1.32 and aOR, 1.12; 95% CI, 1.10-1.14, respectively). In addition, several maternal and fetal conditions were noted to be associated with an increased risk for malpresentation at term, including older maternal age (aOR, 2.81; 95% CI, 2.74-2.88; for patients >40 years), nulliparity (aOR, 1.50; 95% CI, 1.48-1.51), low birthweight (aOR, 1.80; 95% CI, 1.77-1.83 for birthweight under 2500 g), and fetal malformations of the CNS and chromosomal anomalies (aOR, 3.53; 95% CI, 3.06-4.06 and aOR, 2.32; 95% CI, 2.05-2.63, respectively). CONCLUSION Based on a large US population database, we identified several maternal, fetal, and racial and ethnic factors that are associated with an increased rate of noncephalic malpresentation at term. Specifically, fetal CNS malformations, congenital or chromosomal anomalies, advanced maternal age, low birthweight, and nulliparity are risk factors for noncephalic presentation. Interestingly, non-Hispanic White women have the highest risk for malpresentation, whereas non-Hispanic Black women have the lowest risk. Previous publications found that low birthweight, advanced maternal age, nulliparity, and congenital fetal malformations are risk factors for malpresentation.1-3 Nonetheless, the current data available on race and ethnicity are sporadic, with limited reports suggesting that sub-Saharan ethnicity is associated with a lower rate of malpresentation2 and that White race is associated with a higher rate.4 We present a large-scale, nationwide US-based study to confirm the racial and ethnic disparity regarding malpresentation in the United States. This may be explained by the known variation in the shape of the bony birth canal in different racial and ethnic groups and populations from different geographic locations.5 Further investigation is needed to explore the racial and ethnic disparity described.
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Association of Persistent Breech Presentation With External Cephalic Version Success. Obstet Gynecol 2021; 137:258-262. [PMID: 33416280 DOI: 10.1097/aog.0000000000004231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate a possible correlation between a new variable-persistent breech presentation-and the success rate of external cephalic version (ECV). METHODS This was a retrospective study of ECVs performed from January 2008 through January 2019 in an Israeli tertiary care hospital. The study group included all pregnant women who underwent an ECV at or beyond 37 weeks of gestation. Persistent breech presentation was defined as persistent breech presentation during all ultrasound examinations performed between the anatomy scan at mid-pregnancy and the gestational week when ECV was attempted. Women in whom cephalic presentation was documented at least once on these ultrasound examinations were defined as not having persistent breech presentation. The primary outcome was defined as the success rate of ECV, and the secondary outcome was defined as the mode of delivery after a successful ECV. RESULTS We identified 1,271 women with breech presentation during the study period. They had undergone median of five (range 2-7) ultrasound examinations. External cephalic version was attempted in 684 women (53.8%), with a success rate of 61.5%. External cephalic version succeeded in 19.6% of those with persistent breech presentation (44/224) compared with 82.0% (377/460) of those without persistent breech presentation (P<.001). Ultimately, women with persistent breech presentation and successful ECV experienced a lower rate of vaginal delivery (27.3% vs 79%, P<.001), and a higher rate of instrumental (29% vs 13%, P<.001) and cesarean deliveries (43% vs 7%, P<.001) compared with the nonpersistent breech presentation group. The rate of noninstrumental vaginal delivery among women with persistent breech presentation, regardless of ECV, was 5.4%. CONCLUSION Women with persistent breech presentation experienced a high rate of ECV failure and a low rate of spontaneous vaginal delivery.
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Toijonen A, Heinonen S, Gissler M, Macharey G. Risk factors for adverse outcomes in vaginal preterm breech labor. Arch Gynecol Obstet 2021; 303:93-101. [PMID: 32767041 PMCID: PMC7854455 DOI: 10.1007/s00404-020-05731-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess the risk factors for adverse outcomes in attempted vaginal preterm breech deliveries. METHODS A retrospective case-control study, including 2312 preterm breech deliveries (24 + 0 to 36 + 6 gestational weeks) from 2004 to 2018 in Finland. The preterm breech fetuses with adverse outcomes born vaginally or by emergency cesarean section were compared with the fetuses without adverse outcomes with the same gestational age. A multivariable logistic regression analysis was used to calculate the risk factors for adverse outcomes (umbilical arterial pH below 7, 5-min Apgar score below 4, intrapartum stillbirth and neonatal death < 28 days of age). RESULTS Adverse outcome in vaginal preterm breech delivery was associated with maternal obesity (aOR 32.19, CI 2.97-348.65), smoking (aOR 2.29, CI 1.12-4.72), congenital anomalies (aOR 4.50, 1.56-12.96), preterm premature rupture of membranes (aOR 1.87, CI 1.00-3.49), oligohydramnios (28-32 weeks of gestation: aOR 6.50, CI 2.00-21.11, 33-36 weeks of gestation: aOR 19.06, CI 7.15-50.85), epidural anesthesia in vaginal birth (aOR 2.44, CI 1.19-5.01), and fetal growth below the second standard deviation (28-32 weeks of gestation: aOR 5.89, CI 1.00-34.74, 33-36 weeks of gestation: aOR 12.27, CI 2.81-53.66). CONCLUSION The study shows that for each subcategory of preterm birth, there are different risk factors for adverse neonatal outcomes in planned vaginal breech delivery. Due to the extraordinary increased risk of adverse outcomes, we would recommend a planned cesarean section in very preterm breech presentation (28 + 0 to 32 + 6 weeks) with severe maternal obesity, oligohydramnios, or fetal growth restriction and in moderate to late preterm breech presentation (33 + 0 to 36 + 6 weeks) with oligohydramnios or fetal growth restriction.
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Affiliation(s)
- Anna Toijonen
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland
| | - Mika Gissler
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Georg Macharey
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland
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Mu XH, Shi HX, An R. Anesthesia efficacy of bupivacaine in pregnant participants with breech presentation receiving external cephalic version: A protocol of systematic review of randomized controlled trials. Medicine (Baltimore) 2020; 99:e20786. [PMID: 32569223 PMCID: PMC7310873 DOI: 10.1097/md.0000000000020786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The objective of this study is to appraise the efficacy and safety of bupivacaine in pregnant participants with breech presentation (BP) receiving external cephalic version (ECV). METHODS The following electronic databases will be searched from the origin to the January 31, 2020: PUBMED, EMBASE, Cochrane Library, CINAHL, ACMD, PsycINFO, Scopus, OpenGrey, and China National Knowledge Infrastructure. No language and publication time limitations will be applied to all of them. Randomized controlled trials comparing bupivacaine to other interventions for pain relief in pregnant participants with BP undergoing ECV will be included in this study. Two authors will employ the selection of searched records, extraction of essential data from included RCTs, and risk of bias assessment for each eligible trail independently and respectively. Any doubts between 2 authors will be figured out by a third author through discussion. The risk of bias assessment will be judged using Cochrane risk of bias tool. The data pooling and analysis will be performed using RevMan 5.3 software. RESULTS This study will summarize the up-to-date high-quality evidence and will synthesis the outcome data from that evidence to explore the efficacy and safety of bupivacaine for pain relief in pregnant participants with BP undergoing ECV. CONCLUSION The findings of this study may present important guidance for patients, clinical practice, as well as health-policy makers regarding the utilization of bupivacaine for pain relief in pregnant participants with BP receiving ECV. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020164409.
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Affiliation(s)
- Xin-hua Mu
- Department of Anaesthesiology, The Affiliated Hospital of Inner Mongolia Medical University
| | - Hai-Xia Shi
- Department of Anaesthesiology, The Affiliated Hospital of Inner Mongolia Medical University
| | - Ran An
- Department of Emergency, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study. Arch Gynecol Obstet 2019; 301:393-403. [PMID: 31741046 PMCID: PMC7033046 DOI: 10.1007/s00404-019-05385-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/09/2019] [Indexed: 11/01/2022]
Abstract
PURPOSE To determine if the common risks for breech presentation at term labor are also eligible in preterm labor. METHODS A Finnish cross-sectional study included 737,788 singleton births (24-42 gestational weeks) during 2004-2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation. RESULTS The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24-27 to 2.5% in term pregnancies. In gestational weeks 24-27, preterm premature rupture of membranes was associated with breech presentation. In 28-31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32-36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile. CONCLUSION Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.
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Mattuizzi A. [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. ACTA ACUST UNITED AC 2019; 48:70-80. [PMID: 31682966 DOI: 10.1016/j.gofs.2019.10.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery. METHODS MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019. RESULTS Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3). CONCLUSION Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.
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Affiliation(s)
- A Mattuizzi
- Service de gynécologie-obstétrique et de médecine fœtale, centre Aliénor d'Aquitaine, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
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What if something goes wrong? A grounded theory study of parents’ decision-making processes around mode of breech birth at term gestation. Midwifery 2019; 78:114-122. [DOI: 10.1016/j.midw.2019.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 07/03/2019] [Accepted: 08/08/2019] [Indexed: 11/20/2022]
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Preterm Birth, Low Gestational Age, Low Birth Weight, Parity, and Other Determinants of Breech Presentation: Results from a Large Retrospective Population-Based Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9581439. [PMID: 31637259 PMCID: PMC6766171 DOI: 10.1155/2019/9581439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/04/2019] [Indexed: 11/28/2022]
Abstract
Aim of this study is to analyze determinants of breech presentation using information from two regional databases of Lombardy (Italy) including data on consecutive singleton breech and vertex deliveries occurred in the Region, between January 2010 and December 2015. Breech presentation occurred in 3.8% of all single deliveries. Main determinants of breech presentation at birth were: gestational age and birth weight (the lower, the higher the incidence of breech presentation), maternal age (the older the mother, the higher the risk of breech presentation), parity (the frequency of breech decreased with increasing parity) and previous cesarean section. Breech presentation resulted more frequent after assisted reproduction procedures.
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Bjellmo S, Hjelle S, Krebs L, Magnussen E, Vik T. Adherence to guidelines and suboptimal practice in term breech delivery with perinatal death- a population-based case-control study in Norway. BMC Pregnancy Childbirth 2019; 19:330. [PMID: 31500581 PMCID: PMC6734432 DOI: 10.1186/s12884-019-2464-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 08/20/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In a recent population-based study we reported excess risk of neonatal mortality associated with vaginal breech delivery. In this case-control study we examine whether deviations from Norwegian guidelines are more common in breech deliveries resulting in intrapartum or neonatal deaths than in breech deliveries where the offspring survives, and if these deaths are potentially avoidable. MATERIAL AND METHODS Case-control study completed as a perinatal audit including term breech deliveries of singleton without congenital anomalies in Norway from 1999 to 2015. Deliveries where the child died intrapartum or in the neonatal period were case deliveries. For each case, two control deliveries who survived were identified. All the included deliveries were reviewed by four obstetricians independently assessing if the deaths in the case group might have been avoided and if the management of the deviations from Norwegian guidelines were more common in case than in control deliveries. RESULTS Thirty-one case and 62 control deliveries were identified by the Medical Birth Registry of Norway. After exclusion of non-eligible deliveries, 22 case and 31 control deliveries were studied. Three case and two control deliveries were unplanned home deliveries, while all in-hospital deliveries were in line with national guidelines. Antenatal care and/or management of in-hospital deliveries was assessed as suboptimal in seven (37%) case and two (7%) control deliveries (p = 0.020). Three case deliveries were completed as planned caesarean delivery and 12 (75%) of the remaining 16 deaths were considered potentially avoidable had planned caesarean delivery been done. In seven of these 16 deliveries, death was associated with cord prolapse or difficult delivery of the head. CONCLUSION All in-hospital breech deliveries were in line with Norwegian guidelines. Seven of twelve potentially avoidable deaths were associated with birth complications related to breech presentation. However, suboptimal care was more common in case than control deliveries. Further improvement of intrapartum care may be obtained through continuous rigorous training and feedback from repeated perinatal audits.
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Affiliation(s)
- Solveig Bjellmo
- Department of Obstetrics and Gynecology, More and Romsdal Hospital Trust, Postbox 1600, 6026, Aalesund, Norway.
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sissel Hjelle
- Department of Obstetrics and Gynecology, More and Romsdal Hospital Trust, Postbox 1600, 6026, Aalesund, Norway
| | - Lone Krebs
- Department of Gynecology and Obstetrics, University of Copenhagen Holbaek Hospital, Holbaek, Denmark
| | - Elisabeth Magnussen
- Department of Obstetrics and Gynecology, St Olav's University Hospital, Trondheim, Norway
| | - Torstein Vik
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Katsuragi S, Okamura T, Kokubo Y, Watanabe M, Higashiyama A, Ikeda T, Miyamoto Y. The Perinatal Condition Around Birth and Cardiovascular Risk Factors in the Japanese General Population: The Suita Study. J Atheroscler Thromb 2019; 27:204-214. [PMID: 31341116 PMCID: PMC7113139 DOI: 10.5551/jat.49577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aim: To investigate the relationship between perinatal condition around birth and cardiovascular risk in later life. Methods: Retrospective data were examined from 1241 city dwellers (521 men, 720 women; age 41–69 years) who had undergone medical examination at a single institution including blood tests and physical measurements from 2007 to 2008. The questionnaire was conducted to determine how perinatal factors affect their lives later. We also selected and studied a total of 28 individuals (12 men and 16 women) specifically about the conformity rate of the breastfeeding method between participants' memories and what was written in the maternal and child health handbooks. Results: The conformity rate of the breastfeeding method between a self-questionnaire and his/her maternal and child health handbook was well correlated (r = 0.73; p < 0.025). Among the data in women who were born at home, HbA1C levels (5.36 ± 0.03 vs. 5.25 ± 0.05 mg/dL, p = 0.03) and low-density lipoprotein cholesterol (136.0 ± 1.4 vs. 129.3 ± 2.5 mg/dL, p = 0.04) were higher than women who were born at the hospital. Women raised by formula showed higher low-density lipoprotein cholesterol levels than women fed breast milk or a mixture of breast milk and formula (150.2 ± 4.8 vs. 138.7 ± 3.7, 142.5 ± 2.6 mg/dL, p = 0.04). Fasting blood glucose levels at an adult time in men and women born through breech presentation were higher than those by the cephalic presentation (123.2 ± 7.8 vs. 106.8 ± 1.2 mg/dL, p = 0.03). Conclusion: The study proposed that some perinatal conditions around birth such as delivery place, presenting part, and lactation affected especially Japanese women's cardiovascular risks between ages 41 and 69 years.
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Affiliation(s)
- Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute.,Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center
| | - Makoto Watanabe
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center
| | - Aya Higashiyama
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University
| | - Yoshihiro Miyamoto
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center
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Londero AP, Rossetti E, Pittini C, Cagnacci A, Driul L. Maternal age and the risk of adverse pregnancy outcomes: a retrospective cohort study. BMC Pregnancy Childbirth 2019; 19:261. [PMID: 31337350 PMCID: PMC6651936 DOI: 10.1186/s12884-019-2400-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 07/04/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The increased potential for negative pregnancy outcomes in both extremes of reproductive age is a well-debated argument. The aim of this study was to analyze the prevalence and the outcome of pregnancies conceived at extreme maternal ages. METHODS This retrospective study considered all single consecutive pregnancies delivered in a tertiary referral center between 2001 and 2014. Patients were categorized into 4 groups according to maternal age at delivery (< 17 years; 18-28 years; 29-39 years; > 40 years). The following outcomes were considered (amongst others): pregnancy-related hypertensive disorders (PRHDs), neonatal resuscitation (NR), neonatal intensive care unit (NICU) admission, periventricular leucomalacia (PVL), and grade 3 and 4 intraventicular hemorrhage (IVH). RESULTS During the considered period 22,933 single pregnancies gave birth in our unit. We observed 71 women aged < 17 years, and 1552 aged > 40 years. In each year throughout the study period, there was a significant increment in maternal age of 0.041 years (95% CI 0.024-0.058) every new year. Multivariate analysis concluded out that maternal age over 40 years was an independent risk factor for preterm delivery (OR 1.36 95% CI 1.16-1.61, p < 0.05, PRHDs (OR 2.36 95% CI 1.86-3.00, p < 0.05), GDM (OR 1.71 95% CI 1.37-2.12, p < 0.05) cesarean section (OR 1.99 95% CI 1.78-2.23, p < 0.05), abnormal fetal presentation (OR 1.29 95% CI 1.03-1.61, p < 0.05), and fetal PVL (OR 3.32 95% CI 1.17-9.44, p < 0.05). We also observed that maternal age under 17 years or over 40 years was an independent risk factor for grade 3 or 4 neonatal IVH (OR 2.97 95% CI 1.24-7.14, p < 0.05). CONCLUSIONS These findings confirm a negative impact of extreme maternal ages on pregnancy. These results should be carefully taken into account by maternal care providers in order to inform women adequately, supporting them in understanding potential risks associated with their procreation choices, and to improve clinical surveillance.
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Affiliation(s)
- Ambrogio P. Londero
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, Academic Hospital of Udine, Piazza Santa Maria della Misericordia, 15, 33100 Udine, Italy
| | - Emma Rossetti
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, Academic Hospital of Udine, Piazza Santa Maria della Misericordia, 15, 33100 Udine, Italy
| | - Carla Pittini
- Unit of Neonatology, Academic Hospital of Udine, 33100 Udine, Italy
| | - Angelo Cagnacci
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, Academic Hospital of Udine, Piazza Santa Maria della Misericordia, 15, 33100 Udine, Italy
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, Academic Hospital of Udine, Piazza Santa Maria della Misericordia, 15, 33100 Udine, Italy
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Tonei V. Mother's mental health after childbirth: Does the delivery method matter? JOURNAL OF HEALTH ECONOMICS 2019; 63:182-196. [PMID: 30594609 DOI: 10.1016/j.jhealeco.2018.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 08/05/2018] [Accepted: 11/26/2018] [Indexed: 06/09/2023]
Abstract
The dramatic increase in the utilization of caesarean section has raised concerns on its impact on public expenditure and health. While the financial costs associated with this surgical procedure are well recognized, less is known on the intangible health costs borne by mothers and their families. We contribute to the debate by investigating the effect of unplanned caesarean deliveries on mothers' mental health in the first nine months after the delivery. Differently from previous studies, we account for the unobserved heterogeneity due to the fact that mothers who give birth through an unplanned caesarean delivery may be different than mothers who give birth with a natural delivery. Identification is achieved exploiting exogenous variation in the position of the baby in the womb at the time of delivery while controlling for hospital unobserved factors. We find that mothers having an unplanned caesarean section are at higher risk of developing postnatal depression and this result is robust to alternative specifications.
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Duffy CR, Moore JL, Saleem S, Tshefu A, Bose CL, Chomba E, Carlo WA, Garces AL, Krebs NF, Hambidge KM, Goudar SS, Derman RJ, Patel A, Hibberd PL, Esamai F, Liechty EA, Wallace DD, McClure EM, Goldenberg RL. Malpresentation in low- and middle-income countries: Associations with perinatal and maternal outcomes in the Global Network. Acta Obstet Gynecol Scand 2018; 98:300-308. [PMID: 30414270 DOI: 10.1111/aogs.13502] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/26/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Uncertainty exists regarding the impact of malpresentation on pregnancy outcomes and the optimal mode of delivery in low- and middle-income countries. We sought to compare outcomes between cephalic and non-cephalic pregnancies. MATERIAL AND METHODS Using the NICHD Global Network's prospective, population-based registry of pregnancy outcomes from 2010 to 2016, we studied outcomes in 436 112 singleton pregnancies. Robust Poisson regressions were used to estimate the risk of adverse outcomes associated with malpresentation. We examined rates of cesarean delivery for malpresentation and compared outcomes between cesarean and vaginal delivery by region. RESULTS Across all regions, stillbirth and neonatal mortality rates were higher among deliveries with malpresentation. In adjusted analysis, malpresentation was significantly associated with stillbirth (adjusted relative risk [aRR] 4.0, 95% confidence interval [CI] 3.7-4.5) and neonatal mortality (aRR 2.3, 95% CI 2.1-2.6). Women with deliveries complicated by malpresentation had higher rates of morbidity and mortality. Rates of cesarean delivery for malpresentation ranged from 27% to 87% among regions. Compared with cesarean delivery, vaginal delivery for malpresentation was associated with increased maternal risk, especially postpartum hemorrhage (aRR 5.0, 95% CI; 3.6-7.1). CONCLUSIONS In a cohort of deliveries in low- and middle-income countries, malpresentation was associated with increased perinatal and maternal risk. Further research is needed to determine the best management of these pregnancies.
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Janet L Moore
- Social, Statistical and Environmental Health Sciences, Durham, NC, USA
| | | | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Carl L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Ana L Garces
- Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | | | | | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Belagavi, India
| | | | | | | | | | | | - Dennis D Wallace
- Social, Statistical and Environmental Health Sciences, Durham, NC, USA
| | | | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Kapinos KA, Yakusheva O, Weiss M. Cesarean deliveries and maternal weight retention. BMC Pregnancy Childbirth 2017; 17:343. [PMID: 28978303 PMCID: PMC5628485 DOI: 10.1186/s12884-017-1527-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean delivery accounts for nearly one-third of all births in the U.S. and contributes to an additional $38 billion in healthcare costs each year. Although Cesarean delivery has a long record of improving maternal and neonatal mortality and morbidity, increased utilization over time has yielded public health concerns and calls for reductions. Observational evidence suggests Cesarean delivery is associated with increased maternal postpartum weight, which may have significant implications for the obesity epidemic. Previous literature, however, typically does not address selection biases stemming from correlations of pre-pregnancy weight and reproductive health with Cesarean delivery. METHODS We used fetal malpresentation as a natural experiment as it predicts Cesarean delivery but is uncorrelated with pre-pregnancy weight or maternal health. We used hospital administrative data (including fields used in vital birth record) from the state of Wisconsin from 2006 to 2013 to create a sample of mothers with at least two births. Using propensity score methods, we compared maternal weight prior to the second pregnancy of mothers who delivered via Cesarean due to fetal malpresentation to mothers who deliver vaginally. RESULTS We found no evidence that Cesarean delivery in the first pregnancy causally leads to greater maternal weight, BMI, or movement to a higher BMI classification prior to the second pregnancy. CONCLUSIONS After accounting for correlations between pre-pregnancy weight, gestational weight gain, and mode of delivery, there is no evidence of a causal link between Cesarean delivery and maternal weight retention.
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Affiliation(s)
| | - Olga Yakusheva
- University of Michigan, School of Nursing and School of Public Health, 400 North Ingalls Building, Ann Arbor, MI 48109-5482 USA
| | - Marianne Weiss
- Marquette University College of Nursing, 530 N 16th St, Milwaukee, WI 53233 USA
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Abstract
Breech presentation is the most common abnormal fetal presentation and complicates approximately 3% to 4% of all pregnancies. External cephalic version (ECV) should be recommended to women with a breech singleton pregnancy, if there is no maternal or fetal contraindication. ECV increases the chance of cephalic presentation at the onset of labor and decreases the rate of cesarean delivery by almost 40%. The success rate of ECV is approximately 60%. Review of the risks and benefits for performing an ECV and for both the timing of ECV and the number of attempts should be should be discussed with the patient.
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Affiliation(s)
- Stephanie Lim
- Division of Obstetric Anesthesia, Department of Anesthesia & Perioperative Care, University California San Francisco School of Medicine, San Francisco, CA 94143, USA
| | - Jennifer Lucero
- Division of Obstetric Anesthesia, Department of Anesthesia & Perioperative Care, University California San Francisco School of Medicine, San Francisco, CA 94143, USA; Department of Obstetrics, Gynecology & Reproductive Sciences, University California San Francisco School of Medicine, San Francisco, CA 94143, USA.
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Robillard PY, Boukerrou M, Bonsante F, Hulsey TC, Dekker G, Gouyon JB, Iacobelli S. Linear association between maternal age and spontaneous breech presentation in singleton pregnancies after 32 weeks gestation. J Matern Fetal Neonatal Med 2017; 31:376-381. [PMID: 28110591 DOI: 10.1080/14767058.2017.1285897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the association between maternal age and spontaneous breech presentation. MATERIAL AND METHODS Fifteen-year observational study over (2001-2015). All consecutive singleton births delivered at the Centre Hospitalier Universitaire Sud Reunion's maternity. The only single exclusion criterion was uterine malformations (N = 123) women. RESULTS Of the 60,963 singleton births, there was a linear association (χ2 for linear trend, p< 0.0001) between maternal age and spontaneous breech presentation. Overall rate of breech presentation was 2.7% in deliveries over 32 weeks gestation, while it was 1.9% in women aged 15 to 19 years and 4.0% in women aged 45+, with a linear progression for each 5-year age category. This linearity remained significant controlling for early prematurity (<33 weeks) and severe fetal malformations (χ2 for linear trend = 64, p < 0.0001). Controlling in a multiple logistic regression model for other major risk factors gestational age, female sex, primiparity, maternal age remained significantly an independent risk factor, p < 0.0001. CONCLUSION Maternal age (x) is an independent factor for breech presentation in singleton pregnancies after 32 weeks gestation with a linear association that may be approximated at y = 0.1x. (y: incidence, percent).
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Affiliation(s)
- Pierre-Yves Robillard
- a Service de Néonatologie , Centre Hospitalier Universitaire Sud Réunion , La Réunion , Saint Pierre , France.,b Centre d'Etudes Périnatales Océan Indien (CEPOI), Centre Hospitalier Universitaire Sud Réunion , La reunion , Saint Pierre , France
| | - Malik Boukerrou
- b Centre d'Etudes Périnatales Océan Indien (CEPOI), Centre Hospitalier Universitaire Sud Réunion , La reunion , Saint Pierre , France.,c Service de Gynécologie et Obstétrique , Centre Hospitalier Universitaire Sud Réunion , La reunion , Saint Pierre , France
| | - Francesco Bonsante
- a Service de Néonatologie , Centre Hospitalier Universitaire Sud Réunion , La Réunion , Saint Pierre , France.,b Centre d'Etudes Périnatales Océan Indien (CEPOI), Centre Hospitalier Universitaire Sud Réunion , La reunion , Saint Pierre , France
| | - Thomas C Hulsey
- d Department of epidemiology, school of public health , West Virginia University, School of Public Health , Morgantown , VA , USA
| | - Gustaaf Dekker
- e Department of Obstetrics and Gynaecology , University of Adelaide, Robinson Institute. Lyell McEwin Hospital , Elizabeth Vale , Australia
| | - Jean-Bernard Gouyon
- a Service de Néonatologie , Centre Hospitalier Universitaire Sud Réunion , La Réunion , Saint Pierre , France.,b Centre d'Etudes Périnatales Océan Indien (CEPOI), Centre Hospitalier Universitaire Sud Réunion , La reunion , Saint Pierre , France
| | - Silvia Iacobelli
- a Service de Néonatologie , Centre Hospitalier Universitaire Sud Réunion , La Réunion , Saint Pierre , France.,b Centre d'Etudes Périnatales Océan Indien (CEPOI), Centre Hospitalier Universitaire Sud Réunion , La reunion , Saint Pierre , France
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Macharey G, Gissler M, Rahkonen L, Ulander VM, Väisänen-Tommiska M, Nuutila M, Heinonen S. Breech presentation at term and associated obstetric risks factors-a nationwide population based cohort study. Arch Gynecol Obstet 2017; 295:833-838. [PMID: 28176014 DOI: 10.1007/s00404-016-4283-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/22/2016] [Indexed: 01/21/2023]
Abstract
PURPOSE The aim of this study was to estimate whether breech presentation at term was associated with known individual obstetric risk factors for adverse fetal outcome. METHODS This was a retrospective, nationwide Finnish population-based cohort study. Obstetric risks in all breech and vertex singleton deliveries at term were compared between the years 2005 and 2014. A multivariable logistic regression model was used to determine significant risk factors. RESULTS The breech presentation rate at term for singleton pregnancies was 2.4%. The stillbirth rate in term breech presentation was significantly higher compared to cephalic presentation (0.2 vs 0.1%). The odds ratios (95% CIs) for fetal growth restriction, oligohydramnios, gestational diabetes, a history of cesarean section and congenital fetal abnormalities were 1.19 CI (1.07-1.32), 1.42 CI (1.27-1.57), 1.06 CI (1.00-1.13), 2.13 (1.98-2.29) and 2.01 CI (1.92-2.11). CONCLUSIONS The study showed that breech presentation at term on its own was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes. The risk factors included oligohydramnios, fetal growth restriction, gestational diabetes, history of caesarean section and congenital anomalies.
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Affiliation(s)
- Georg Macharey
- Department of Obstetrics and Gynecology, Helsinki University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland.
| | - Mika Gissler
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Leena Rahkonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Veli-Matti Ulander
- Department of Obstetrics and Gynecology, Helsinki University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Mervi Väisänen-Tommiska
- Department of Obstetrics and Gynecology, Helsinki University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Mika Nuutila
- Department of Obstetrics and Gynecology, Helsinki University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
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Bin YS, Roberts CL, Nicholl MC, Nassar N, Ford JB. Contribution of changing risk factors to the trend in breech presentation at term. Aust N Z J Obstet Gynaecol 2016; 56:564-570. [DOI: 10.1111/ajo.12556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/12/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Yu Sun Bin
- Clinical and Population Perinatal Health Research The Kolling Institute St Leonards New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Christine L. Roberts
- Clinical and Population Perinatal Health Research The Kolling Institute St Leonards New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Michael C. Nicholl
- Department of Obstetrics and Gynaecology Royal North Shore Hospital St Leonards New South Wales Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy Sydney School of Public Health University of Sydney Sydney New South Wales Australia
| | - Jane B. Ford
- Clinical and Population Perinatal Health Research The Kolling Institute St Leonards New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
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Cooper MI, Papanagnou D, Meguerdichian M, Bajaj K. Emergency Obstetrics for the Emergency Medicine Provider. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2016; 12:10481. [PMID: 30984823 PMCID: PMC6440410 DOI: 10.15766/mep_2374-8265.10481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION Emergency medicine physicians must have the knowledge and skills to stabilize all life-and-limb-threatening conditions. These skills are especially important considering that the 1989 COBRA act clearly defines active labor as a condition unsuitable to transfer. Given this context, we thought it necessary to create a work that could be used to provide emergency physicians with the necessary skills to assist in deliveries both routine and complex. METHODS The total time requirement for the workshop is 4 hours. Before the session begins, learners are asked to fill out a survey. Learners complete two 40-minute small-group sessions on the topics of normal vaginal delivery and shoulder dystocia with hands-on training with birthing manikins. After a short break learners complete a 65-minute small-group session for breech delivery with hands-on training. Each small-group session is preceded by a whole-group demonstration of required skills lasting 15 minutes as well a mini lecture on maternal hemorrhage and estimation of blood loss. RESULTS Our workshop has been shown to successfully educate emergency physicians with a range of obstetric experience and improve their knowledge base and hands-on skills. One hundred percent of our learners felt this workshop was appropriate for them and met its stated goals. DISCUSSION While this is not the first workshop to educate on obstetric deliveries and their possible complications, it is the first to be created with the emergency medicine provider as the intended audience and the first to create a curriculum around uncomplicated delivery, shoulder dystocia, breech delivery, and postpartum hemorrhage.
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Affiliation(s)
- Maxwell Ian Cooper
- Emergency Medicine Physician and Former Resident, Sidney Kimmel Medical College at Thomas Jefferson University
- Corresponding author:
| | - Dimitrios Papanagnou
- Associate Professor of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University; Vice Chair for Education, Sidney Kimmel Medical College at Thomas Jefferson University; Assistant Dean For Faculty Development, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Mike Meguerdichian
- Clinical Co-director, Simulation Center, NYC Health + Hospitals; Medical Director, Simulation Center Harlem, NYC Health + Hospitals
| | - Komal Bajaj
- Associate Professor of Clinical Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine
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Peelen MJCS, Kazemier BM, Ravelli ACJ, De Groot CJM, Van Der Post JAM, Mol BWJ, Hajenius PJ, Kok M. Impact of fetal gender on the risk of preterm birth, a national cohort study. Acta Obstet Gynecol Scand 2016; 95:1034-41. [PMID: 27216473 DOI: 10.1111/aogs.12929] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 05/18/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Fetal gender is associated with preterm birth; however, a proper subdivision by onset of labor and corresponding neonatal outcome by week of gestation is lacking. MATERIAL AND METHODS Data from the Netherlands Perinatal Registry (1999-2010) were used to calculate relative risk ratios for gender by week of gestation and gender-related risk on adverse neonatal outcomes using a moving average technique. White European women with an alive fetus at onset of labor were included. Adverse neonatal outcomes were defined as neonatal mortality and a composite of neonatal morbidity. Onset of labor was categorized as spontaneous onset with intact membranes, premature rupture of membranes, and induction or elective cesarean section. RESULTS The study population comprised 1 736 615 singleton deliveries (25(+0) -42(+6) weeks). Male fetuses were at increased risk of spontaneous preterm birth with intact membranes compared with a female fetus with a peak between 27 and 31 weeks [relative risk (RR) 1.5; 95% CI 1.4-1.6]. Male fetuses were also at increased risk of preterm premature rupture of membranes between 27 and 37 weeks (RR 1.2; 95% CI 1.16-1.23). No gender effect was seen for medically indicated preterm birth. No significant differences were seen for neonatal mortality. Males were at significantly increased risk of composite neonatal morbidity from 29 weeks onwards (RR 1.3; 95% CI 1.3-1.4). CONCLUSIONS Male fetal gender is a relevant risk factor for spontaneous preterm birth, both for intact membranes and for preterm premature rupture of membranes in white European women. In addition, male infants are at increased risk of neonatal morbidity.
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Affiliation(s)
- Myrthe J C S Peelen
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Brenda M Kazemier
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Anita C J Ravelli
- Department of Medical Informatics, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Joris A M Van Der Post
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ben W J Mol
- The Robinson Research Institute, School of Medicine, University of Adelaide, The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Petra J Hajenius
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marjolein Kok
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, the Netherlands
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Zsirai L, Csákány GM, Vargha P, Fülöp V, Tabák ÁG. Breech presentation: its predictors and consequences. An analysis of the Hungarian Tauffer Obstetric Database (1996-2011). Acta Obstet Gynecol Scand 2015; 95:347-54. [PMID: 26660231 DOI: 10.1111/aogs.12834] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 10/11/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Breech presentation is linked to abnormal pregnancy outcomes. However, the causality of this association is unknown. We aimed to investigate predictors of term breech presentation and pregnancy outcomes of breech presentation. MATERIAL AND METHODS Using a Hungarian registry, all term (≥ 37 weeks), singleton pregnancies with cephalic, and breech presentation in 1996-2011 were analyzed (n = 41 796). Covariates were maternal medical history and data on the present pregnancy. Multivariable logistic regression was used to investigate predictors of breech presentation and of delivery (cesarean section or other obstetrical interventions at birth) and fetal outcomes (Apgar score ≤ 7, need for perinatal intensive treatment, intrauterine death or perinatal mortality) related to breech presentation. RESULTS Breech presentation was independently associated with older maternal age, medical history (primiparity, stillbirth, spontaneous abortion, hormone treatment, and assisted reproduction), maternal morbidities (hypertension and oligohydramnios), and the fetal factors (female sex, younger gestational age at delivery, developmental abnormalities, small for gestational age, and birthweight). An adverse delivery outcome was 11.7 times (95% confidence interval 11.3-12.0) and an adverse fetal outcome was 1.39 times (95% confidence interval 1.33-1.45) more frequent in pregnancies with breech presentation compared with cephalic presentation. Further adjustment for predictors of breech presentation had no major effect on the delivery outcome, but it reduced the risk of adverse fetal outcome (odds ratio 1.18, 95% confidence interval 1.14-1.24). CONCLUSIONS Breech presentation is a marker of pathological pregnancy and is independently associated with an increased risk of gestational complications. Closer surveillance and appropriate management of pregnancies with breech presentation is warranted to prevent adverse perinatal outcomes.
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Affiliation(s)
- László Zsirai
- Department of Gynecology and Family Planning, Istenhegyi GeneDiagnostic Center, Budapest, Hungary
| | - György M Csákány
- Department of Obstetrics and Gynecology, Jahn Ferenc Hospital, Budapest, Hungary
| | - Péter Vargha
- Department of Cardiology, Cardiology Center, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | - Vilmos Fülöp
- Department of Obstetrics and Gynecology, Military Hospital, Budapest, Hungary
| | - Ádám G Tabák
- 1st Department of Internal Medicine, Semmelweis University Faculty of Medicine, Budapest, Hungary.,Department of Epidemiology and Public Health, University College London, London, UK
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Sharoni L, Lyell DJ, Weiniger CF. Too late to back out? Options for breech presentation management. J Epidemiol Community Health 2015; 69:1135-8. [PMID: 26139643 DOI: 10.1136/jech-2015-205528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Limor Sharoni
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Deirdre J Lyell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lucile Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Carolyn F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Sharoni L, Weiniger CF. Anesthesia and External Cephalic Version. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0095-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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External cephalic version – the bad, the good and the what now? Int J Obstet Anesth 2014; 23:4-7. [DOI: 10.1016/j.ijoa.2013.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 11/23/2022]
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