Prospective risk of fetal death with gastroschisis

OBJECTIVE

To evaluate the ongoing risk of intrauterine fetal demise (IUFD) in fetuses with gastroschisis compared to non-anomalous fetuses.

METHODS

This was a retrospective cohort study of all births in the United States in 2005-2006, as recorded in the National Center for Health Statistics natality database. Risk of IUFD in fetuses with gastroschisis was compared to non-anomalous fetuses, utilizing total at-risk fetuses as the denominator.

RESULTS

Risk of IUFD in fetuses with gastroschisis was 4.5%, compared to 0.6% in non-anomalous fetuses (p < 0.001). When controlling for gestational age and other confounders, the adjusted odds ratio for IUFD in fetuses with gastroschisis was 7.06 (95% CI: 3.33-14.96). After 32 weeks, risk of IUFD/ongoing pregnancy was greater at each week of gestation in fetuses with gastroschisis.

CONCLUSIONS

Risk of IUFD for fetuses with gastroschisis is greater than in non-anomalous fetuses. This risk increases significantly after 32 weeks' gestation. Demographic variables are associated with higher rates of gastroschisis and ultimately IUFD. These data may be useful in consideration of timing of delivery.

The risk of stillbirth and infant death by each additional week of expectant management stratified by maternal age

OBJECTIVE

The objective of the study was to examine fetal/infant mortality by gestational age at term stratified by maternal age.

STUDY DESIGN

A retrospective cohort study was conducted using 2005 US national birth certificate data. For each week of term gestation, the risk of mortality associated with delivery was compared with composite mortality risk of expectant management. The expectant management measure included stillbirth and infant death. This expectant management risk was calculated to estimate the composite mortality risk with remaining pregnant an additional week by combining the risk of stillbirth during the additional week of pregnancy and infant death risk following delivery at the next week. Maternal age was stratified by 35 years or more compared with women younger than 35 years as well as subgroup analyses of younger than 20, 20-34, 35-39, or 40 years old or older.

RESULTS

The fetal/infant mortality risk of expectant management is greater than the risk of infant death at 39 weeks' gestation in women 35 years old or older (15.2 vs 10.9 of 10,000, P < .05). In women younger than 35 years old, the risk of expectant management also exceeded that of infant death at 39 weeks (21.3 vs 18.8 of 10,000, P < .05). For women younger than 35 years old, the overall expectant management risk is influenced by higher infant death risk and does not rise significantly until 41 weeks compared with women 35 years old or older in which it increased at 40 weeks.

CONCLUSION

Risk varies by maternal age, and delivery at 39 weeks minimizes fetal/infant mortality for both groups, although the magnitude of the risk reduction is greater in older women.

Gestational age at delivery and perinatal outcomes of twin gestations

OBJECTIVE

The optimal gestational duration for twin gestations is unknown. Epidemiologic studies show that the lowest perinatal mortality rate for twins is at 37-38 weeks, but these studies lack information on pregnancy complications and neonatal morbidities. This study evaluates pregnancy characteristics and perinatal outcomes of twins in order to assess the optimal gestational age for delivery.

STUDY DESIGN

This is a retrospective study of twins delivered at ≥36 weeks at our institution from 1991-2009. The composite rate of perinatal morbidity and mortality (including perinatal death, respiratory distress, suspected sepsis, and need for neonatal intensive care) was determined for weekly intervals from 36-39(+) weeks.

RESULTS

There were 377 twin gestations included. Of those 83% were dichorionic. Fifty-three percent had spontaneous labor and 48% were delivered by cesarean section. Perinatal outcomes improved as gestational age advanced to 38 weeks.

CONCLUSION

Perinatal morbidity and mortality rates suggest that the optimal time for delivery of twins is at 38 weeks or greater.

The risk of intrauterine fetal death in the small-for-gestational-age fetus

OBJECTIVE

We sought to evaluate the risk of intrauterine fetal death (IUFD) in small-for-gestational-age (SGA) fetuses.

STUDY DESIGN

We analyzed a retrospective cohort of all births in the United States in 2005, as recorded in a national database. We calculated the risk of IUFD within 3 sets of SGA threshold categories as well as within non-SGA pregnancies using the number of at-risk fetuses as the denominator.

RESULTS

The risk of IUFD increased with gestational age and was inversely proportional to percentile of birthweight for gestational age. The risk for IUFD in those <3rd percentile was as high as 58.0 IUFDs per 10,000 at-risk fetuses, 43.9 for <5th percentile, and 26.3 for <10th percentile compared to 5.1 for non-SGA gestations.

CONCLUSION

There is an increase in the risk of IUFD in SGA fetuses compared to non-SGA fetuses at all gestational ages with the greatest risk demonstrated in the lowest percentile cohort evaluated.

Antibiotic prophylaxis for cesarean delivery: survey of maternal-fetal medicine physicians in the U.S

OBJECTIVE

To describe practices concerning antibiotic prophylaxis for cesarean delivery among maternal-fetal medicine (MFM) physicians in the United States.

METHODS

A 10-item self-administered survey about their routine use of antibiotics for cesarean delivery was mailed once only to a random sample of 1000 US-based fellows of the Society of Maternal-Fetal Medicine in November 2009.

RESULTS

There were a total of 250 respondents from 40 US states between 10/09 and 4/2010, corresponding to a response rate of 25%. Among respondents, 95.5% reported routine use of a cephalosporin only (including 84.4% who reported use of cefazolin) as antibiotic prophylaxis for cesarean delivery; less than 3% reported use of an extended spectrum regimen such as cefazolin + azithromycin. Preoperative administration of antibiotic prophylaxis was reported by 84.6% compared to 15.0% who reported giving antibiotic prophylaxis after umbilical cord clamping. Administration of a single dose of antibiotic was reported by 96%.

CONCLUSION

The majority of MFM specialists in the US report routine and preoperative use of a single prophylactic dose of a 1st generation cephalosporin for cesarean delivery.

The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes

OBJECTIVE

We sought to compare the different mortality risks between delivery and expectant management in women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This is a retrospective cohort study that included singleton pregnancies of women diagnosed with GDM delivering at 36-42 weeks' gestational age in California from 1997 through 2006. A composite mortality rate was developed to estimate the risk of expectant management at each gestational age incorporating the stillbirth risk during the week of continuing pregnancy plus the infant mortality risk at the gestational age 1 week hence.

RESULTS

In women with GDM, the risk of expectant management is lower than the risk of delivery at 36 weeks (17.4 vs 19.3/10,000), but at 39 weeks, the risk of expectant management exceeds that of delivery (relative risk, 1.8; 95% confidence interval, 1.2-2.6).

CONCLUSION

In women with GDM, infant mortality rates at 39 weeks are lower than the overall mortality risk of expectant management for 1 week; absolute risks of stillbirth and infant death are low.

Tracheal replacements: Part 2

In this review, we summarize the history of tracheal reconstruction and replacement as well as progress in current tracheal substitutes. In Part 1, we covered the historical highlights of grafts, flaps, tube construction, and tissue transplants and addressed the progress made in tracheal stenting as a means of temporary tracheal support. In Part 2 we analyze solid and porous tracheal prostheses in experimental and clinical trials and provide a summary of efforts aimed at generating a bioengineered trachea. In both parts, we provide an algorithm on the spectrum of options available for tracheal replacement.

Tracheal replacements: part 1

In this review, we summarize the history of tracheal reconstruction and replacement as well as progress in current tracheal substitutes. In Part 1, we cover the historical highlights of grafts, flaps, tube construction, and tissue transplants and address the progress made in tracheal stenting as a means of temporary tracheal support. This is followed in Part 2 by an analysis of solid and porous tracheal prostheses in experimental and clinical trials. We conclude Part 2 with a summary of recent efforts toward generating a bioengineered trachea. Finally, we provide an algorithm on the spectrum of options available for tracheal replacement.