Cesarean Delivery Complicated by Peripartum Infection and Risk of Uterine Rupture During Subsequent Trial of Labor

Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery.

Head position and vacuum-assisted delivery using the Kiwi Omnicup

OBJECTIVE

To evaluate the association between fetal head position during prevacuum assessment and adverse outcomes.

METHOD

This retrospective cohort study included all vacuum-assisted deliveries using the Kiwi Omnicup over 5 years. Primary outcomes were third- or fourth-degree perineal tear, pH < 7.1, and subgaleal hematoma (SGH). AGAR, neonatal intensive care unit admission, cephalohematoma, Erb's palsy, third-stage duration, and postpartum hemorrhage were secondary. Outcomes were compared between the occiput posterior (OP) and occiput anterior (OA) positions.

RESULTS

The study included 1960 patients. OP position was more likely to involve epidural analgesia (311 [82.5%] vs. 1216 [77%], P = 0.020), higher fetal head station (P = 0.001), higher percentage of cup detachments (121 cases [32.1%] vs. 307 [19.4%], P = 0.001), and longer procedure (5.5 ± 3.7 min vs. 4.7 ± 2.8 min, P = 0.001). OP was associated with umbilical cord pH < 7.1 (21 [5.5%] vs. 52 [3.9%], P = 0.032), NICU admissions (16 [4.2%] vs. 38 [2.4%], P = 0.049), SGH (18 [4.8%] vs. 38 [2.4%], P = 0.013), and high-degree perineal tears (12 [3.2%] vs. 26 [1.7%], with borderline significance, P = 0.051). SGH and high-grade tears remained significantly associated with OP position (P = 0.008 and P = 0.016, respectively) after adjusting for maternal age, nulliparity, diabetes, epidural anesthesia, preprocedure head station, and birth weight.

CONCLUSION

OP position is an independent risk-factor for anal sphincter injury and SGH during vacuum-assisted delivery.

The Effect of External Cephalic Version on Fetal Circulation: A Prospective Cohort Study

External cephalic version (ECV) is a cost-effective and safe treatment option for breech presentation at term. Following ECV, fetal well-being is assessed via a non-stress test (NST). An alternative option to identify signs of fetal compromise is via the Doppler indices of the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV). Inclusion criteria were an uncomplicated pregnancy with breech presentation at term. Doppler velocimetry of the UA, MCA and DV were performed up to 1 h before and up to 2 h after ECV. The study included 56 patients who underwent elective ECV with a success rate of 75%. After ECV, the UA S/D ratio, UA pulsatility index (PI) and UA resistance index (RI) were increased compared to before the ECV (p = 0.021, p = 0.042, and p = 0.022, respectively). There were no differences in the Doppler MCA and DV before or after ECV. All patients were discharged after the procedure. ECV is associated with changes in the UA Doppler indices that might reflect interference in placental perfusion. These changes are probably short-term and have no detrimental effects on the outcomes of uncomplicated pregnancies. ECV is safe; yet it is a stimulus or stress that can affect placental circulation. Therefore, careful case selection for ECV is important.

Vacuum-Assisted Delivery Complication Rates Based on Ultrasound-Estimated Fetal Weight

This retrospective cohort study investigated the association between ultrasonographic estimated fetal weight (EFW) and adverse maternal and neonatal outcomes after vacuum-assisted delivery (VAD). It included women with singleton pregnancies at 34−41 weeks gestation, who underwent ultrasonographic pre-labor EFW and VAD in an academic institution, over 6 years. Adverse neonatal and maternal outcomes included shoulder dystocia, clavicular fracture, or third- and fourth-degree perineal tears. A receiver−operator characteristic curve was used to identify the optimal weight cut-off value to predict adverse outcomes. Fetuses above and below this point were compared. Multivariate analysis was used to control for factors that could lead to adverse outcomes. Eight-hundred and fifty women met the inclusion criteria and had sonographic EFW within two-weeks before delivery. Receiver−operator characteristic curve analysis found that ultrasonographic EFW 3666 g is the optimal threshold for adverse outcomes. Based on these results, outcomes were compared using EFW 3700 g. The average EFW in the ≥3700 g group (n = 220, 25.9%) was 3898 ± 154 g (average birthweight 3710 ± 324 g). In the group <3700 g (n = 630, 74.1%), average EFW was 3064 ± 411 g (birthweight 3120 ± 464 g). Shoulder dystocia and clavicular fractures were more frequent in the higher EFW group (6.4% and 2.3% vs. 1.6% and 0.5%, respectively; p < 0.05). Women in the ≥3700 g group experienced more third- and fourth-degree perineal tears (3.2% vs. 1%, p = 0.02). Multivariate logistic regression analysis found maternal age, diabetes and sonographic EFW ≥ 3700 g as independent risk-factors for adverse outcomes. Sonographic EFW ≥ 3700 g is an independent risk-factor for adverse outcomes in VAD. This should be considered when choosing the optimal mode of delivery.

Can we improve our ability to interpret category II fetal heart rate tracings using additional clinical parameters?

OBJECTIVES

This study examined predictive factors, in addition to Category II Fetal Herat Rate (FHR) monitoring that might imply fetal acidosis and risk of asphyxia.

METHODS

This retrospective cohort study compared three groups of patients with Category II FHR monitoring indicating need for imminent delivery. Groups were divided based on fetal cord blood pH: pH≤7.0, 7.0<pH<7.2 and pH≥7.2. Demographics, medical history, delivery data and early neonatal outcomes were reviewed.

RESULTS

The cohort included 417 women. Nine (2.2%) had cord pH≤7.0, 105 (25.2%) pH 7.0 to 7.2 and 303 (72.6%) ad pH≥7.2. Background characteristics, pregnancy follow-up and intrauterine fetal evaluation prior to delivery were similar in all groups. As expected, more patients in the low pH group had cesarean section (55.6%), than vaginal delivery or vacuum extraction (p=0.02). Five-minute Apgar scores were similar in all groups.

CONCLUSIONS

This retrospective study did not detect a specific parameter that could help predict the prognosis of fetal acidosis and risk of asphyxia. As we only included patients with a Category II tracing that was worrisome enough to lead to imminent delivery, it is reasonable to believe that this is due to patient selection, meaning that when the Category II FHR results in decision for prompt delivery, there is no added value in additional clinical characteristics. The evaluation should be expanded to all patients with Category II tracing for better interpretation tools for Category II FHR monitors, as well as a larger study population.

Adverse outcomes in vacuum-assisted delivery after detachment of non-metal cup: a retrospective cohort study

PURPOSE

To evaluate neonatal and maternal outcomes associated with detachment of non-metal vacuum cup during delivery and to identify risk factors for these detachments.

METHODS

This retrospective cohort study included women with singleton pregnancy, who underwent vacuum-assisted vaginal delivery with a non-metal vacuum cup in a single academic institution, January 2014-August 2019. Failed vacuum deliveries were excluded. Primary outcomes were defined as subgaleal hematoma (SGH) and cord blood pH < 7.15. Secondary outcome included other neonatal complications and adverse maternal outcomes. Outcomes were compared between vacuum-assisted deliveries with and without cup detachment during the procedure.

RESULTS

A total of 3246 women had successful VAD and met the inclusion criteria. During the procedure, the cup detached at least once in 665 (20.5%) deliveries and did not detach in 2581 (79.5%). The cup detachment group experienced higher rates of SGH (8.9% vs. 3.5%, p = 0.001) and cord blood pH < 7.15 (9.8% vs. 7.1%, p = 0.03). There were also more neonatal intensive care unit admissions (NICU) (4.4% vs. 2.7%, p = 0.03) and more fetuses with occiput posterior position (70.8% vs. 79.4%, p = 0.001), the vacuum duration was slightly longer (6 ± 3.7 vs. 5 ± 2.9 min) and more neonates had birth weights > 3700 g (14.1% vs, 10.3%, p = 0.006). Interestingly, there were more males in that group (60.6 vs. 54.6, p = 0.005). All these factors remained significant after controlling for potential confounders.

CONCLUSIONS

Vacuum cup detachment has several predictive characteristics and is associated with adverse neonatal outcomes that should be incorporated into decisions made during the procedure.

The role of mediolateral episiotomy during vacuum-assisted vaginal delivery with soft cup devices

PURPOSE

This study evaluated whether episiotomy during vacuum-assisted delivery leads to fewer third- and fourth-degree tears.

METHODS

This was a retrospective cohort study of all nulliparas who underwent a singleton, soft cup, vacuum-assisted vaginal delivery in one institution, from January 2014 to August 2019. Failed vacuum deliveries were excluded. Based on power analysis calculation, a sample size of 500 women in each group was sufficient to detect an advantage of episiotomy, if present. Primary outcome was third- or fourth-degree perineal tear. Secondary outcomes were other maternal complications, and low neonatal cord pH and Apgar scores. Outcomes were compared between women with and without episiotomy.

RESULTS

During the study period, 2370 nulliparas had a vacuum-assisted vaginal delivery using soft vacuum cup and met the study inclusion criteria. Episiotomy was performed in 1868 (79%) women, and 502 (21%) delivered without episiotomy. Background characteristics were similar in both groups. There were no significant differences in the rates of third and fourth grade perineal lacerations between the two groups. Episiotomy was associated with higher rate of postpartum hemorrhage (p < 0.01) CONCLUSIONS: Using selective episiotomy for patients delivering vaginally with the assistance of soft cap vacuum does not increase third- or fourth-degree perineal tears.

Prevalence, risk factors and pregnancy outcomes of women with vascular brain lesions in pregnancy

BACKGROUND

Vascular brain lesions (VBL) occur in up to 4.0% of the general population. With the increasing availability and use of sophisticated imaging techniques, there are more patients being diagnosed with asymptomatic intracranial AVMs and cavernous hemangiomas.

OBJECTIVES

Here we evaluate the association between VBL in pregnancy and the maternal and fetal outcomes.

STUDY DESIGN

The study cohort was identified by isolating all pregnancies from the nationwide inpatient sample (NIS), from the healthcare cost and utilization project (HCUP) over a five-year period. Within this cohort, cases with an arteriovenous malformation (AVM) or cerebral vascular malformations (CVM) were identified and their prevalence was calculated. Baseline demographic characteristics were compared and the odds ratios for various complications and outcomes were calculated.

RESULTS

Amongst 4,012,396 deliveries, VBL were identified in 214 cases: a prevalence of 5.33 cases per 100,000 deliveries. Majority of VBL cases were identified in women between 25 and 35 years of age, but the proportion of women aged 35 and older was greater amongst those patients with VBL. 74% of cases were of Caucasian race and more cases with VBL had a private insurance payer (62.1%). Seizure disorders were present in 63.6% of the cases with VBL. Whilst VBL are not associated with unfavorable obstetrical complications, they are more likely to be delivered by caesarean section (CS) - 79% of VBL cases were delivered by CS compared to 33% of the patients without VBL (OR 7.03 CI 95% 4.98-9.92). Instrumental delivery was performed in 10.3% of the vaginal deliveries for index cases. Index cases were less prone to fetal growth restriction. VBL accounted for 8.4% of 166 cases of intracranial bleeding occurring during the antepartum period within the entire pregnant population.

CONCLUSIONS

Presence of VBL does not appear to carry additional risk to mother or fetus during pregnancy.

Neonatal outcomes of pregnancy-associated breast cancer: Population-based study on 11 million births

BACKGROUND

As the age at first pregnancy continues to rise in the United States so does the incidence of breast cancer diagnosed during pregnancy. Our objective was to evaluate temporal trends in the incidence of pregnancy-associated breast cancer (PABC) and to measure neonatal outcomes associated with PABC.

METHODS

We conducted a population-based cohort study using the 1999-2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from the United States. Logistic regression models, adjusted for maternal baseline characteristics, examined the effect of PABC on neonatal outcomes.

RESULTS

There were 11 846 300 deliveries between 1999 and 2012, of which 772 cases of PABC were identified, resulting in an overall incidence of 6.5 cases/100 000 pregnancies. There was a significant increase in the incidence of PABC during the study period (P < 0.05). Women with PABC tended to be older, of white ethnicity, belong to a higher income quartile and to be treated in an urban teaching hospital. In pregnancies complicated by breast cancer, there was a greater risk of preterm delivery (OR 4.84, 95% CI 4.05-5.79) and preterm premature rupture of membranes (OR 1.79, 95% CI 1.06-3.05). No associations were observed between PABC and intrauterine growth restriction, congenital anomalies or intrauterine fetal demise.

CONCLUSION

There is an uptrend in the incidence of PABC and therefore, the need for counseling these patients is also increasing. Although pregnancies with the diagnosis of maternal breast cancer are more prone to premature births, it is encouraging that these babies do not appear to be at increased risk for congenital anomalies, growth restriction, or fetal demise.